FULLENKAMP DOMINIC (US)
SADLEIR KATHERINE (US)
VASSAR ROBERT (US)
MCNALLY ELIZABETH (US)
WHAT IS CLAIMED IS: 1. A method of treating a patient suffering from a disorder comprising administering to the patient a therapeutically effective amount of a composition comprising an agent that increases the activity of an annexin protein, wherein the disorder is stroke, dementia, Alzheimer Dementia, Frontotemporal Dementia, Parkinsons Disease, spinal cord injury, small vessel disease, transient ischemic attack, cerebrovascular accident, dementia due to small vessel disease, Guillain Barré, Acute Inflammatory Demyelinating, Polyradiculopathy, Peripheral nerve disease, neuropathy, diabetic neuropathy, acute myocardial infarction, hypertrophic cardiomyopathy, dilated cardiomyopathy, myocarditis, arrhythmogenic cardiomyopathy, restrictive cardiomyopathy, ischemic cardiomyopathy, myocardiac injury acute, or myocardial injury. 2. A method of delaying onset, enhancing recovery from cellular membrane injury, or preventing a disorder comprising administering to a patient in need thereof a therapeutically effective amount of a composition comprising an agent that increases the activity of an annexin protein, wherein the disorder is stroke, dementia, Alzheimer Dementia, Frontotemporal Dementia, Parkinsons Disease, spinal cord injury, small vessel disease, transient ischemic attack, cerebrovascular accident, dementia due to small vessel disease, Guillain Barré, Acute Inflammatory Demyelinating, Polyradiculopathy, Peripheral nerve disease, neuropathy, diabetic neuropathy, acute myocardial infarction, hypertrophic cardiomyopathy, dilated cardiomyopathy, myocarditis, arrhythmogenic cardiomyopathy, restrictive cardiomyopathy, ischemic cardiomyopathy, myocardiac injury acute, or myocardial injury. 3. The method of claim 1 or claim 2, wherein the agent is a recombinant protein, a steroid, a polynucleotide capable of expressing an annexin protein, or a combination thereof. 4. The method of claim 3, wherein the steroid is a corticosteroid or a glucocorticoid. 5. The method of claim 3, wherein the recombinant protein is an annexin protein or a modified form thereof. 6. The method of claim 5, wherein the annexin protein is annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof) or a modified form thereof. 7. The method of any one of claims 1-6, further comprising administering an effective amount of a second agent, wherein the second agent is mitsugumin 53 (MG53), a modulator of latent TGF-β binding protein 4 (LTBP4), a modulator of transforming growth factor β (TGF-β) activity, a modulator of androgen response, a modulator of an inflammatory response, a promoter of muscle growth, a chemotherapeutic agent, a modulator of fibrosis, or a combination thereof. 8. The method of any one of claims 3-7, wherein the polynucleotide is associated with a nanoparticle. 9. The method of any one of claims 3-8, wherein the polynucleotide is contained in a vector. 10. The method of claim 9, wherein the vector is within a chloroplast. 11. The method of claim 9 wherein the vector is a viral vector. 12. The method of claim 11 wherein the viral vector is a herpes virus vector, an adeno-associated virus (AAV) vector, an adeno virus vector, or a lentiviral vector. 13. The method of claim 12 wherein the AAV vector is recombinant AAV5, AAV6, AAV8, AAV9, or AAV74. 14. The method of claim 13, wherein the AAV74 vector is AAVrh74. 15. The method of any one of claims 1-14, wherein the composition increases the activity of annexin A1 (SEQ ID NO: 1), annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3), annexin A3 (SEQ ID NO: 4), annexin A4 (SEQ ID NO: 5), annexin A5 (SEQ ID NO: 6), annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof), annexin A7 (SEQ ID NO: 9 or SEQ ID NO: 10), annexin A8 (SEQ ID NO: 11 or SEQ ID NO: 12), annexin A9 (SEQ ID NO: 13), annexin A10 (SEQ ID NO: 14), annexin A11 (SEQ ID NO: 15 or SEQ ID NO: 16), annexin A13 (SEQ ID NO: 17 or SEQ ID NO: 18), or a combination thereof. 16. The method of claim 15, wherein the composition increases the activity of annexin A1 (SEQ ID NO: 1), annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3), and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 17. The method of claim 15, wherein the composition increases the activity of annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3) and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 18. The method of claim 15, wherein the composition increases the activity of annexin A1 (SEQ ID NO: 1) and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 19. The method of claim 15, wherein the composition increases the activity of annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 20. The method of any one of claims 1-19, wherein the composition is the pharmaceutical composition of any one of claims 21-41. 21. A pharmaceutical composition comprising an annexin protein, or a modified form thereof, and a pharmaceutically acceptable carrier, buffer, and/or diluent. 22. The pharmaceutical composition of claim 21, wherein the annexin protein is annexin A1 (SEQ ID NO: 1), annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3), annexin A3 (SEQ ID NO: 4), annexin A4 (SEQ ID NO: 5), annexin A5 (SEQ ID NO: 6), annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof), annexin A7 (SEQ ID NO: 9 or SEQ ID NO: 10), annexin A8 (SEQ ID NO: 11 or SEQ ID NO: 12), annexin A9 (SEQ ID NO: 13), annexin A10 (SEQ ID NO: 14), annexin A11 (SEQ ID NO: 15 or SEQ ID NO: 16), annexin A13 (SEQ ID NO: 17 or SEQ ID NO: 18), or a combination thereof. 23. The pharmaceutical composition of claim 21 or claim 22, wherein the annexin protein is annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 24. The pharmaceutical composition of claim 21 or claim 22, wherein the pharmaceutical composition comprises annexin A1 (SEQ ID NO: 1), annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3), and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 25. The pharmaceutical composition of claim 21 or claim 22, wherein the pharmaceutical composition comprises annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3) and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 26. The pharmaceutical composition of claim 21 or claim 22, wherein the pharmaceutical composition comprises annexin A1 (SEQ ID NO: 1) and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 27. The pharmaceutical composition of any one of claims 21-26, further comprising a steroid. 28. The pharmaceutical composition of claim 27, wherein the steroid is a corticosteroid or a glucocorticoid. 29. The pharmaceutical composition of any one of claims 21-28, further comprising an effective amount of a second agent, wherein the second agent is mitsugumin 53 (MG53), a modulator of latent TGF-β binding protein 4 (LTBP4), a modulator of transforming growth factor β (TGF-β) activity, a modulator of androgen response, a modulator of an inflammatory response, a promoter of muscle growth, a chemotherapeutic agent, a modulator of fibrosis, or a combination thereof. 30. The pharmaceutical composition of any one of claims 21-29, wherein purity of the annexin protein in the composition is about 90% or higher as measured by standard release assay. 31. The pharmaceutical composition of any one of claims 21-30, wherein the composition has an endotoxin level that is less than about 0.50000 endotoxin units per milligram (EU/mg). 32. A pharmaceutical composition comprising annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof), or a modified form thereof, and a pharmaceutically acceptable carrier, buffer, and/or diluent. 33. The pharmaceutical composition of claim 32, further comprising annexin A1 (SEQ ID NO: 1), or a modified form thereof, and annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3), or a modified form thereof. 34. The pharmaceutical composition of claim 32, further comprising annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3), or a modified form thereof. 35. The pharmaceutical composition of claim 32, further comprising annexin A1 (SEQ ID NO: 1), or a modified form thereof. 36. The pharmaceutical composition of any one of claims 32-35, further comprising a steroid. 37. The pharmaceutical composition of claim 36, wherein the steroid is a corticosteroid or a glucocorticoid. 38. The pharmaceutical composition of any one of claims 32-37, further comprising an effective amount of a second agent, wherein the second agent is mitsugumin 53 (MG53), a modulator of latent TGF-β binding protein 4 (LTBP4), a modulator of transforming growth factor β (TGF-β) activity, a modulator of androgen response, a modulator of an inflammatory response, a promoter of muscle growth, a chemotherapeutic agent, a modulator of fibrosis, or a combination thereof. 39. The pharmaceutical composition of any one of claims 32-38, wherein purity of the annexin protein in the composition is about 90% or higher as measured by standard release assay. 40. The pharmaceutical composition of any one of claims 32-39, wherein the composition has an endotoxin level that is less than about 0.50000 endotoxin units per milligram (EU/mg). 41. The pharmaceutical composition of any one of claims 32-40, wherein the annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof), or a modified form thereof, is produced in a prokaryotic cell. 42. A method of treating a patient suffering from a nerve injury comprising administering to the patient a therapeutically effective amount of a composition comprising an agent that increases the activity of an annexin protein. 43. A method of delaying onset, enhancing recovery from a nerve injury, or preventing a nerve injury, comprising administering to a patient in need thereof a therapeutically effective amount of a composition comprising an agent that increases the activity of an annexin protein. 44. The method of claim 42 or claim 43, wherein the nerve injury is an acute nerve injury or a chronic nerve injury. 45. The method of any one of claims 42-44, wherein the nerve injury is a partially transected nerve, a wholly transected nerve, a nerve injury due to ischemia, a nerve injury due to infection, a nerve injury due to trauma, or a combination thereof. 46. The method of any one of claims 42-45, wherein the patient has a crush injury, a concussion, traumatic brain injury (TBI), or peripheral nerve disease. 47. A method comprising administering a therapeutically effective amount of a composition comprising an agent that increases the activity of an annexin protein to a patient, wherein the patient has an elevated serum or plasma level of lactate dehydrogenase (LDH), cardiac troponin T, cardiac troponin I, creatine kinase (CK), or a combination thereof, relative to a control level. 48. A method of reducing serum or plasma level of lactate dehydrogenase (LDH), cardiac troponin T, cardiac troponin I, creatine kinase (CK), or a combination thereof, in a patient in need thereof, comprising administering a therapeutically effective amount of a composition comprising an agent that increases the activity of an annexin protein to the patient, thereby reducing the serum or plasma level of lactate dehydrogenase (LDH), cardiac troponin T, cardiac troponin I, creatine kinase (CK), or a combination thereof in the patient. 49. The method of claim 47 or claim 48, wherein the serum or plasma level of LDH in the patient prior to administration of the agent is elevated about 1.25-fold or more over a normal control range. 50. The method of any one of claims 47-49, wherein the serum or plasma level of cardiac troponin T and/or cardiac troponin I in the patient prior to administration of the agent is elevated about 1.25-fold or more over a normal control range. 51. The method of any one of claims 47-50, wherein the serum or plasma level of CK in the patient prior to administration of the agent is elevated about 1.25-fold or more over a normal control range. 52. The method of any one of claims 47-51, wherein the serum or plasma level of LDH in the patient is reduced by about 25% or more 24-48 hours after administration of the agent. 53. The method of any one of claims 47-52, wherein the serum or plasma level of cardiac troponin T and/or cardiac troponin I in the patient is reduced by about 25% or more 24-48 hours after administration of the agent. 54. The method of any one of claims 47-53, wherein the serum or plasma level of CK in the patient is reduced by about 25% or more 24-48 hours after administration of the agent. 55. The method of any one of claims 42-54, wherein the agent is a recombinant protein, a steroid, a polynucleotide capable of expressing an annexin protein, or a combination thereof. 56. The method of claim 55, wherein the steroid is a corticosteroid or a glucocorticoid. 57. The method of claim 55, wherein the recombinant protein is an annexin protein. 58. The method of claim 57, wherein the annexin protein is annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof) or a modified form thereof. 59. The method of any one of claims 47-58, wherein the patient suffers from an acute injury. 60. The method of claim 59, wherein the acute injury results from surgery, a burn, a toxin, a chemical, radiation-induced injury, acute myocardial injury, acute muscle injury, acute lung injury, acute epithelial injury, acute epidermal injury, acute kidney injury, acute liver injury, vascular injury, an excessive mechanical force, trauma, acute brain injury from stroke or trauma, myositis, or acute cardiac injury. 61. The method of any one of claims 47-58, wherein the patient suffers from a chronic disorder. 62. The method of claim 61, wherein the chronic disorder is Becker Muscular Dystrophy (BMD), Duchenne Muscular Dystrophy (DMD), Limb Girdle Muscular Dystrophy, Friedreich’s Ataxia, congenital Muscular Dystrophy, Emery-Dreifuss Muscular Dystrophy (EDMD), Myotonic Dystrophy, Fascioscapulohumeral Dystrophy (FSHD), Oculopharyngeal Muscular Dystrophy, Distal Muscular Dystrophy, cystic fibrosis, pulmonary fibrosis, muscle atrophy, cerebral palsy, an epithelial disorder, an epidermal disorder, a kidney disorder, a liver disorder, sarcopenia, chronic cardiac injury ,or cardiomyopathy (hypertrophic, dilated, congenital, arrhythmogenic, restrictive, ischemic, heart failure). 63. The method of claim 62, wherein the cardiomyopathy is hypertrophic, dilated, congenital, arrhythmogenic, restrictive, ischemic, Friedreich Ataxia, or heart failure. 64. The method of any one of claims 42-63, further comprising administering an effective amount of a second agent, wherein the second agent is mitsugumin 53 (MG53), a modulator of latent TGF-β binding protein 4 (LTBP4), a modulator of transforming growth factor β (TGF-β) activity, a modulator of androgen response, a modulator of an inflammatory response, a promoter of muscle growth, a chemotherapeutic agent, a modulator of fibrosis, or a combination thereof. 65. The method of any one of claims 55-64, wherein the polynucleotide is associated with a nanoparticle. 66. The method of any one of claims 55-65, wherein the polynucleotide is contained in a vector. 67. The method of claim 66, wherein the vector is within a chloroplast. 68. The method of claim 66 wherein the vector is a viral vector. 69. The method of claim 68 wherein the viral vector is a herpes virus vector, an adeno-associated virus (AAV) vector, an adeno virus vector, or a lentiviral vector. 70. The method of claim 69 wherein the AAV vector is recombinant AAV5, AAV6, AAV8, AAV9, or AAV74. 71. The method of claim 70, wherein the AAV74 vector is AAVrh74. 72. The method of any one of claims 42-71, wherein the composition increases the activity of annexin A1 (SEQ ID NO: 1), annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3), annexin A3 (SEQ ID NO: 4), annexin A4 (SEQ ID NO: 5), annexin A5 (SEQ ID NO: 6), annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof), annexin A7 (SEQ ID NO: 9 or SEQ ID NO: 10), annexin A8 (SEQ ID NO: 11 or SEQ ID NO: 12), annexin A9 (SEQ ID NO: 13), annexin A10 (SEQ ID NO: 14), annexin A11 (SEQ ID NO: 15 or SEQ ID NO: 16), annexin A13 (SEQ ID NO: 17 or SEQ ID NO: 18), or a combination thereof. 73. The method of claim 72, wherein the composition increases the activity of annexin A1 (SEQ ID NO: 1), annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3), and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 74. The method of claim 72, wherein the composition increases the activity of annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3) and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 75. The method of claim 72, wherein the composition increases the activity of annexin A1 (SEQ ID NO: 1) and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 76. The method of claim 72, wherein the composition increases the activity of annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 77. The method of any one of claims 42-76, wherein the composition is the pharmaceutical composition of any one of claims 78-98. 78. A pharmaceutical composition comprising an annexin protein, or a modified form thereof, and a pharmaceutically acceptable carrier, buffer, and/or diluent. 79. The pharmaceutical composition of claim 78, wherein the annexin protein is annexin A1 (SEQ ID NO: 1), annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3), annexin A3 (SEQ ID NO: 4), annexin A4 (SEQ ID NO: 5), annexin A5 (SEQ ID NO: 6), annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof), annexin A7 (SEQ ID NO: 9 or SEQ ID NO: 10), annexin A8 (SEQ ID NO: 11 or SEQ ID NO: 12), annexin A9 (SEQ ID NO: 13), annexin A10 (SEQ ID NO: 14), annexin A11 (SEQ ID NO: 15 or SEQ ID NO: 16), annexin A13 (SEQ ID NO: 17 or SEQ ID NO: 18), or a combination thereof. 80. The pharmaceutical composition of claim 78 or claim 79, wherein the annexin protein is annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 81. The pharmaceutical composition of claim 78 or claim 79, wherein the pharmaceutical composition comprises annexin A1 (SEQ ID NO: 1), annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3), and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 82. The pharmaceutical composition of claim 78 or claim 79, wherein the pharmaceutical composition comprises annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3) and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 83. The pharmaceutical composition of claim 78 or claim 79, wherein the pharmaceutical composition comprises annexin A1 (SEQ ID NO: 1) and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 84. The pharmaceutical composition of any one of claims 78-83, further comprising a steroid. 85. The pharmaceutical composition of claim 84, wherein the steroid is a corticosteroid or a glucocorticoid. 86. The pharmaceutical composition of any one of claims 78-85, further comprising an effective amount of a second agent, wherein the second agent is mitsugumin 53 (MG53), a modulator of latent TGF-β binding protein 4 (LTBP4), a modulator of transforming growth factor β (TGF-β) activity, a modulator of androgen response, a modulator of an inflammatory response, a promoter of muscle growth, a chemotherapeutic agent, a modulator of fibrosis, or a combination thereof. 87. The pharmaceutical composition of any one of claims 78-86, wherein purity of the annexin protein in the composition is about 90% or higher as measured by standard release assay. 88. The pharmaceutical composition of any one of claims 78-87, wherein the composition has an endotoxin level that is less than about 0.50000 endotoxin units per milligram (EU/mg). 89. A pharmaceutical composition comprising annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof), or a modified form thereof, and a pharmaceutically acceptable carrier, buffer, and/or diluent. 90. The pharmaceutical composition of claim 89, further comprising annexin A1 (SEQ ID NO: 1), or a modified form thereof, and annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3), or a modified form thereof. 91. The pharmaceutical composition of claim 89, further comprising annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3), or a modified form thereof. 92. The pharmaceutical composition of claim 89, further comprising annexin A1 (SEQ ID NO: 1), or a modified form thereof. 93. The pharmaceutical composition of any one of claims 89-92, further comprising a steroid. 94. The pharmaceutical composition of claim 93, wherein the steroid is a corticosteroid or a glucocorticoid. 95. The pharmaceutical composition of any one of claims 89-94, further comprising an effective amount of a second agent, wherein the second agent is mitsugumin 53 (MG53), a modulator of latent TGF-β binding protein 4 (LTBP4), a modulator of transforming growth factor β (TGF-β) activity, a modulator of androgen response, a modulator of an inflammatory response, a promoter of muscle growth, a chemotherapeutic agent, a modulator of fibrosis, or a combination thereof. 96. The pharmaceutical composition of any one of claims 89-95, wherein purity of the annexin protein in the composition is about 90% or higher as measured by standard release assay. 97. The pharmaceutical composition of any one of claims 89-96, wherein the composition has an endotoxin level that is less than about 0.50000 endotoxin units per milligram (EU/mg). 98. The pharmaceutical composition of any one of claims 89-97, wherein the annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof), or a modified form thereof is produced in a prokaryotic cell. 99. A method of treating preclinical Alzheimer’s disease or mild-to- moderate congnitive impairment comprising administering a therapeutically effective amount of a composition comprising an agent that increases the activity of an annexin protein to a patient in need thereof. 100. The method of claim 99, wherein the patient has a plasma level of Aβ42 that is greater than zero and less than about 1000 picograms per milliliter (pg/ml). 101. The method of claim 99 or claim 100, wherein the patient has a cerebrospinal fluid (CSF) ratio of Aβ42/Aβ40 ratio that is less than about 0.07. 102. The method of any one of claims 99-101, wherein the patient has a serum or plasma level of phosphorylated tau protein that is about 24 picograms per milliliter (pg/ml) or greater. 103. The method of any one of claims 99-102, wherein the patient has an amount of phosphorylated tau protein in their cerebrospinal fluid (CSF) that is about 52 picograms per milliliter (pg/ml) or greater. 104. The method of any one of claims 99-103, wherein the patient has an amount of amyloid plaques in their brain that is about 10 to about 60 centiloids. 105. The method of any one of claims 99-104, wherein the patient was previously diagnosed with preclinical Alzheimer’s disease or mild-to-moderate cognitive impairment via cognitive testing. 106. The method of any one of claims 99-104, wherein the method includes diagnosing the patient with preclinical Alzheimer’s disease or mild-to-moderate cognitive impairment via cognitive testing. 107. The method of any one of claims 99-106, wherein the patient is amyloid positive, tau negative, and neurodegeneration negative. 108. The method of any one of claims 99-106, wherein the patient is amyloid positive, tau positive, and neurodegeneration negative. 109. The method of any one of claims 99-106, wherein the patient is amyloid positive, tau negative, and neurodegeneration positive. 110. The method of any one of claims 99-106, wherein the patient is amyloid positive, tau positive, and neurodegeneration positive. 111. A method comprising administering a therapeutically effective amount of a composition comprising an agent that increases the activity of an annexin protein to a patient having preclinical Alzheimer’s disease or mild-to-moderate cognitive impairment. 112. The method of claim 111, wherein the patient has: (i) a cerebrospinal fluid (CSF) ratio of Aβ42/Aβ40 ratio that is less than about 0.07; (ii) a plasma level of Aβ42 that is greater than zero and less than about 1000 pg/ml; (iii) a serum or plasma level of phosphorylated tau protein that is about 24 pg/ml or greater; (iv) an amount of phosphorylated tau protein in their cerebrospinal fluid (CSF) that is about 52 pg/ml or greater; and/or (v) an amount of amyloid plaques in their brain that is about 10 to about 60 centiloids. 113. The method of claim 111 or claim 112, wherein the patient was previously diagnosed with preclinical Alzheimer’s disease or mild-to-moderate cognitive impairment via cognitive testing. 114. The method of claim 111 or claim 112, wherein the method includes diagnosing the patient with preclinical Alzheimer’s disease or mild-to-moderate cognitive impairment via cognitive testing. 115. The method of any one of claims 99-114, wherein the phosphorylated tau protein is p-tau181, p-tau231, p-tau217, or a combination thereof. 116. The method of claim 115, wherein the phosphorylated tau protein is p- tau181. 117. The method of any one of claims 99-116, wherein the agent is a recombinant protein, a steroid, a polynucleotide capable of expressing an annexin protein, or a combination thereof. 118. The method of claim 117, wherein the steroid is a corticosteroid or a glucocorticoid. 119. The method of claim 117, wherein the recombinant protein is an annexin protein or a modified form thereof. 120. The method of claim 119, wherein the annexin protein is annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof) or a modified form thereof. 121. The method of any one of claims 99-120, further comprising administering an effective amount of a second agent, wherein the second agent is an acetylcholinesterase inhibitor, a mild to moderate NMDA-receptor antagonist, an anti- amyloid antibody, a beta-secretase enzyme inhibitor, an anti-tau antibody, a modulator of microglial activity, mitsugumin 53 (MG53), a modulator of latent TGF-β binding protein 4 (LTBP4), a modulator of transforming growth factor β (TGF-β) activity, a modulator of androgen response, a modulator of an inflammatory response, a chemotherapeutic agent, or a combination thereof. 122. The method of any one of claims 117-121, wherein the polynucleotide is associated with a nanoparticle. 123. The method of any one of claims 117-122, wherein the polynucleotide is contained in a vector. 124. The method of claim 123, wherein the vector is within a chloroplast. 125. The method of claim 123 wherein the vector is a viral vector. 126. The method of claim 125 wherein the viral vector is a herpes virus vector, an adeno-associated virus (AAV) vector, an adeno virus vector, or a lentiviral vector. 127. The method of claim 126 wherein the AAV vector is recombinant AAV1, AAV2, AAV4, AAV5, AAV7, AAV8, AAV9, AAVrh10, AAV PHP.B, or AAV PDP.eB. 128. The method of any one of claims 99-127, wherein the composition increases the activity of annexin A1 (SEQ ID NO: 1), annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3), annexin A3 (SEQ ID NO: 4), annexin A4 (SEQ ID NO: 5), annexin A5 (SEQ ID NO: 6), annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof), annexin A7 (SEQ ID NO: 9 or SEQ ID NO: 10), annexin A8 (SEQ ID NO: 11 or SEQ ID NO: 12), annexin A9 (SEQ ID NO: 13), annexin A10 (SEQ ID NO: 14), annexin A11 (SEQ ID NO: 15 or SEQ ID NO: 16), annexin A13 (SEQ ID NO: 17 or SEQ ID NO: 18), or a combination thereof. 129. The method of claim 128, wherein the composition increases the activity of annexin A1 (SEQ ID NO: 1), annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3), and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 130. The method of claim 128, wherein the composition increases the activity of annexin A2 (SEQ ID NO: 2 or SEQ ID NO: 3) and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 131. The method of claim 128, wherein the composition increases the activity of annexin A1 (SEQ ID NO: 1) and annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 132. The method of claim 128, wherein the composition increases the activity of annexin A6 (SEQ ID NO: 7, SEQ ID NO: 8, SEQ ID NO: 37, or a combination thereof). 133. The method of any one of claims 99-132, wherein the composition is the pharmaceutical composition of any one of claims 78-98. |
[0127] Refseq Accession Number NP_004025.1 annexin A7 isoform 2 [Homo sapiens] (SEQ ID NO: 10): [0128] Refseq Accession Number NP_001258631.1 annexin A8 isoform 1 [Homo sapiens] (SEQ ID NO: 11): [0129] Refseq Accession Number NP_001035173.1 annexin A8 isoform 2 [Homo sapiens] (SEQ ID NO: 12): [0130] Refseq Accession Number NP_003559.2 annexin A9 [Homo sapiens] (SEQ ID NO: 13): [0131] Refseq Accession Number NP_009124.2 annexin A10 [Homo sapiens] (SEQ ID NO: 14): [0132] Refseq Accession Number NP_665875.1 annexin A11 isoform 1 [Homo sapiens] (SEQ ID NO: 15): [0133] Refseq Accession Number NP_001265338.1 annexin A11 isoform 2 [Homo sapiens] (SEQ ID NO: 16): [0134] Refseq Accession Number NP_004297.2 annexin A13 isoform a [Homo sapiens] (SEQ ID NO: 17): [0135] Refseq Accession Number NP_001003954.1 annexin A13 isoform b [Homo sapiens] (SEQ ID NO: 18): [0136] Refseq Accession Number NP_001350043.1 annexin A6 isoform 3 [Homo sapiens] (SEQ ID NO: 37): [0137] The disclosure also contemplates corresponding polynucleotides that encode each of the foregoing annexin proteins. The following polynucleotides are contemplated for use according to the disclosure. Specifically, the following polynucleotides are messenger RNA (mRNA) sequences contemplated for use with a vector of the disclosure to increase activity of an annexin protein. As discussed above, when more than one sequence identifier is used to identify an mRNA sequence in relation to the same annexin species herein (e.g., mRNA sequences relating to annexin A2 are identified herein by SEQ ID NO: 20 and SEQ ID NO: 21) it will be understood that the different sequence identifiers serve to identify transcript variants that may be utilized with a vector of the disclosure to be translated into the particular annexin protein, and that the transcript variants may be used interchangeably or in combination in the methods and compositions of the disclosure. [0138] NM_000700.3 Homo sapiens annexin A1 (ANXA1), mRNA (SEQ ID NO: 19) [0140] NM_001002858.2 Homo sapiens annexin A2 (ANXA2), transcript variant 1, mRNA (SEQ ID NO: 20) [0142] NM_001136015.2 Homo sapiens annexin A2 (ANXA2), transcript variant 4, mRNA (SEQ ID NO: 21) [0144] NM_005139.3 Homo sapiens annexin A3 (ANXA3), mRNA (SEQ ID NO: 22) [0146] NM_001153.5 Homo sapiens annexin A4 (ANXA4), transcript variant 2, mRNA (SEQ ID NO: 23) [0148] NM_001154.4 Homo sapiens annexin A5 (ANXA5), mRNA (SEQ ID NO: 24) [0150] NM_001155.5 Homo sapiens annexin A6 (ANXA6), transcript variant 1, mRNA (SEQ ID NO: 25) [0152] NM_001193544.1 Homo sapiens annexin A6 (ANXA6), transcript variant 2, mRNA (SEQ ID NO: 26) [0154] NM_001156.5 Homo sapiens annexin A7 (ANXA7), transcript variant 1, mRNA (SEQ ID NO: 27) [0156] NM_004034.3 Homo sapiens annexin A7 (ANXA7), transcript variant 2, mRNA (SEQ ID NO: 28) [0158] NM_001271702.1 Homo sapiens annexin A8 (ANXA8), transcript variant 1, mRNA (SEQ ID NO: 29) [0160] NM_001040084.2 Homo sapiens annexin A8 (ANXA8), transcript variant 2, mRNA (SEQ ID NO: 30) [0162] NM_003568.3 Homo sapiens annexin A9 (ANXA9), mRNA (SEQ ID NO: 31) [0164] NM_007193.4 Homo sapiens annexin A10 (ANXA10), mRNA (SEQ ID NO: 32) [0166] NM_145868.2 Homo sapiens annexin A11 (ANXA11), transcript variant b, mRNA (SEQ ID NO: 33) [0168] NM_001278409.1 Homo sapiens annexin A11 (ANXA11), transcript variant f, mRNA (SEQ ID NO: 34) [0170] NM_004306.4 Homo sapiens annexin A13 (ANXA13), transcript variant 1, mRNA (SEQ ID NO: 35) [0172] NM_001003954.2 Homo sapiens annexin A13 (ANXA13), transcript variant 2, mRNA (SEQ ID NO: 36) [0174] NM_001363114.2 Homo sapiens annexin A6 (ANXA6), transcript variant 3, mRNA (SEQ ID NO: 38): THERAPEUTIC ENDPOINTS [0176] In various aspects of the disclosure, use of the agent(s) and optional additional agent(s) as described herein provide one or more benefits related to specific therapeutic endpoints relative to a patient not receiving the agent(s) and/or additional agent(s). [0177] Creatine kinase (CK) is a clinically validated serum biomarker of skeletal muscle, cardiac, kidney, and brain injury. Lactate dehydrogenase (LDH) is a clinically validated serum biomarker of skeletal muscle, cardiac, kidney, liver, lung, and brain injury. Creatine kinase and lactate dehydrogenase levels in serum are elevated with both acute and chronic tissue injury. In theoretical or verified conditions of comparable muscle mass levels, a reduction in creatine kinase and/or lactate dehydrogenase and/or cardiac troponin T and/or cardiac troponin I may be indicative of enhanced repair or protection against injury. Aspartate aminotransferase (AST) is yet another clinically validated serum biomarker of skeletal muscle, cardiac, kidney, liver, and brain injury. Additionally, increased serum troponin (e.g., cardiac troponin T and/or cardiac troponin I) is indicative of cardiac injury, while elevated alanine transaminase (ALT) is a biomarker of liver injury. Reduction in AST, ALT, or troponin in the acute period following injury may indicate enhanced repair or protection against injury. Evan’s blue due is a vital dye that binds serum albumin and is normally excluded from healthy, intact muscle. Membrane disruption due to acute or chronic injury promotes the influx of dye into the damaged cell. Evan’s blue dye is commonly used to quantify cellular damage in experimental settings, measuring inherent dye fluorescence and/or through measuring radiolabeled-dye uptake. Reduction in dye uptake after acute injury or in models of chronic damage would indicate protection against injury and/or enhanced repair. Indocyanine green (ICG) is a near-infared dye that binds plasma proteins and is used clinically to evaluate blood flow and tissue damage (ischemia; necrosis) in organs including heart, liver, kidney, skin, vasculature, lung, muscle and eye. Improved blood flow and reduction in ischemic areas indicate protection from injury and/ or improved repair. [0178] In some aspects, the disclosure provides methods of identifying patients who would benefit from administration of agent(s) and optional additional agent(s) of the disclosure. In any of the aspects or embodiments of the disclosure, such patients are identified by a serum or plasma level (e.g., an elevated level relative to a normal control range) of one or more biomarkers as described herein. Thus, in some embodiments such patients have not yet been diagnosed with a disease/disorder described herein. Accordingly, in some aspects, the disclosure provides methods comprising administering a therapeutically effective amount of an agent that increases the activity of an annexin protein to a patient, wherein the patient has an elevated serum or plasma level of lactate dehydrogenase (LDH), cardiac troponin T, cardiac troponin I, creatine kinase (CK), or a combination thereof, relative to a control level. In further aspects, the disclosure provides methods of reducing serum or plasma level of lactate dehydrogenase (LDH), cardiac troponin T, cardiac troponin I, creatine kinase (CK), or a combination thereof, in a patient in need thereof, comprising administering a therapeutically effective amount of an agent that increases the activity of an annexin protein to the patient, thereby reducing the serum or plasma level of lactate dehydrogenase (LDH), cardiac troponin T, cardiac troponin I, creatine kinase (CK), or a combination thereof in the patient relative to a previously measured serum or plasma level. [0179] Serum or plasma levels of biomarkers described herein (e.g., lactate dehydrogenase (LDH), cardiac troponin T, cardiac troponin I, creatine kinase (CK), or a combination thereof) are measured via tests known in the art and described herein. These tests include, but are not limited to, standard clinical assays for molecule quantitation in blood, serum or plasma samples, such as enzymatic dosing (colorimetry), enzyme-linked immunosorbent assay (ELISA), radioimmunoassay (RIA), blood monitoring devices (glucometer). A “normal control range” of a biomarker level refers to the range that is present in a healthy population and is expressed in units that are particular to the assay used to measure the level of the biomarker (e.g., lactate dehydrogenase (LDH), cardiac troponin T, cardiac troponin I, creatine kinase (CK), or a combination thereof). It will be appreciated that different assays for measuring a level of a biomarker may yield results in different units. Thus, a “normal control range” expressed in units obtained using a particular assay may be numerically different than a “normal control range” expressed in units obtained using a different assay, but regardless of the assay that is used, the range present in a healthy population is known in the art. Strictly by way of example, a normal range of the serum or plasma level of LDH is about 140-280 U/L, a normal range of cardiac troponin T and/or cardiac troponin I is 10ng/L for women, 15ng/L for men, and a normal range of CK is about 22-198 U/L (and can vary with age, sex, race). [0180] In some aspects, the disclosure provides methods of reducing serum or plasma level of lactate dehydrogenase (LDH), cardiac troponin T, cardiac troponin I, creatine kinase (CK), or a combination thereof, in a patient in need thereof, comprising administering a therapeutically effective amount of an agent that increases the activity of an annexin protein to the patient, thereby reducing the serum or plasma level of lactate dehydrogenase (LDH), cardiac troponin T, cardiac troponin I, creatine kinase (CK), or a combination thereof in the patient. In various embodiments, the serum or plasma level of LDH, cardiac troponin T, cardiac troponin I, CK, or a combination thereof in the patient prior to administration of the agent is elevated about 1.25-fold or more over a normal control range. In further embodiments, the serum or plasma level of LDH, cardiac troponin T, cardiac troponin I, CK, or a combination thereof in the patient prior to administration of the agent is elevated about, at least about, or less than about 1.25-fold, 1.5-fold, 2-fold, 2.5-fold, 3-fold, 4-fold, 5-fold, or more over a normal control range. [0181] In various aspects, administration of one or more agents that increases the activity of an annexin protein results in a reduction in the serum or plasma level of one or more biomarkers as described herein (e.g., lactate dehydrogenase (LDH), cardiac troponin T, cardiac troponin I, creatine kinase (CK), or a combination thereof) in the patient. The reduction is, for example, relative to a previous serum or plasma level of the biomarker(s) in the patient. In some embodiments, following administration of one or more agents that increase the activity of an annexin protein there is about a 25% reduction in the serum or plasma level of a biomarker of the disclosure (e.g., lactate dehydrogenase (LDH), cardiac troponin T, cardiac troponin I, creatine kinase (CK), or a combination thereof) relative to a previously measured level of the biomarker. In further embodiments, following administration of one or more agents that increase the activity of an annexin protein there is about, at least about, or less than about a 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 50%, 60%, or 70% reduction in the serum or plasma level of a biomarker of the disclosure relative to a previously measured level of the biomarker. In some embodiments, the serum or plasma level of a biomarker is measured about or at least about 24 hours after administration of the agent. In some embodiments, the serum or plasma level of a biomarker is measured about 24-48, 24-72, or 48-72 hours after administration of the agent. In further embodiments, the serum or plasma level of a biomarker is measured about, less than about, or at least about, 24, 30, 36, 48, 60, or 72 hours after administration of the agent. [0182] It is also contemplated that increasing membrane integrity and repair results in enhanced function measured through multiple modalities including plethysmography, echocardiography, muscle force, 6-min walk test. Additionally, histological benefits may be noted, including decreased necrosis, decreased inflammation, reduced fibrosis, reduced fatty infiltrate and reduced edema. These beneficial effects may also be visible through MR and PET imaging. DOSING/ADMINISTRATION/KITS [0183] A particular administration regimen for a particular subject will depend, in part, upon the agent and optional additional agent used, the amount of the agent and optional additional agent administered, the route of administration, the particular ailment being treated, and the cause and extent of any side effects. The amount of agent and optional additional agent administered to a subject (e.g., a mammal, such as a human) is sufficient to effect the desired response. Dosage typically depends upon a variety of factors, including the particular agent and/or additional agent employed, the age and body weight of the subject, as well as the existence and severity of any disease or disorder in the subject. The size of the dose also will be determined by the route, timing, and frequency of administration. Accordingly, the clinician may titer the dosage and modify the route of administration to obtain optimal therapeutic effect, and conventional range-finding techniques are known to those of ordinary skill in the art. Purely by way of illustration, in some embodiments, the method comprises administering an agent (e.g., a protein), e.g., from about 0.1 µg/kg up to about 100 mg/kg or more, depending on the factors mentioned above. In other embodiments, the dosage may range from 1 µg/kg up to about 75 mg/kg; or 5 µg/kg up to about 50 mg/kg; or 10 µg/kg up to about 20 mg/kg. In certain embodiments, the dose comprises about 0.5 mg/kg to about 20 mg/kg (e.g., about 1 mg/kg, 1.5 mg/kg, 2 mg/kg, 2.3 mg/kg, 2.5 mg/kg, 3 mg/kg, 3.5 mg/kg, 4 mg/kg, 4.5 mg/kg, 5 mg/kg, 5.5 mg/kg, 6 mg/kg, 6.5 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, or 10 mg/kg) of agent and optional additional agent. In embodiments in which an agent and additional agent are administered, the above dosages are contemplated to represent the amount of each agent administered, or in further embodiments the dosage represents the total dosage administered. In some embodiments wherein a chronic condition is treated, it is envisioned that a subject will receive the agent and/or additional agent over a treatment course lasting weeks, months, or years, and may require one or more doses daily or weekly. In some embodiments, a subject will receive the agnet and/or additional agent via continuous infusion. In any of the aspects or embodiments of the disclosure, the amount of an annexin protein in a pharmaceutical composition is from about 0.1 µg/kg up to about 100 mg/kg or more, depending on the factors mentioned above. In other embodiments, the dosage may range from 1 µg/kg up to about 75 mg/kg; or 5 µg/kg up to about 50 mg/kg; or 10 µg/kg up to about 20 mg/kg. In some embodiments, the dose comprises about 0.5 mg/kg to about 20 mg/kg (e.g., about 1 mg/kg, 1.5 mg/kg, 2 mg/kg, 2.3 mg/kg, 2.5 mg/kg, 3 mg/kg, 3.5 mg/kg, 4 mg/kg, 4.5 mg/kg, 5 mg/kg, 5.5 mg/kg, 6 mg/kg, 6.5 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, or 10 mg/kg) of annexin protein. Dosages are also contemplated for once daily, twice daily (BID) or three times daily (TID) dosing. A unit dose may be formulated in either capsule or tablet form. In other embodiments, the agent and optional additional agent is administered to treat an acute condition (e.g., acute muscle injury or acute myocardial injury) for a relatively short treatment period, e.g., one to 14 days. [0184] Suitable methods of administering a physiologically-acceptable composition, such as a pharmaceutical composition comprising an agent (e.g., a recombinant protein) and optional additional agent described herein, are well known in the art. Although more than one route can be used to administer an agent and/or additional agent, a particular route can provide a more immediate and more effective avenue than another route. Depending on the circumstances, a pharmaceutical composition is applied or instilled into body cavities, absorbed through the skin or mucous membranes, ingested, inhaled, and/or introduced into circulation. In some embodiments, a composition comprising an agent and/or additional agent is administered intravenously, intraarterially, or intraperitoneally to introduce an agent and optional additional agent into circulation. Non-intravenous administration also is appropriate, particularly with respect to low molecular weight therapeutics. In certain circumstances, it is desirable to deliver a pharmaceutical composition comprising the agent and/or additional agent orally, topically, sublingually, vaginally, rectally; through injection by intracerebral (intra-parenchymal), intracerebroventricular, intramuscular, intra-ocular, intraportal, intralesional, intramedullary, intrathecal, intraventricular, transdermal, subcutaneous, intranasal, urethral, or enteral means; by sustained release systems; or by implantation devices. If desired, the agent and/or additional agent is administered regionally via intraarterial or intravenous administration to a region of interest, e.g., via the femoral artery for delivery to the leg. In one embodiment, the composition is administered via implantation of a membrane, sponge, or another appropriate material within or upon which the desired agent and optional additional agent has been absorbed or encapsulated. Where an implantation device is used, the device in one aspect is implanted into any suitable tissue, and delivery of the desired agent and/or additional agent is, in various embodiments, effected via diffusion, time-release bolus, or continuous administration. In other embodiments, the agent and optional additional agent is administered directly to exposed tissue during surgical procedures or treatment of injury, or is administered via transfusion of blood products. Therapeutic delivery approaches are well known to the skilled artisan, some of which are further described, for example, in U.S. Patent No.5,399,363. [0185] In some embodiments facilitating administration, the agent and optional additional agent in one embodiment is formulated into a physiologically acceptable composition comprising a carrier (i.e., vehicle, adjuvant, buffer, or diluent). The particular carrier employed is limited only by chemico-physical considerations, such as solubility and lack of reactivity with the agent and/or additional agent, by the route of administration, and by the requirement of compatibility with the recipient organism. Physiologically acceptable carriers are well known in the art. Illustrative pharmaceutical forms suitable for injectable use include, without limitation, sterile aqueous solutions or dispersions and sterile powders for the extemporaneous preparation of sterile injectable solutions or dispersions (for example, see U.S. Patent No.5,466,468). Injectable formulations are further described in, e.g., Pharmaceutics and Pharmacy Practice, J. B. Lippincott Co., Philadelphia. Pa., Banker and Chalmers. eds., pages 238-250 (1982), and ASHP Handbook on Injectable Drugs, Toissel, 4th ed., pages 622-630 (1986), incorporated herein by reference). [0186] A pharmaceutical composition comprising an agent (e.g., a recombinant protein) and optional additional agent as provided herein is optionally placed within containers/kits, along with packaging material that provides instructions regarding the use of such pharmaceutical compositions. Generally, such instructions include a tangible expression describing the reagent concentration, as well as, in certain embodiments, relative amounts of excipient ingredients or diluents that may be necessary to reconstitute the pharmaceutical composition. [0187] The disclosure thus includes, in various embodiments, administering to a subject one or more agent(s), in combination with one or more additional agent(s), each being administered according to a regimen suitable for that medicament. In some embodiments, the agent is a recombinant protein such as an annexin protein (e.g., annexin A6). Administration strategies include concurrent administration (i.e., substantially simultaneous administration) and non-concurrent administration (i.e., administration at different times, in any order, whether overlapping or not) of the agent and one or more additional agents(s). It will be appreciated that different components are optionally administered in the same or in separate compositions, and by the same or different routes of administration. [0188] All publications, patents and patent applications cited in this specification are herein incorporated by reference as if each individual publication or patent application were specifically and individually indicated to be incorporated by reference. In addition, the entire document is intended to be related as a unified disclosure, and it should be understood that all combinations of features described herein are contemplated, even if the combination of features are not found together in the same sentence, or paragraph, or section of this document. For example, where protein therapy is described, embodiments involving polynucleotide therapy (using polynucleotides/vectors that encode the protein) are specifically contemplated, and the reverse also is true. With respect to elements described as one or more members of a set, it should be understood that all combinations within the set are contemplated. EXAMPLES EXAMPLE 1 [0189] This Example describes experiments designed to assess the impact physiologic mechanical stress on healthy control and patient-derived Duchenne-muscular dystrophy (DMD) induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) and to use this platform to test recombinant annexin A6 as a membrane resealing agent. [0190] Heart failure is a major source of mortality in Duchenne muscular dystrophy (DMD). DMD arises from mutations that ablate expression of the protein dystrophin, disrupting the dystrophin-associated protein complex and rendering the plasma membrane unusually fragile and prone to disruption. In DMD patients, cardiomyopathy develops from repeated mechanical stress leading to membrane damage and cardiomyocyte loss. Induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) offer the opportunity to study specific mutations in the context of a human cell, but these models can be improved by modulating conditions including the use of physiologic stressors. In this example, the primary defect underlying DMD was modeled by subjecting DMD iPSC-CMs to equibiaxial mechanical strain. DMD iPSC-CMs demonstrated an increased susceptibility to equibiaxial strain after 2 hours at 10% strain relative to control, measured by increased lactate dehydrogenase (LDH) release. After 24 hours, both DMD and healthy control iPSC-CMs showed evidence of injury with release of both LDH and cardiac troponin T. The iPSC-CMs were exposed to recombinant annexin A6, a protein resealing agent, and reduced LDH and troponin release was found in DMD and control iPSC-CMs that had been subjected to 24 hour strain at 10%. By developing an injury assay that specifically targets the mechanism of injury seen in DMD-related cardiomyopathy, the potential therapeutic efficacy of protein membrane resealer, recombinant annexin A6, for the treatment of DMD-related cardiomyopathy and general cardiac injury, was demonstrated. Introduction [0191] Duchenne muscular dystrophy (DMD) is an X-linked disease that results from mutations in DMD, which codes for the protein dystrophin (1). Clinically, DMD presents in the first decade with weakness and markedly elevated serum biomarkers like creatine kinase (2). Cardiac involvement is uniformly present by the second decade and contributes to morbidity and mortality in DMD (3). Dystrophin localizes to the plasma membrane and is concentrated in the membrane above the Z-disc, colocalizing with other proteins of the dystrophin complex, including the sarcoglycans and dystroglycans (4-6). This complex forms a critical transmembrane structural and signaling connection between the sarcomere and the extracellular matrix (4,7-10). Disruptions along this axis produce membrane fragility and account for multiple forms of muscular dystrophy with cardiac involvement (11-13). Daily glucocorticoid administration is the mainstay of current therapy, which delays a loss of mobility by 2-4 years (14). While early initiation of ACE inhibitors has been shown to delay the progression of cardiomyopathy (15-17), other aspects of cardiomyopathy prevention and treatment of heart failure rely on standard heart failure strategies (3,18). Novel therapeutics for the treatment of DMD are currently under investigation, including gene replacement therapy with micro-dystrophins, gene editing approaches, and membrane re-sealants (19- 22). Several antisense-mediated exon skipping agents are now approved for use in DMD, but these agents have relatively poor penetration into the myocardium and are useful for less than 25% of DMD mutations (23,24). For clinical agents that treat skeletal muscle in DMD, most studies have relied on endpoints like time to loss of mobility or measures of muscle strength or performance. Clinical trials for DMD cardiomyopathy are complicated by patients having reduced or no ambulatory capabilities (24). [0192] iPSC-derived cardiomyocytes (iPSC-CMs) are now commonly used to evaluate patient-specific therapies in a human cell context (25). However, iPSC-CMs are immature in nature and are generally cultured under conditions that fail to mimic the load and strain seen by the human heart (26,27). Engineered heart tissues promote greater cellular maturity compared to two-dimensional iPSC-CM cultures, and the most common methods rely on allowing cells to organize around microfabricated anchor points (28,29). Despite progress with engineered heart tissues, approaches to evaluate dynamic physiologic mechanical stress are still under development. The effects of mechanical stress have previously been studied to understand early signaling responses that lead to cardiac hypertrophy (30) and pathological signaling responses in nuclear membrane defects (31), and these prior studies utilized rat neonatal cardiomyocytes or mouse embryonic fibroblasts. The differential response of mechanical stress on DMD and healthy control iPSC-CMs and the response to a resealing protein, recombinant annexin A6, which was previously identified as a genetic modifier of muscular dystrophy and a potential therapeutic target (32,33), was investigated. Methods [0193] Briefly, DMD and healthy control iPSC-CMs were cultured and subjected to 5, 10, and 15% equibiaxial strain for 2 and 24 h time periods. Release of the clinically relevant biomarkers lactate dehydrogenase (LDH) and cardiac troponin T were measured, and the effects of recombinant annexin A6 on biomarker release were determined. [0194] iPSC generation, iPSC culture, cardiac differentiation, enrichment, and expansion. Urine-derived epithelial cells were obtained from a DMD patient and reprogrammed using published methods to generate the cell line DMD-G01 (34). The control line iPSC line (GM033488) has been previously published (35). iPSC culture and differentiation were performed per previously published methods (35,36). At day 8-10 post initiation of differentiation with CHIR99021, iPSC-CMs were harvested by collagenase digestion for 2 h per Breckwoldt et al (28) with the following modified digestion solution: 1 mg/mL collagenase II mg/mL (Worthington, LS0041762), 10 mM HEPES, 2 µM thiazovivin (Stemcell Technologies, 72254), and 30 µM N-benzyl-p-toluenesulfonamide (TCI, B3082- 5G) in Hank’s balanced salt solution (Gibco, 14175095). iPSC-CMs were separated from non-cardiomyocytes by magnetic labeling of non-iPSC-CMs, using a commercially available kit (Miltenyi Biotec, 130-110-188). Manufacturer instructions were followed, with the following modifications: (1) MACS buffer was defined as 0.5% KOSR (Gibco, 10828028), 2 mM EDTA in calcium and magnesium free DPBS (Gibco, 14190144) and (2) only the first negative selection step was performed, and the second positive selection step was omitted. Enriched iPSC-CMs were expanded in a protocol adapted from Buikema et al (37). iPSC- CMs were replated at 2 million cells per 10 cm plate in B27 (Gibco, 17-504-044) in RPMI 1640 (Gibco, 11875101), 2 µM thiazovivin, and 10% KOSR in RPMI 1640. 10 cm plates were coated with 1:400 Matrigel® (Corning, 354277) in DMEM/F12 (Corning, MT10090CV) for at least 1 h prior to replating. After 24 h media was exchanged with 2 µM CHIR99021 (Tocris 4423) in B27 in RPMI 1640 and exchanged every 48 hours. After 7-10 days of expansion, cells were confluent and harvested for downstream applications by collagenase digestion protocol as above. [0195] Preparation of flexible membranes and application of equibiaxial strain. Silanization of flexible membrane 6 well plates (Bioflex® culture plates, FlexCell International) was performed by adding 1 mL 5% (v/v) 3-aminopropyltriethoxysilane (Acros, AC430941000) in 95% ethanol for 10 min. The solution was aspirated, and 1 mL 100% ethanol was added and immediately aspirated. Plates were incubated at 65 C for 20 minutes, washed once with 1 mL 95% ethanol, twice with 2 mL DPBS, and once with DI water. Plates were then coated with 3 mL 1:400 Matrigel® as per iPSC-CM expansion protocol. Expanded iPSC-CMs were harvested by collagenase digestion as above and plated at a density of 1.5 million cells/well in B27 in RPMI 1640 with 10% FBS (Gibco, 26140079) and 1% penicillin/streptomycin (Gibco, 15070063). Media was exchanged with B27 in RPMI 1640 and 1% penicillin/streptomycin, every-other day. On day 7 post-replating, media was exchanged with fresh B27 in RPMI 1640 and cyclic sinusoidal equibiaxial strain at 1 Hz was applied using a FX-6000T™ Tension System (FlexCell International). [0196] iPSC cardiomyocyte troponin T staining and flow cytometry analysis. iPSC- CMs were collected before or after enrichment in initial experiments and at the time of replating onto flexible membranes for all differentiations. All centrifugation steps in this protocol were performed at 600 g for 5 min. 500,000-1,000,000 cells were resuspended in 2 mL DPBS in FACS tubes (Falcon, 352057), centrifuged and decanted. Cells were resuspended in 1 mL DPBS and 1 mL 8% paraformaldehyde (EMS, 15710) in DPBS was added. Cells were incubated in a 37 C shaker for 10 min and then centrifuged and decanted. Cells were resuspended in 200 µL of ice cold 90% methanol, 10% DPBS and stored at -20 C until staining for flow cytometry. Fresh incubation buffer was prepared: 0.5% w/v bovine serum albumin (Sigma Aldrich, A7906) in DPBS. 1:200 Alexa Fluor® 647 mouse anti-cardiac troponin T (BD Biosciences 565744) and 1:200 Alexa Fluor® 647 mouse IgG1 κ isotype control (BD Biosciences 557732) was prepared in incubation buffer. Cells were split evenly into two FACS tubes and 2 mL incubation buffer was added to each tube and centrifuged and decanted. Cells were incubated with 100 µL primary antibody or isotype control solution and incubated at room temperature in the dark for 1 h. 4 mL incubation buffer was then added to each tube, they were then centrifuged and decanted. Cells were then resuspended in 100 µL DPBS and analyzed with a BD Accuri C6 Plus flow cytometer. If iPSC-CM purity was <85%, cells were rejected for downstream applications. [0197] Recombinant annexin A6. iPSC-CMs were treated with recombinant annexin A6 (33) at a concentration of 10 µg/mL. In the case of binding studies, iPSC-CMs were strained at 10% for 23 h, followed by addition of recombinant annexin A6-488, which was strained for 1 additional h, incubated for an additional 2 hours, followed by 2x 2 mL wash with Hanks balanced salt solution (Gibco, 14175095), collagenase digestion as described above, harvested after 2 h by quenching with an equal volume of media, centrifuged for 10 m at 100 g, resuspended in 100 µL DPBS and analyzed by flow cytometry as described above. [0198] Biomarker measurement. LDH and cardiac troponin T release was quantified per manufacturer instructions using Promega LDH-Glo™ Cytotoxicity Assay (Promega J2380) and human cardiac troponin T ELISA kit (Abcam, ab223860). [0199] Statistical methods. Data was analyzed using Prism 9.3.0. Where comparisons of two conditions were made an unpaired t test was used. Where comparisons of more than two conditions were made an ordinary one-way ANOVA was used with Tukey correction for multiple comparisons. In all cases, p< 0.05 was defined as statistically significant. Statistical data is reported as mean ± SEM. Confidence intervals are reported as 95% (95% CI). Results [0200] Generation, differentiation and expansion of high-quality iPSC-CMs. IPSCs were generated from a DMD patient who with an out of frame, large deletion spanning DMD exons (46-47). The patient had a typical DMD course with loss of ambulation before the age of 11 and developed an associated severe cardiomyopathy with LVEF ~10% despite guideline directed therapy and biventricular chronic resynchronization therapy. To improve variability in iPSC-CM differentiation, a two-step iPSC-CM enrichment was employed (Figure 1A). iPSCs were initially differentiated into iPSC-CMs by conventional methods (35,36), followed by a second step in which iPSC-CMs were enriched using a magnetic separation system. Assessment, pre- and post-enrichment by magnetic separation confirmed improved cardiac troponin T positivity (Figure 1B and 1C). This enriched iPSC-CM cell population was then expanded by adapting a recently published method (37). Combining iPSC-CM enrichment with expansion generated sufficient numbers of high-quality iPSC-CMs for downstream applications. [0201] Increased susceptibility of dystrophic iPSC-CMs to mechanical strain. Dystrophin deficient cardiomyocytes from animal models have increased susceptibility to mechanical stress relative to controls (19,38). Similarly, serum biomarkers reflective of membrane leak are elevated in DMD patients (39,40). Therefore, it was initially sought to define a physiologic degree of mechanical stress to impart on iPSC-CMs that differentiated DMD iPSC-CMs from healthy control iPSC-CMs. iPSC-CMs were plated onto flexible membranes in a 6 well plate format and radial deformation was applied to impart a homogenous equibiaxial strain on plated cells in vitro (Figure 2A). Healthy control iPSC- CMs and DMD iPSC-CMs were subjected to 2 h of 0% (unflexed), 5%, 10% or 15% strain and the cell culture media was collected for biomarker determination (Figure 2B). Lactate dehydrogenase (LDH) is a clinically relevant serum biomarker of tissue injury, including cardiac injury (41). Control iPSC-CM media LDH levels after 5% and 10% strain remained similar to that of unflexed cells (Figure 2C). At 15% strain there was an increase LDH release, however there was also an increase in the variability of the data, likely from the severity of the injury. Media collected from DMD iPSC-CMs showed a dose-dependent increase in LDH levels following strain injury (Figure 2D), demonstrating that dystrophic iPSC-CMs are more susceptible to strain-induced injury compared to control iPSC-CMs. Similar to control iPSC-CMs, the variability of LDH release for DMD iPSC-CMs increased at 15% strain, likely related to the severe injury at this high level of strain. Based on initial considerations to define a physiologic degree of mechanical stress, it was observed that 10% strain did not result in significant LDH release in control iPSC-CMs, while it resulted in a significant increase LDH release in DMD iPSC-CMs. Thus, subsequent experiments were performed at 10% strain. [0202] Recombinant annexin A6 promotes membrane repair in control iPSC-CMs. Having defined a strain exposure that differentiated between DMD and healthy control iPSC- CMs, whether applying longer exposure to strain could induce injury in healthy control iPSC- CMs (Figure 3A) was tested. As shown in Figure 3B, LDH release fold change increased by 5.1 (95% CI: 2.9 to 7.2, ****p<0.0001) after 24 h of flexing compared to the non-injury- inducing 2 h time period. This demonstrated that 24 h of 10% strain surpassed the threshold required to induce mechanical membrane injury sufficient for LDH leak in control iPSC-CMs. Recombinant annexin A6 was previously shown to promote resealing in mouse skeletal myofibers injured with a laser (32,33), so the efficacy of recombinant annexin A6 to enhance repair in cardiomyocytes injury using this mechanical injury model was assessed. It was first assessed whether fluorescently labelled recombinant annexin A6 binds control iPSC-CMs that had been strained. As show in Figure 3C, relative mean fluorescent intensity increased by 3.7 (95% CI: 2.5 to 5.0, ****p<0.0001) in treated compared to untreated control iPSC- CMs as assessed by flow cytometry, consistent with recombinant annexin A6-iPSC-CM binding. Figure 3D depicts the experimental strategy for assessing membrane repair and response to recombinant annexin A6 in which membrane damage is followed by exposure to recombinant annexin A6 or vehicle, and then strain was continued for 1 h, followed by a 2 h recovery period. In the absence of annexin A6, strain resulted in an increase in LDH release fold change of 1.7 (95% CI: 0.4 to 3.0, **p = 0.01) compared to unflexed controls (Figure 3E). When annexin A6 is present during the post-injury recovery period, LDH levels were similar to LDH levels of unflexed cells (95% CI: -1.6 to 1.0, p = 0.79). To corroborate these findings, troponin release was also quantified (Figure 3F), and was found to be similarly increase with application of mechanical stress (95% CI: 3.5 to 6.7, ****p<0.0001) and reduce to near baseline levels with recombinant annexin A6 treatment (95% CI: -0.4 to 1.1, p = 0.19). Together these data demonstrated that recombinant annexin A6 promoted repair of injured control iPSC-CMs. [0203] Annexin A6 promotes dystrophic iPSC-CM membrane repair. Knowing that dystrophic cells are highly prone to membrane injury, it was determined whether recombinant annexin A6 could enhance repair of severely injured DMD iPSC-CMs. Fluorescently labelled recombinant annexin A6 binding to DMD iPSC-CMs after a 24 h strain protocol was first assessed. As shown in Figure 4A, relative mean fluorescent intensity increased by 3.4 (95% CI: 2.2 to 4.5, ****p<0.0001) in treated strained DMD iPSC-CMs, demonstrating recombinant annexin A6 binding. DMD iPSC-CMs were subjected to the same 24 h, 10% strain injury protocol that is capable of injuring control iPSC-CMs (Figure 4B). When recombinant annexin A6 was absent during the post-injury recovery period, LDH release fold change increased by 4.1 (95% CI: 1.2 to 7.0, **p = 0.005) compared to unflexed DMD iPSC-CMs. Figure 4C shows that with the addition of recombinant annexin A6 during the post-injury recovery period, LDH levels were similar to unflexed iPSC-CM media (95% CI: -2.8 to 2.9, p = 0.9989) and significantly less than in media from flexed cells lacking annexin A6 (95% CI: 1.2 to 6.9, **p = 0.005). Troponin release fold change mirrored LDH levels, increasing 3.9 (95% CI: 3.1 to 4.7, ****p<0.0001) post-injury in the absence of annexin A6 compared to unflexed controls (Figure 4D). Treatment with recombinant annexin A6, reduced fold change troponin levels by 3.5 (95% CI: 2.7 to 4.3, ****p<0.0001) with no significant difference compared to the unflexed condition (95% CI: -0.4 to 1.1, p = 0.52). Consistent with the effects seen on membrane repair in control iPSC-CMs, these results demonstrate efficacy of recombinant annexin A6 in promoting membrane in dystrophic iPSC- CMs. [0204] DMD iPSC-CMs demonstrated an increased susceptibility to mechanical stress relative to healthy (non-dystrophic) controls seen as increased LDH release. Healthy control cells required equibiaxial strain for a longer duration to sustain a significant increase in LDH and troponin release. DMD iPSC-CM and healthy controls each demonstrated a decrease in LDH and troponin release after recombinant annexin A6 treatment. Discussion [0205] In vivo, cardiomyocytes are under constant cyclic stress due to the cardiac cycle. Membrane damage and repair are part of normal physiology, however certain diseases are associated with excessive membrane damage (42,43). Previous work has demonstrated in both the in vitro and in vivo setting that physiologic stress of the rat myocardium with isoproterenol induces transient membrane damage (43). Consistent with the role of dystrophin in skeletal muscle, the mdx mouse, which harbors a premature stop codon in DMD and is the most commonly studied DMD animal model, has demonstrated an increased susceptibility to cardiomyocyte membrane injury by an increase in afterload or treatment with isoproterenol (38). Collectively, the literature supports membrane fragility as the primary deficit in DMD and consequent membrane damage as the initial insult with a host of downstream consequences (11-13,19,20), and this is reflected by elevated serum biomarkers from both skeletal and cardiac origin in DMD patients (39,40). [0206] Human iPSCs offer the advantage of harboring human specific mutations in an appropriate cellular environment (27,44). However, despite the ability to generate of iPSC- CMs, the conditions under which most cells are studied fail to simulate afterload and preload, and in the case of DMD cardiomyopathy, this is critical to creating micro-injury in the plasma membrane. Three dimensional engineered heart tissues can be used to improve the maturity of iPSC-CMs enabling measurements of contractility; however, at present, there is no readily available method for imparting dynamic mechanical stress (28). In a recent report, Sewanan et and colleagues simulated pressure volume loops in decellularized porcine myocardium engineered heart tissue seeded with iPSC-CMs (45). While precise time-dependent tailoring of the preload and afterload in an engineered heart tissue is a promising technique for studying the effects of cardiac therapeutics, at present, it requires a significant degree of technical engineering expertise and cannot easily be ported into a high- throughput method for studying drug effects. By employing flexible membranes capable of deformation by equibiaxial strain, iPSC-CMs were successfully stressed in a physiologically meaningful way for the study of DMD-associated cardiomyopathy with clinically relevant biomarker outputs. [0207] This Example demonstrated an ability to enhance membrane repair in injury that occurs in human DMD iPSC-CMs. Furthermore, recombinant annexin A6 also promoted resealing of healthy control iPSC-CMs, highlighting a conserved mechanism in both normal and diseased cells. [0208] The schematic in Figure 5 shows that recombinant annexin A6 enhances endogenous cardiomyocyte membrane repair processes. Given these findings, recombinant annexin A6 is useful in treating genetic forms of cardiomyopathy that lead to increased baseline membrane fragility, as well as pathologic injury such as myocardial infarction or acute pressure overload where activation of membrane repair processes are essential for recovery from an acute insult. [0209] In this Example, an in vitro assay using physiologic mechanical stress by application of equibiaxial strain to iPSC-CMs was described. Using this assay, a dose dependent increase in susceptibility of biomarker release in DMD iPSC-CMs relative to controls, as well as response to a protein resealing therapeutic, was demonstrated. Specifically, it was demonstrated that recombinant annexin A6 is a protein-based membrane resealer that enhanced membrane repair after mechanical stress in Duchenne cardiomyocytes and non-dystrophic, control cardiomyocytes. [0210] In summary, the data provided herein showed that recombinant annexin A6 promoted membrane resealing and reduced biomarker levels in DMD and healthy control iPSC-CMs, demonstrating its use as a treatment for DMD-related cardiomyopathy and general cardiac injury. References cited in Example 1 1. Koenig M, Hoffman EP, Bertelson CJ, Monaco AP, Feener C, Kunkel LM. Complete cloning of the Duchenne muscular dystrophy (DMD) cDNA and preliminary genomic organization of the DMD gene in normal and affected individuals. Cell 1987;50:509-17. 2. Bushby K, Finkel R, Birnkrant DJ et al. Diagnosis and management of Duchenne muscular dystrophy, part 1: diagnosis, and pharmacological and psychosocial management. Lancet Neurol 2010;9:77-93. 3. McNally EM, Kaltman JR, Benson DW et al. Contemporary cardiac issues in Duchenne muscular dystrophy. Working Group of the National Heart, Lung, and Blood Institute in collaboration with Parent Project Muscular Dystrophy. Circulation 2015;131:1590- 8. 4. Campbell KP, Kahl SD. Association of dystrophin and an integral membrane glycoprotein. Nature 1989;338:259-62. 5. Ervasti JM, Kahl SD, Campbell KP. Purification of dystrophin from skeletal muscle. J Biol Chem 1991;266:9161-5. 6. Ervasti JM, Campbell KP. Membrane organization of the dystrophin-glycoprotein complex. Cell 1991;66:1121-31. 7. Briggs DC, Yoshida-Moriguchi T, Zheng T et al. Structural basis of laminin binding to the LARGE glycans on dystroglycan. Nat Chem Biol 2016;12:810-4. 8. Ibraghimov-Beskrovnaya O, Ervasti JM, Leveille CJ, Slaughter CA, Sernett SW, Campbell KP. Primary structure of dystrophin-associated glycoproteins linking dystrophin to the extracellular matrix. Nature 1992;355:696-702. 9. Rybakova IN, Patel JR, Ervasti JM. The dystrophin complex forms a mechanically strong link between the sarcolemma and costameric actin. J Cell Biol 2000;150:1209-14. 10. Klietsch R, Ervasti JM, Arnold W, Campbell KP, Jorgensen AO. Dystrophin- glycoprotein complex and laminin colocalize to the sarcolemma and transverse tubules of cardiac muscle. Circ Res 1993;72:349-60. 11. Bloch RJ, Gonzalez-Serratos H. Lateral force transmission across costameres in skeletal muscle. Exerc Sport Sci Rev 2003;31:73-8. 12. Ervasti JM. Costameres: the Achilles' heel of Herculean muscle. J Biol Chem 2003;278:13591-4. 13. Townsend D, Yasuda S, McNally E, Metzger JM. Distinct pathophysiological mechanisms of cardiomyopathy in hearts lacking dystrophin or the sarcoglycan complex. FASEB J 2011;25:3106-14. 14. McDonald CM, Henricson EK, Abresch RT et al. Long-term effects of glucocorticoids on function, quality of life, and survival in patients with Duchenne muscular dystrophy: a prospective cohort study. Lancet 2018;391:451-461. 15. Duboc D, Meune C, Pierre B et al. Perindopril preventive treatment on mortality in Duchenne muscular dystrophy: 10 years' follow-up. Am Heart J 2007;154:596-602. 16. Duboc D, Meune C, Lerebours G, Devaux JY, Vaksmann G, Becane HM. Effect of perindopril on the onset and progression of left ventricular dysfunction in Duchenne muscular dystrophy. J Am Coll Cardiol 2005;45:855-7. 17. Silva MC, Magalhaes TA, Meira ZM et al. Myocardial Fibrosis Progression in Duchenne and Becker Muscular Dystrophy: A Randomized Clinical Trial. JAMA Cardiol 2017;2:190-199. 18. Yancy CW, Jessup M, Bozkurt B et al.2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation 2017;136:e137-e161. 19. Yasuda S, Townsend D, Michele DE, Favre EG, Day SM, Metzger JM. Dystrophic heart failure blocked by membrane sealant poloxamer. Nature 2005;436:1025-9. 20. Houang EM, Sham YY, Bates FS, Metzger JM. Muscle membrane integrity in Duchenne muscular dystrophy: recent advances in copolymer-based muscle membrane stabilizers. Skelet Muscle 2018;8:31. 21. Duan D. Systemic AAV Micro-dystrophin Gene Therapy for Duchenne Muscular Dystrophy. Mol Ther 2018;26:2337-2356. 22. Kyrychenko V, Kyrychenko S, Tiburcy M et al. Functional correction of dystrophin actin binding domain mutations by genome editing. JCI Insight 2017;2. 23. Sheikh O, Yokota T. Pharmacology and toxicology of eteplirsen and SRP-5051 for DMD exon 51 skipping: an update. Arch Toxicol 2022;96:1-9. 24. Johnston JR, McNally EM. Genetic correction strategies for Duchenne Muscular Dystrophy and their impact on the heart. Prog Pediatr Cardiol 2021;63. 25. Sayed N, Liu C, Wu JC. Translation of Human-Induced Pluripotent Stem Cells: From Clinical Trial in a Dish to Precision Medicine. J Am Coll Cardiol 2016;67:2161-2176. 26. Karakikes I, Ameen M, Termglinchan V, Wu JC. Human induced pluripotent stem cell-derived cardiomyocytes: insights into molecular, cellular, and functional phenotypes. Circ Res 2015;117:80-8. 27. Tu C, Chao BS, Wu JC. Strategies for Improving the Maturity of Human Induced Pluripotent Stem Cell-Derived Cardiomyocytes. Circ Res 2018;123:512-514. 28. Breckwoldt K, Letuffe-Breniere D, Mannhardt I et al. Differentiation of cardiomyocytes and generation of human engineered heart tissue. Nat Protoc 2017;12:1177-1197. 29. Stein JM, Mummery CL, Bellin M. Engineered models of the human heart: Directions and challenges. Stem Cell Reports 2021;16:2049-2057. 30. Yamamoto K, Dang QN, Maeda Y, Huang H, Kelly RA, Lee RT. Regulation of cardiomyocyte mechanotransduction by the cardiac cycle. Circulation 2001;103:1459-64. 31. Lammerding J, Schulze PC, Takahashi T et al. Lamin A/C deficiency causes defective nuclear mechanics and mechanotransduction. J Clin Invest 2004;113:370-8. 32. Swaggart KA, Demonbreun AR, Vo AH et al. Annexin A6 modifies muscular dystrophy by mediating sarcolemmal repair. Proc Natl Acad Sci U S A 2014;111:6004-9. 33. Demonbreun AR, Fallon KS, Oosterbaan CC et al. Recombinant annexin A6 promotes membrane repair and protects against muscle injury. J Clin Invest 2019;129:4657- 4670. 34. Kim EY, Barefield DY, Vo AH et al. Distinct pathological signatures in human cellular models of myotonic dystrophy subtypes. JCI Insight 2019;4. 35. Gacita AM, Fullenkamp DE, Ohiri J et al. Genetic Variation in Enhancers Modifies Cardiomyopathy Gene Expression and Progression. Circulation 2021;143:1302-1316. 36. Burridge PW, Holmstrom A, Wu JC. Chemically Defined Culture and Cardiomyocyte Differentiation of Human Pluripotent Stem Cells. Curr Protoc Hum Genet 2015;87:2131-21 315. 37. Buikema JW, Lee S, Goodyer WR et al. Wnt Activation and Reduced Cell-Cell Contact Synergistically Induce Massive Expansion of Functional Human iPSC-Derived Cardiomyocytes. Cell Stem Cell 2020;27:50-63 e5. 38. Danialou G, Comtois AS, Dudley R et al. Dystrophin-deficient cardiomyocytes are abnormally vulnerable to mechanical stress-induced contractile failure and injury. FASEB J 2001;15:1655-7. 39. Hathout Y, Brody E, Clemens PR et al. Large-scale serum protein biomarker discovery in Duchenne muscular dystrophy. Proc Natl Acad Sci U S A 2015;112:7153-8. 40. Spurney CF, Ascheim D, Charnas L et al. Current state of cardiac troponin testing in Duchenne muscular dystrophy cardiomyopathy: review and recommendations from the Parent Project Muscular Dystrophy expert panel. Open Heart 2021;8. 41. Jaffe AS, Landt Y, Parvin CA, Abendschein DR, Geltman EM, Ladenson JH. Comparative sensitivity of cardiac troponin I and lactate dehydrogenase isoenzymes for diagnosing acute myocardial infarction. Clin Chem 1996;42:1770-6. 42. McNeil PL, Steinhardt RA. Loss, restoration, and maintenance of plasma membrane integrity. J Cell Biol 1997;137:1-4. 43. Clarke MS, Khakee R, McNeil PL. Loss of cytoplasmic basic fibroblast growth factor from physiologically wounded myofibers of normal and dystrophic muscle. J Cell Sci 1993;106 ( Pt 1):121-33. 44. Blinova K, Schocken D, Patel D et al. Clinical Trial in a Dish: Personalized Stem Cell- Derived Cardiomyocyte Assay Compared With Clinical Trial Results for Two QT-Prolonging Drugs. Clin Transl Sci 2019;12:687-697. 45. Sewanan LR, Shen S, Campbell SG. Mavacamten preserves length-dependent contractility and improves diastolic function in human engineered heart tissue. Am J Physiol Heart Circ Physiol 2021;320:H1112-H1123. 46. Cai C, Masumiya H, Weisleder N et al. MG53 nucleates assembly of cell membrane repair machinery. Nat Cell Biol 2009;11:56-64. 47. Cao CM, Zhang Y, Weisleder N et al. MG53 constitutes a primary determinant of cardiac ischemic preconditioning. Circulation 2010;121:2565-74. 48. Weisleder N, Takizawa N, Lin P et al. Recombinant MG53 protein modulates therapeutic cell membrane repair in treatment of muscular dystrophy. Sci Transl Med 2012;4:139ra85. 49. Demonbreun AR, Quattrocelli M, Barefield DY, Allen MV, Swanson KE, McNally EM. An actin-dependent annexin complex mediates plasma membrane repair in muscle. J Cell Biol 2016;213:705-18. EXAMPLE 2 [0211] Membrane instability and disruption underlie a myriad of acute and chronic disorders. Anxa6 encodes the membrane-associated protein annexin A6 and was identified as a genetic modifier of muscle repair and muscular dystrophy. To evaluate annexin A6’s role in membrane repair in vivo, sequences encoding green fluorescent protein (GFP) were inserted into the last coding exon of Anxa6. Heterozygous Anxa6gfp mice expressed a normal pattern of annexin A6 with reduced Anxa6-GFP mRNA and protein. High-resolution imaging of wounded muscle fibers showed annexin A6GFP rapidly formed a repair cap at the site of injury. Injured cardiomyocytes and neurons also displayed repair caps after wounding, highlighting annexin A6-mediated repair as a feature in multiple cell types. By surface plasmon resonance, recombinant annexin A6 bound phosphatidylserine-containing lipids in a Ca 2+ and dose-dependent fashion with appreciable binding at approximately 50µM Ca 2+ and sub-nM (0.34) affinity. Exogenously added recombinant annexin A6 localized to repair caps and improved muscle membrane repair capacity in a dose-dependent fashion without disrupting endogenous annexin A6 localization, indicating annexin A6 promotes repair from both intracellular and extracellular compartments. Annexin A6 was expressed in cardiomyocytes and neurons and formed a repair cap at the site of damage. Recombinant annexin A6 similarly localized to the site of membrane injury in cardiomyocytes and neurons, enhancing repair capacity in control and diseased cells. Thus, annexin A6 orchestrates repair in multiple cell types, and recombinant annexin A6 is useful in additional chronic disorders beyond skeletal muscle myopathies, including disorders of the heart, brain, and nerve. [0212] In this Example, the in vivo role of annexin A6 in plasma membrane repair was evaluated by using CRISPR-Cas9 to engineer a green fluorescent protein (GFP) tag at the carboxyl-terminus of annexin A6 (A6). In this model, annexin A6 expression is driven from the Anxa6 gene locus and it is not overexpressed. When subjected to plasma membrane injury, genomically-encoded annexin A6GFP formed time-dependent repair caps in skeletal muscle, cardiomyocytes and neurons. Exogenously added recombinant annexin A6, labelled with an alternative fluorescent tag, targeted the endogenous repair cap at the site of membrane injury in muscle and neurons. Together, these data support a general model of cellular repair for which recombinant annexin A6 is a useful resealing agent. Methods [0213] Animals. Wildtype mice from the 129T2/SvEmsJ background were bred and housed in a specific pathogen free facility on a 12-hour light/dark cycle and fed ad libitum in accordance with the Northwestern University’s Institutional Animal Care and Use Committee regulations.129T2/SvEmsJ (129T2) mice were originally purchased from the Jackson Laboratory (Bar Harbor, ME; Stock # 002065). Two to three-month-old male and female mice were used for all experiments. mdxC57BL10 mice were obtained from Jackson Laboratory (Bar Harbor, ME; Stock # 001801). [0214] Generation of gene edited mice. The Anxa6-TurboGFP mouse line was generated by the Northwestern University Transgenic and Targeted Mutagenesis Facility. CRISPR/Cas9 technology was used to insert the TurboGFP coding sequence before the Anxa6 stop codon creating a fusion construct. Briefly, two guide RNA (gRNA) were identified using Broad Institute online software (https://portals.broadinstitute.org/gpp/public/analysis-tool s/sgrna-design). The gRNA sequences are: gRNA6, (SEQ ID NO: 39), and gRNA10, (SEQ ID NO: 40). Each gRNA was cloned into the PX459 V 2.0 Cas9 vector (Addgene #62988) as previously described (PMID 24157548). A repair vector was synthesized then cloned into the pUC57 backbone by GeneWiz (South Plainfield, NJ). This vector encodes TurboGFP flanked by 700 base pair (bp) homology arms. Three silent mutations were introduced in Anxa6 to destroy the gRNA6 recognition site. [0215] Both gRNA/Cas9 plasmids (0.5µg/each) and the repair template (2µg) were introduced into 129S6 embryonic stem (ES) cells via nucleofection (Nucleofector 2b, Lonza, Basel, Switzerland). After 24h, ES cells were subjected to puromycin selection for 48h. ES cell clones were isolated and genotyped for insertion of the repair template into the Anxa6 locus. Targeted clones were microinjected into blastocyst stage C57BL/6J (https://www.jax.org/strain/000664) embryos which were then surgically transferred into the reproductive tract of recipient females. Chimeric mice were genotyped for the Anxa6 TurboGFP allele. [0216] PCR and Genomic DNA analysis. Genomic DNA was isolated from mouse tail tissues. Gene-edited mice were genotyped based on the presence of either the wildtype annexin A6 and/or turbo GFP. PCR was performed using the following primer sequences: (1) Forward primer: (SEQ ID NO: 41), (2) Reverse primer for wild-type annexin A6: (SEQ ID NO: 42), (3) Reverse primer for tGFP: (SEQ ID NO: 43). Products were amplified by PCR using Phusion High-Fidelity DNA Polymerase (NEB) with the following cycle conditions: initial denaturation 98°C, 45 seconds followed by 98˚C, 10 seconds; 64˚C, 30 seconds; 72˚C 30 seconds for 35 cycles, and a final extension 72°C for 5 minutes. Products were run on 2% agarose gel with ethidium bromide. Additionally, Sanger sequencing was performed on the amplified product to verify in-frame GFP insertion.129/S6 (SvEvTac) ES cell genomic DNA was isolated and sequenced to confirm the absence of the annexin A6 truncated polymorphism. [0217] Plasmids. A plasmid encoding annexin A6 with a carboxyl-terminal turboGFP tag was obtained from Origene (Rockville, MD). Subcloning of annexin A6 to replace the GFP tag with tdTomato (Addgene) was performed by Mutagenix (Suwanee, GA). Constructs were sequenced to verify mutagenesis. Plasmid DNA was isolated using the Qiagen endo- free Maxi prep kit (Qiagen #12362). [0218] Sequence comparison and schematics. Snapgene and Lasergene were used to view and align chromatograms. [0219] Protein isolation. Muscles were dissected and flash frozen. Tissues were lysed in whole tissue lysis buffer (50mM HEPES pH 7.5, 150mM NaCl, 2mM EDTA, 10mM NaF, 10mM Na-pyrophosphate, 10% glycerol, 1% Triton X-100, 1 mM phenyl-methylsulfonyl fluoride (PMSF), 1X Roche cOmplete™ Protease Inhibitor Cocktail (Cat# 11697498001 CO- RO; Roche, Basel, Switzerland;) and homogenized using a bead beater tissue homogenizer (BioSpec). [0220] Immunoblotting. The protein concentration of the muscle or cell lysate was determined using the Quick Start™ Bradford Protein Assay (Cat #5000205 Bio-Rad Laboratories, Hercules, CA). Proteins were heated to 70 °C in 2x Laemmli buffer and were separated on 4–15% Mini-PROTEAN® TGX™ Precast Protein Gels, 15-well, 15 µl (Cat #4561086; Bio-Rad Laboratories, Hercules, CA) and transferred to Immun-Blot PVDF Membranes for Protein Blotting (Cat #1620177; Bio-Rad Laboratories, Hercules, CA). Blocking and antibody incubations were done using StartingBlock T20 (TBS) Blocking Buffer (Cat #37543; Thermo Fisher Scientific, Waltham, MA). Primary antibodies used were: annexin A6 (Cat #31026; Abcam) and turbo GFP (Evrogen, cat#AB513) used at 1:1000 diluted in starting block. Secondary antibodies conjugated to horseradish peroxidase were used at 1:5000 (Jackson ImmunoResearch Laboratories, West Grove, PA). SuperSignal™ West Pico Chemiluminescent Substrate and SuperSignal™ West Femto Maximum Sensitivity Substrate (Cat #34080 and #34096; Thermo Fisher Scientific, Waltham, MA) were applied to membranes and membranes were visualized using an Invitrogen™ iBright™ CL1000 Imaging System (Cat # A32749; Thermo Fisher Scientific, Waltham, MA). Pierce™ Reversible Protein Stain Kit for PVDF Membranes (Cat #24585; Thermo Fisher Scientific, Waltham, MA) was used to stain the entire blot to ensure complete transfer and equal loading. Immunoblot bands were quantified using FIJI gel analysis tools. [0221] Membrane Lipid Assay. Lipid strip assays were performed per manufacturer’s instructions (Echelon P-6003-2). Briefly, membrane was blocked with 5ml TBS-t + 3% BSA for 1hr at room temperature. Protein (1ug/ml rANXA6 in TBS-t + 3% BSA + 1mM calcium) was incubated on the membrane for 1hr at room temperature. Membranes were rinsed 3 x 5mins in TBS-t and then incubated with anti-HIS-HRP (MA1-21315-HRP, ThermoFischer) for 1hr at room temperature diluted 1:500 in TBS-t + 3% BSA. Membranes were rinsed 3 x 5mins in TBS-t and developed with 2mL K-TMBP (Echelon) for 2-20 minutes. [0222] Electroporation and myofiber isolation. Flexor digitorum brevis (FDB) fibers were transfected with endo-free plasmid DNA by in vivo electroporation. Methods were described previously in (Demonbreun AR, Fallon KS, Oosterbaan CC, Bogdanovic E, Warner JL, Sell JJ, et al. Recombinant annexin A6 promotes membrane repair and protects against muscle injury. The Journal of Clinical Investigation.2019;129(11):4657-70; Demonbreun AR, Quattrocelli M, Barefield DY, Allen MV, Swanson KE, and McNally EM. An actin-dependent annexin complex mediates plasma membrane repair in muscle. The Journal of cell biology.2016;213(6):705-18; Demonbreun AR, and McNally EM. DNA Electroporation, Isolation and Imaging of Myofibers. Journal of visualized experiments : JoVE.2015;106(106):e53551; DiFranco M, Quinonez M, Capote J, and Vergara J. DNA transfection of mammalian skeletal muscles using in vivo electroporation. Journal of visualized experiments : JoVE.2009;32(32)). Briefly, fibers were dissociated in 0.2% BSA plus collagenase type II (Cat # 17101, Thermo Fisher Scientific, Waltham, MA) for 90-120 minutes at 37 degrees in 10% CO 2 . Fibers were then moved to Ringers solution and placed on MatTek confocal microscopy dishes (Cat # P35G-1.5-14-C, MatTek, Ashland MA). [0223] Cardiomyocyte isolation. Mice were treated with 50 U heparin intraperitoneally 20 min before sacrifice. Mice were anesthetized under 5% vaporized isoflurane mixed with 100% oxygen. A thoracotomy was performed and the heart and lungs rapidly excised and submerged into ice-cold Tyrode solution without calcium (143-mM NaCl, 2.5-mM KCl, 16- mM MgCl 2 , 11-mM glucose, 25-mM NaHCO 3 , pH adjusted to 7.4). The ascending aorta was dissected out of the surrounding tissue and cannulated with an animal feeding needle (7900, Cadence Science, Staunton, Virginia) and secured with a 6-0 silk suture. The heart was initially perfused with 1 ml of ice-cold calcium-free Tyrode solution before being transferred to a Langendorff apparatus (Radnoti, Covina, California). Hearts were perfused with 37°C calcium-free Tyrode solution using a constant pressure (65-cm vertical distance between the buffer reservoir and cannula tip) for 1 to 2 min before perfusion for 5.5 min with digestion solution (0.15% collagenase type 2 [Worthington Biochemical, Lakewood, New Jersey], 0.1% 2,3-butanedione monoxime, 0.1% glucose, 100-U/ml penicillin/streptomycin, 112-mM NaCl, 4.7-mM KCl, 0.6-mM KH 2 PO 4 , 40-μM CaCl 2 , 0.6-mM Na 2 HPO 4 , 1.2-mM MgSO 4 , 30- μM phenol red, 21.4-mM NaHCO 3 , 10-mM HEPES, and 30-mM taurine; pH adjusted to 7.4). The heart was removed from the cannula, triturated with a transfer pipette, and filtered through a 100-μm cell strainer. Cardiomyocytes were allowed to pellet by gravity for 7 min, followed by aspiration of digestion media and washing with stop buffer (formulated identically to digestion solution except with no collagenase and with 1% bovine serum albumin). Cells were again allowed to gravity pellet followed by a wash in stop buffer without bovine serum albumin. Cardiomyocytes were tolerated to calcium by adding Tyrode buffer with 0.3-mM CaCl 2 dropwise. Cell culture dishes were coated with 20 μg/ml laminin (Cat #23017-015; Gibco, Thermo Fisher Scientific, Waltham, Massachusetts) for 1 h at room temperature. Laminin solution was aspirated followed by plating of cardiomyocytes for 1 h to allow cell adhesion before experimentation. [0224] Multiphoton laser injury and imaging. Isolated fibers were subjected to laser- induced damage at room temperature using the Nikon A1R-MP multiphoton microscope as described previously (Demonbreun AR, Fallon KS, Oosterbaan CC, Bogdanovic E, Warner JL, Sell JJ, et al. Recombinant annexin A6 promotes membrane repair and protects against muscle injury. The Journal of Clinical Investigation.2019;129(11):4657-70). Imaging was performed using a 25x1.1NA objective directed by the NIS-Elements AR imaging software. Green fluorescence protein (GFP) and FM 4-64 were excited using a 920nm wavelength laser and emission wavelengths of 575nm and 629nm were collected respectively. To induce laser damage on isolated myofibers, a diffraction limited spot (diameter approximately 410nm) was created on the lateral membrane of the myofiber using a 920nm wavelength laser at 10-15% laser power for 1s. Time lapse images were collected as follows: one image was collected prior to damage, one image upon damage, then every 8 s for 80s (10 images) followed by every 30s for 5 min (10 images). At the end of the time lapsed image series, z-stack images were collected at 250nm intervals through the damaged site on the myofiber directed by the NIS-Elements AR imaging software. Fluorescence intensity and cap area were measured using Fiji (NIH). To damage cardiomyocytes, the cells were isolated and plated on laminin coated MatTek confocal microscopy dishes as described above. The cells were incubated for 1 h at 37°C to allow cell attachment. Prior to laser damage, the cells were incubated in Tyrode buffer containing 0.5mM CaCl 2 and damaged as described. To damage neurons, the cells were grown in 35mm culture dishes in growth media. Prior to damage, the cells were washed twice in PBS and incubated in Ringer’s buffer containing 1mM CaCl 2 and damaged as described above. [0225] For recombinant protein studies, myofibers were isolated from mice as described above. Myofibers were incubated in specified concentrations of recombinant annexin A6 and 1mM Ca 2+ Ringers or BSA control. Cap size was assessed from acquired images in FIJI. FM 4-64 (Cat #T13320; ThermoFisher) (2.5µm) was added to the myofibers just prior to imaging. Images were acquired and quantitated as described above. FM 4-64 fluorescence at endpoint was measured using FIJI. Isolated myofibers were treated with 20µM wortmannin (Cat #12-338; Sigma). [0226] Neuron Isolation and Immunoblot. Mixed cortical and hippocampal neurons were isolated from day 15.5–16.5 A6-GFP or C57B6 mouse embryos via dissociation at 37 °C in 0.25 % trypsin. Neurons were plated in poly-l-lysine coated 12-well plates (750,000 cells per well) or Mat-Tek glass-bottomed 3cm dishes (450,000 cells per dish) containing neurobasal media supplemented with 2 % B-27, 500 μM glutamine, 10 % horse serum and 2.5 μM glutamate. After 2 hours, the media was replaced with neurobasal media with 2 % B- 27, 500 μM glutamine. All cell culture reagents were from Thermo Scientific. For immunoblotting, cells in 12 well plates were lysed in in RIPA buffer (150 mM NaCl, 1 % IGEPAL CA-630, 0.5 % sodium deoxycholate, 0.1 % SDS, 50 mM Tris pH 8, 1 mM PMSF) with Protease Inhibitor Cocktail III (Calbiochem) and Halt Phosphatase Inhibitor Cocktail (Thermo Scientific). Lysates were centrifuged at 10,000 rpm, 4 °C, 10 min and the supernatant protein was quantified by BCA (Thermo Scientific). 10ug protein were separated on Invitrogen NuPAGE Bolt 4-12% Bis-Tris gels and transferred overnight to PVDF (Millipore). Membranes were blocked in Pierce Superblock and then probed for 1 h at room temperature with either anti-Turbo GFP (Wako/FujiFilm Evrogen,1:1000) in 10% SuperBlock in TBS 0.1% Triton, or anti-GAPDH (Cell Signaling #14C10) in 5% milk in TBS- 0,1% Triton followed by horseradish peroxidase–conjugated anti-rabbit antibody (Vector Laboratories PI-1000, 1:5000). Blots were visualized using the Pierce reagents West Femto (Turbo-GFP) or SuperSignal West Pico (GAPDH) and signals were imaged using a FluorChemR imager (ProteinSimple) and then quantified with Alphaview software (ProteinSimple). Turbo-GFP signal was normalized to GAPDH, and Student's two-tailed t test was done using InStat software (GraphPad Software, Inc., San Diego, CA.) [0227] Brain Sectioning and Imaging. Two to four-month old heterozygous A6-GFP or wild type mice were euthanized and transcardially perfused with ice-cold PBS containing protease and phosphatase inhibitors. After perfusion, the brain was bisected and one hemibrain was drop fixed in 4% paraformaldehyde/PBS and cryopreserved in 30% w/v sucrose/PBS for sectioning. The other hemibrain was flash frozen in LN2 for biochemical analysis.30 μm coronal floating brain sections were cut and stained as follows. Sections were washed 3 times in Tris Buffered Saline, incubated in 16 mM glycine in Tris Buffered Saline with 0.25% Triton-X 100 (TBS-T), blocked first in 5% donkey serum in TBS-T, then with 1% BSA in TBS-T. Sections were incubated overnight at 4oC with anti-Turbo GFP (Wako/FujiFilm Evrogen,1:500) and mouse anti-NeuN (Millipore Sigma, MAB377, 1:1000) in 1% BSA TBS-T. The following day, they were incubated with 1:750 donkey anti-rabbit Alexa 488 and donkey anti-mouse 594 (ThermoFisher). All staining was performed at the same time. Sections were mounted with ProLong Gold Antifade (Cat # P36930, ThermoFisher) and images acquired on a Nikon A1R or W1 confocal microscope with a 20x or 40x objective, using NIS Elements software. All image acquisition settings were maintained the same between genotypes. [0228] Recombinant Protein Production. Recombinant annexin A6 protein and annexin A6-tdTomato protein was generated by Evotec using E. coli and Expi293 cells and standard methods (Princeton, New Jersey). Media was purified using IMAC chromatography. The final recovery of purified recombinant annexin A6 protein was diluted in TBS with an endotoxin level at approximately 1.5EU/mg, with a purity >80%. Recombinant annexin A6 was labelled with Alexa-488 using standard methods (Cat #A10235, ThermoFisher). [0229] In vitro injury and binding. A stock of 50ng/mL Listeriolysin-O (LLO) (Cat #ab83345; Abcam) in PBS without calcium and without magnesium (PBS-/-) prepared on ice. L6 rat myoblasts were trypsinized and resuspended in PBS-/- to achieve a concentration of 10,000 cells/uL.1,000,000 cells were added to each tube of the prepared LLO and incubated on ice for 5 minutes. After 5 minutes, cells were pelleted, rinsed twice and resuspended in PBS with 0.45nm Ca 2+ with varying concentrations of Annexin A6-488 ( 0 to 100 µg/ml). Cells were incubated at 25°C for 5 minutes. Two µL of Sytox Red dye (Cat #S34859; ThermoFisher) was added to each tube of cells and incubated at 25°C for an additional 10 minutes. Cells were rinsed and then resuspended in 300uL of PBS-/-. Flow cytometry was performed on the BD-Accuri C6 Flow Cytometer. A cell count of 30,000 was achieved for each tube. Analysis was performed using FlowJo software (Becton, Dickinson & Company). [0230] Liposome preparation. The preparation of uniform approximately 100 nm diameter liposomes was carried out as described previously (Hamman et al., 2002). PS, Phosphatidylserine, SM, sphingomyelin, CH, cholesterol, PE, phosphatidylethanolamine, and PC, phosphatidylcholine were commercially purchased (Sigma-Aldrich). PS was re- suspended in chloroform:methanol solution to make a 10.7 mg/mL (27.77 mM) stock solution; PC in chloroform to make a 25 mg/mL stock (31.80 mM); PE in chloroform to make a 25 mg/mL stock (33.60 mM), CH in chloroform to make a 100 mg/mL stock (258.63 mM), and SM in methanol to make a 25 mg/mL stock (34.20 mM). Liposomes were prepared with PS (+ PS) and without PS (-PS). The composition ratios for liposome preparations are +PS (3.0 PC: 1.5 PE: 3.0 CH: 1.5 SM: 1.0 PS) and –PS (3.0 PC: 1.5 PE: 3.0 CH: 1.5 SM). All lipids were at room temperature before preparing the +PS and –PS mixture. Each lipid mixture was dried for 15 - 20 minutes under a steady and gentle stream of nitrogen. Each dried lipid mixture was re-suspended in 1 mL of buffer (50 mM HEPES pH 7.3, 50 mM NaCl) to make a 10 mM of +PS and approximately 9 mM stock of –PS in glass vials. The glass vials were sealed with parafilm and sonicated for approximately 10 minutes. The liposome preparation was carried out using an Avanti mini extruder (https://avantilipids.com/divisions/equipment-products/mini- extruder-extrusion-technique). The lipid mixture was cycled through the extruder for 20 -25 cycles. The liposome mixture was transferred to glass scintillation vials and stored at 2-8°C until use. [0231] Surface Plasmon Resonance (SPR) Binding Studies. All SPR studies were performed on a Biacore 8K+ instrument (Cytiva) at 25ºC. A series S L1 chip (lipophilic groups are covalently attached to carboxymethylated dextran, making the surface suitable for direct attachment of lipid membrane vesicles) was used for the AnxA6 / lipid interaction studies. Briefly, the L1 sensor chip (Cytiva) was equilibrated in running buffer (10 mM HEPES, pH 7.4, 150 mM NaCl), and conditioned with two 30 s injections of 40 mM octyl glucoside at 10 ul/min before liposome immobilization (Hodnik et al., 2010).0.5 mM +PS and -PS liposomes (flow rate 2 µl/min) were captured onto the active and reference flow cell surfaces to approximately 10000 RU respectively to form the lipid bilayer. This was followed by two 60 s injections of 10 mM NaOH at 10 µl/min to remove any unbound liposomes on the L1 chip. Initially, the Ca 2+ dependence of AnxA6 binding to +PS and –PS lipid was tested. The CaCl 2 concentration in the running buffer was varied between 0 – 2.5 mM (0, 26, 52, 104, 208, 417, 833, or 2500 µM) and the binding signal RU and kinetics of the AnxA6 / lipid interactions were analyzed. This was followed by dose response kinetics studies on the AnxA6 / +PS lipid interactions at 100 µM CaCl 2 . Since –PS showed very minimal binding at 100 µM CaCl 2 , it was used as a negative control lipid, and captured on the reference flow cell surface. +PS was captured on the active flow cell surface. Parallel dose response kinetics was run with 8 concentrations (0.78 nM – 100 nM) at 2-fold dilutions on 8 different channels of the sensor chip. AnxA6 was injected at 50 µl/min with association time of 240 s and dissociation time of 600 s. All data we analyzed using the Biacore Insight Evaluation software (ver.3.0.12; Cytiva). Raw sensograms were reference subtracted, blank-buffer subtracted before kinetic and affinity analysis to account for nonspecific binding and injection artifacts. Association (k a M -1 s -1 ) and dissociation (k d s -1 ) rate constants, and binding affinity (K D ) values were determined using a 1:1 kinetics binding model. The closeness of fit between the experimental data and fitted curves was assessed using χ2 (average squared residual). [0232] Statistical analysis. Statistical analyses were performed with Prism (GraphPad, La Jolla, CA). Comparisons relied on ANOVA (1way ANOVA for 1 variable). Otherwise, unpaired two-tailed t-tests were performed. P value less than or equal to 0.05 was considered significant. Data were presented as single values were appropriate. Error bars represent +/- standard error of the mean (SEM). Results [0233] Generation of Anxa6gfp mice using gene editing. CRISPr/Cas9 was used to replace the stop codon in the last exon of the Anxa6 locus with sequences encoding GFP (Figure 6A, 6B, and 6C). A dual guide strategy was used to insert the GFP-encoding sequences into embryonic stem cells, which were subsequently injected into blastocysts to create founder mice (Figure 6A, 6B, and 6C). This strategy mirrors the carboxy-terminal GFP tags used in annexin A6 plasmid-mediated overexpression studies. Both heterozygous and homozygous Anxa6gfp mice were characterized. Quantitative PCR analysis documented a reduction in Anxa6 transcript in heterozygous mice compared to WT and further reduction in homozygous mice (Figure 7A). Antibodies specific to annexin A6 and to GFP were used to evaluate protein expression in quadriceps muscles (Figure 7B). A reduction in the expected amount of A6GFP protein compared to endogenous annexin A6 was observed, such that heterozygous Anxa6gfp mice expressed 3-8% of the total annexin A6 protein levels expressed in quadriceps (Figure 7B). To confirm that A6GFP, which was expressed at lower than wildtype annexin A6 levels, localized to the site of membrane injury, flexor digitorum brevis myofibers were isolated from Anxa6gfp mice and imaged. Within seconds of laser-mediated injury, genomically-encoded A6GFP localized to the membrane lesion organizing into a repair cap (Figure 7C). High magnification imaging revealed the presence of A6GFP containing membranous blebs emanating from the repair cap (Figure 7D). These data combined showed that Anxa6gfp mice express genomically-encoded A6GFP protein in the expected pattern in muscle but with reduced A6GFP expression compared to endogenous annexin A6. [0234] Normal muscle in Anxa6gfp mice with normal muscle repair. Prior studies have shown minimal phenotype in Anxa6-null mice with no discernable impact on any of the major organs including skeletal muscle, heart, and brain (Hawkins TE, Roes J, Rees D, Monkhouse J, and Moss SE. Immunological development and cardiovascular function are normal in annexin VI null mutant mice. Mol Cell Biol.1999;19(12):8028-32). Similarly, annexin A6GFP protein expression in heterozygous and homozygous mice resulted in no overt muscle, heart, or brain defects in the background of otherwise healthy mice. Specifically, no immune infiltrate, fibrosis, or internal nuclei was detected, and histologically, normal muscle was indistinguishable from annexin A6GFP-expressing muscle (Figure 8A). Myofibers were incubated in FM 4-64, a fluorescent indicator dye that increases fluorescence intensity upon binding to exposed phosphatidylserine and used as a marker of membrane injury. Homozygous Anxa6gfp myofibers had similar levels of FM dye uptake compared to wildtype myofibers, confirming intact muscle repair capacity (Figure 8B). Thus, the GFP tag on A6 did not alter the properties of A6 in muscle, consistent with prior studies in which A6GFP was expressed from a plasmid. [0235] Genomically-encoded annexin A6GFP forms a repair cap with annexins A1 and A2 at the site of muscle membrane injury. Electroporation of annexin-encoding plasmids was previously used to demonstrate annexin A6 forming a repair cap with annexins A1 and A2, and these studies relied on annexin overexpression. To determine if genomically-encoded A6GFP expressed at lower than wildtype levels could still nucleate the annexin repair complex at the site of injury, Anxa6gfp myofibers were electroporated with annexin A6-tdTomato, A2-tdTomato or annexin A1-tdTomato plasmid and subjected to laser- induced injury. Genomically-encoded annexin A6GFP localized to the site of injury colocalizing with A6-tdTomato, A2-tdTomato and A1-tdTomato (Figure 9). These data demonstrated that annexin A6GFP facilitated membrane repair across a broad range of concentrations including levels of expression lower than endogenous annexin A6. [0236] Annexin A6GFP is expressed in the heart and forms repair caps in injured cardiomyocytes. The degree to which annexin A6-containing membrane repair complexes are found outside of myofiber repair is not known. Similar to skeletal muscle, a reduction in cardiac Anxa6 transcript level in heterozygous and homozygous mice was documented utilizing quantitative PCR analysis (Figure 10A). Immunoblot analysis with anti-annexin A6 antibody confirmed a reduction in ANXA6 protein in Anxa6gfp heterozygous and homozygous cardiac lysates, while anti-GFP antibody detected increasing amounts of annexin A6-GFP protein in Anxa6gfp heterozygous and homozygous cardiac lysates (Figure 10B). Since skeletal myofibers and cardiomyocytes share many structural and functional features, we isolated and injured cardiomyocytes from Anxa6gfp mice to evaluate cardiomyocyte membrane repair (Figure 10C). Anxa6gfp ventricular cardiomyocytes were isolated, and the laser injury protocol was modified for use on cardiomyocytes. Compared to skeletal myofibers, cardiomyocytes were exquisitely sensitive to laser injury. Accordingly, the laser power was reduced by approximately 50% and external calcium levels were reduced 50% (500µM) to accommodate this increased sensitivity to injury. In uninjured cardiomyocytes, A6GFP localized in a sarcomeric pattern in live cells, in a pattern consistent with the known localization of cardiac annexin A6 (Figure 10C) (Mishra S, Chander V, Banerjee P, Oh JG, Lifirsu E, Park WJ, et al. Interaction of annexin A6 with alpha actinin in cardiomyocytes. BMC Cell Biol.2011;12:7). Within 10 seconds of laser-wounding, annexin A6GFP localized to the membrane lesion organizing into a repair cap in the cardiomyocyte (Figure 10C). A magnified image of the white dotted box depicting a bright annexin A6GFP repair cap is shown in the image on the right (Figure 10C). Timelapse images illustrating the progression of annexin A6GFP localization into the repair cap (arrow) in an isolated cardiomyocyte is shown through 50 seconds post injury (Figure 10D). Thus, genomically- encoded annexin A6GFP localized to the site of membrane injury forming a repair cap at the membrane lesion in live, adult ventricular cardiomyocytes, consistent with a conserved role for annexin A6 in mediating membrane repair between cardiomyocytes and skeletal myofibers. [0237] Annexin A6 localized to neuronal membrane lesions. Using the Anxa6gfp mouse model, whether endogenous annexin A6 translocation was a component of primary neuronal cell injury repair was evaluated. Brain imaging of Anxa6gfp mice using anti-GFP antibodies detected A6GFP protein, largely restricted to the plasma membrane, and this was well seen in cortical neurons, marked by NeuN positivity (Figure 11A and 11B). Neurons were isolated at embryonic day 15-16 and cultured under maturation conditions. As neuron maturation progressed from day 4 to day 10 in culture, annexin A6GFP levels significantly increased (Figure 11C). Day 7 neurons were subjected to laser-induced membrane injury. Genomically-encoded annexin A6GFP localized to the site of neuron injury forming a repair cap visible within 1-2 seconds of injury, which persisted through the 60 seconds of imaging (Figure 11D). Together with observations in skeletal myofibers and cardiomyocytes, these findings demonstrated a role for annexin A6 in cellular repair, underscoring the broad nature of this repair mechanism. [0238] Recombinant annexin A6 binds phosphatidylserine in a calcium-dependent manner. Annexins are known calcium-dependent phospholipid binding proteins. Phosphatidylserine (PS) and phosphatidylethalomine (PE) are membrane lipids that normally are found in the inner plasma membrane leaflet and upon membrane injury flip to the outer leaflet. To evaluate phospholipid binding preference in vitro, recombinant annexin A6 was incubated on lipid arrays containing the common membrane lipids diacylglycerol (DAG), phosphatidic acid (PA), phosphatidylserine (PS), phosphatidylinositol (PI), phosphatidylethanolamine (PE), phosphatidylcholine (PC), phosphatidylglycerol (PG) and sphingomyelin (SM). Recombinant annexin A6 preferentially bound PS and PI (Figure 12A). To further evaluate the Ca 2+ dependency and kinetics of recombinant annexin A6 binding to PS, surface plasmon resonance (SPR) was performed +PS or -PS over a range of Ca 2+ concentrations (0, 26, 52, 104, 208, 417, 833, and 2500 µM). Recombinant annexin A6 binding to PS increased with increasing concentrations of Ca 2+ , with appreciable binding at 50µM and higher (Figure 12B, left). Minimal recombinant annexin A6 binding occurred in the absence of PS with virtually no binding present below 200 µM Ca 2+ (Figure 12B, right). Given that minimal to no binding occurred at 100µM Ca 2+ without PS, this was used as a negative control on the reference flow cell surface and for the interaction kinetics of annexin A6 with PS. Dose response kinetics had a very low dissociation rate (2.31 x 10-4) for the interaction and sub-nM binding affinity (0.34 nM) (Figure 12C). It was concluded that PS is a substrate for annexin A6’s membrane binding interactions during cell membrane repair. [0239] Annexin A6 sensed phosphoinositides during cap formation. Biological membranes are composed of lipid microdomains that regulate cell signaling events and membrane trafficking (Simons K, and Toomre D. Lipid rafts and signal transduction. Nature reviews Molecular cell biology.2000;1(1):31-9; Parton RG, and del Pozo MA. Caveolae as plasma membrane sensors, protectors and organizers. Nature reviews Molecular cell biology.2013;14(2):98-112). Annexins bind phospholipids, including PS and phosphatidylinositol 4,5-bisphosphate (PIP2), in response to changes in Ca 2+ levels (Illien F, Piao H-R, Coué M, Di Marco C, and Ayala-Sanmartin J. Lipid organization regulates annexin A2 Ca 2+-sensitivity for membrane bridging and its modulator effects on membrane fluidity. Biochimica et Biophysica Acta (BBA)-Biomembranes.2012;1818(11):2892-900). Additionally, PS and PIP2 have been implicated in cell fusion and membrane repair located at the site of damage (Demonbreun AR, Quattrocelli M, Barefield DY, Allen MV, Swanson KE, and McNally EM. An actin-dependent annexin complex mediates plasma membrane repair in muscle. The Journal of cell biology.2016;213(6):705-18; Vaughan EM, You JS, Elsie Yu HY, Lasek A, Vitale N, Hornberger TA, et al. Lipid domain-dependent regulation of single-cell wound repair. Mol Biol Cell.2014;25(12):1867-76; Leikina E, Melikov K, Sanyal S, Verma SK, Eun B, Gebert C, et al. Extracellular annexins and dynamin are important for sequential steps in myoblast fusion. J Cell Biol.2013;200(1):109-23). To determine the contribution of phosphoinositides during membrane repair, myofibers were incubated in wortmannin, a known inhibitor of phosphatidylinositol 3-kinase (PI3-K). When used at higher concentrations (20 μM), wortmannin also inhibits phosphatidylinositol 4-kinase (PI4-K) leading to PIP and PIP2 depletion (Downing GJ, Kim S, Nakanishi S, Catt KJ, and Balla T. Characterization of a soluble adrenal phosphatidylinositol 4-kinase reveals wortmannin sensitivity of type III phosphatidylinositol kinases. Biochemistry.1996;35(11):3587-94; Nilius B, Mahieu F, Prenen J, Janssens A, Owsianik G, Vennekens R, et al. The Ca2+-activated cation channel TRPM4 is regulated by phosphatidylinositol 4,5-biphosphate. EMBO J. 2006;25(3):467-78; Nakanishi S, Catt KJ, and Balla T. A wortmannin-sensitive phosphatidylinositol 4-kinase that regulates hormone-sensitive pools of inositolphospholipids. Proceedings of the National Academy of Sciences of the United States of America.1995;92(12):5317-21). Depletion of PIP2 after wortmannin treatment was confirmed through electroporation of the PIP2 fluorescent biosensor, PLC-PH-EGFP, in wildtype myofibers, which displayed a visible reduction in PLC-PH-EGFP signal with treatment (Figure 12D, top panel) (Stauffer TP, Ahn S, and Meyer T. Receptor-induced transient reduction in plasma membrane PtdIns(4,5)P2 concentration monitored in living cells. Curr Biol.1998;8(6):343-6). Myofibers from Anxa6gfp mice were subsequently treated with 20µM wortmannin and subjected to laser-induced injury. Genomically encoded annexin A6GFP cap size was significantly reduced (3.3 fold; P < 0.002) by wortmannin treatment (Figure 12D, bottom panel and graph). Combined, these results illustrated the dependency of annexin A6 repair cap formation on membrane lipid composition. [0240] Recombinant annexin A6 binds injured membrane in a concentration- dependent and time-dependent manner. Skalman and colleagues overexpressed annexin A6 from a plasmid in HEK cells and found that it localized to the site of listeriolysin O (LLO)-induced membrane injury (Nygard Skalman L, Holst MR, Larsson E, and Lundmark R. Plasma membrane damage caused by listeriolysin O is not repaired through endocytosis of the membrane pore. Biol Open.2018;7(10)). To better understand the concentration and timing dynamics of recombinant annexin A6 binding of injured membrane, a quantitative, cell-based assay was developed that combined LLO-induced injury and flow cytometry using rat L6 myoblasts. At the amino acid level, rat annexin A6 protein is 94.6% similar to human annexin A6 and 98.3% similar to mouse annexin A6 (Demonbreun AR, Fallon KS, Oosterbaan CC, Bogdanovic E, Warner JL, Sell JJ, et al. Recombinant annexin A6 promotes membrane repair and protects against muscle injury. The Journal of Clinical Investigation. 2019;129(11):4657-70). L6 myoblasts were injured with LLO and then incubated with increasing concentrations of Alexa-488 labelled recombinant annexin A6 protein (referred to as rA6-488) in concentrations ranging from 0 to 100µg/ml and fluorescence as a surrogate measure of binding quantified by flow cytometry. The percentage of rA6-488 positive cells increased with increasing concentrations of rA6-488, with nearly 100% of injured cells showing rA6-488 binding at 100µg/ml (Figure 13A). As another measure of binding, the total fluorescence intensity emitted by rA6-488 binding increased with increasing concentrations of protein with levels 22-fold higher at 100µg/ml than at 1µg/ml (Figure 13B). Furthermore, when L6 injured myoblasts were incubated with the same concentration of rA6-488 but incubation time varied (20 – 90 mins), binding increased with increasing time (Figure 13C). To determine if timing of recombinant annexin A6 treatment altered function, myofibers were pretreated with recombinant annexin A6 for 5 minutes or 60 minutes and then subjected to laser injury in the presence of FM 4-64 dye. FM 4-64 dye uptake was similarly reduced with both 5 minutes and 60 minutes of pretreatment compared to BSA controls (Figure 13D). These data indicated that recombinant annexin A6 binds disrupted membrane and protects against membrane injury in a dose-dependent fashion. [0241] Recombinant annexin localized to the repair cap and enhanced repair. The above data demonstrated that annexin A6 expressed from the endogenous locus was recruited from its position within fibers to the plasma membrane to participate in resealing wounds. It was next evaluated whether exogenously added recombinant annexin A6 interacted with endogenously encoded annexin A6. To do this, Anxa6gfp myofibers were laser-injured in the presence of recombinant annexin A6 labelled with a carboxy terminal tdTomato fused tag (referred to as rA6-tdTomato). rA6-tdTomato localized to the site of membrane injury, colocalizing with genomically-encoded annexin A6GFP (Figure 14A). rA6- tdTomato cap area increased with increasing concentrations (1.3 - 130 µg/ml) of available rA6-tdTomato protein (Figure 14B, left). However, the presence of recombinant annexin rA6-tdTomato did not significantly increase genomically-encoded annexin A6GFP cap size (Figure 14B, right). High-resolution imaging at the site of muscle membrane injury revealed the presence of rA6-tdTomato containing membranous blebs (Figure 14C). To determine if the protective effect of rA6 was concentration-dependent, myofibers were incubated in a range of recombinant annexin A6 protein concentrations (0-130 µg/ml) or BSA control. Subsequently, myofibers were incubated in FM 4-64 dye and subjected to laser injury. Myofibers pretreated with recombinant annexin A6 had a dose-dependent reduction in FM dye uptake, compared to control myofibers (Figure 14D), indicating higher levels of protection with increased concentrations of recombinant annexin A6 protein. These data demonstrated a role for annexin A6 in the immediate repair response required to seal membrane lesions independent of overexpression systems. [0242] The role of annexin A6 in dystrophic muscle, which continually undergoes bouts of injury and repair, was assessed next. Anxa6gfp mice were crossed with the mdx model of Duchenne muscular dystrophy to generate Anxa6gfp mdx mice (Figure 14E). The mdx mouse model lacks dystrophin expression resulting in a fragile sarcolemma that is prone to injury (Bulfield G, Siller WG, Wight PA, and Moore KJ. X chromosome-linked muscular dystrophy (mdx) in the mouse. Proceedings of the National Academy of Sciences of the United States of America.1984;81(4):1189-92; Sicinski P, Geng Y, Ryder-Cook AS, Barnard EA, Darlison MG, and Barnard PJ. The molecular basis of muscular dystrophy in the mdx mouse: a point mutation. Science.1989;244(4912):1578-80) Anxa6gfp mdx myofibers were isolated and laser-injured in the presence of rA6-tdTomato. Like healthy muscle, rA6- tdTomato localized to the site of dystrophic membrane injury, colocalizing with genomically- encoded annexin A6GFP at the lesion (Figure 14F and 14G). Genomically-encoded annexin A6GFP cap size in mdx myofibers was not significantly altered by the presence of rA6- tdTomato (Figure 14F and 14G). However, pretreatment with recombinant annexin A6 had a dose-dependent effect on myofiber FM dye uptake, reducing dye influx compared to control treated myofibers (Figure 14H). Together these findings showed that recombinant annexin A6 protein increases exogenous cap size with increased concentrations, correlating with increased repair capacity in both healthy and dystrophic muscle. [0243] Recombinant annexin A6 localized to injured neurons. The process of neuron regeneration after axonal crush or severing requires resealing of the membrane prior to growth cone formation and regeneration (Geddis MS, and Rehder V. Initial stages of neural regeneration in Helisoma trivolvis are dependent upon PLA2 activity. J Neurobiol. 2003;54(4):555-65). To evaluate the binding potential of recombinant annexin A6 to injured neurons, embryonic neurons were isolated and laser-injured in the presence of rA6- tdTomato. In the first injury assay, the neuronal membrane was nicked with the laser, similar to the protocol used for skeletal myofibers. With this type of injury, rA6-tdTomato localized to the site of neuron membrane injury, colocalizing with genomically-encoded annexin A6GFP at the repair cap (Figure 15A). In the second injury assay, the laser was used to fully transect the neuronal process creating two stumps at the injury site. Wheat germ agglutinin (WGA) was used to label the neuron membrane, which showed clear disruption of the neuronal process after transection (Figure 15B). Four seconds after transection, when the first image was acquired, rA6-tdTomato was detectable at the transected stumps (Figure 15B and 15C). rA6-tdTomato fluorescent intensity at the severed stumps continued to increase through the 60 seconds of imaging (Figure 15C). Therefore, recombinant annexin A6 binds disrupted neuronal membranes after the smaller “nicking” injury and after full transection. Discussion [0244] Impact of annexin A6 expression level on membrane repair. Prior studies examining the role of annexin A6 in membrane repair relied on plasmid-mediated overexpression, which could alter the kinetics and efficiency of membrane repair. In this Example, a genomically-encoded annexin A6GFP, expressed at lower levels than normal annexin A6 protein, was utilized to document the role of annexin A6 in repair cap formation. This decrease in in vivo expression of total annexin A6 did not appear to have deleterious effects on muscle histology, and repair complex formation remained readily visible. The data provided herein showed that the small amount of functional annexin A6 is sufficient to promote repair, consistent with annexin A6 as a modifier gene and not a primary disease- causing gene (Swaggart KA, Demonbreun AR, Vo AH, Swanson KE, Kim EY, Fahrenbach JP, et al. Annexin A6 modifies muscular dystrophy by mediating sarcolemmal repair. Proceedings of the National Academy of Sciences of the United States of America. 2014;111(16):6004-9). [0245] Recombinant annexins mediate closure of membrane lesions. Annexin A6 has been implicated in membrane folding and the constriction forces needed to pull wound edges together for eventual fusion (Boye TL, Jeppesen JC, Maeda K, Pezeshkian W, Solovyeva V, Nylandsted J, et al. Annexins induce curvature on free-edge membranes displaying distinct morphologies. Scientific reports.2018;8(1):10309; Boye TL, Maeda K, Pezeshkian W, Sønder SL, Haeger SC, Gerke V, et al. Annexin A4 and A6 induce membrane curvature and constriction during cell membrane repair. Nature communications. 2017;8(1):1623). The studies by Boye and colleagues used artificial membranes and recombinant purified proteins. Data provided herein revealed A6GFP-positive membrane blebs emanating from the annexin repair cap (model in Figure 16). Additionally, exogenously added recombinant annexin A6 protein also localized to blebs at the site of repair. Together these data indicate that annexin A6 protein can bind exposed membrane phospholipids at the site of injury from the cell interior or exterior. As shown herein, recombinant annexin A6 protein elicited a strong and significant dose-dependent improvement in repair. In some embodiments, and as described herein, an annexin cocktail containing multiple annexin proteins is contemplated. [0246] In summary, this work demonstrated that annexin A6 forms repair caps which mediate resealing, and this process is conserved across multiple cell types. Importantly, it was shown that exogenously administered recombinant annexin A6 rapidly binds to the damaged membrane in skeletal muscle, cardiomyocytes and neurons suggesting a broad role for annexin A6 in repair. EXAMPLE 3 [0247] Aβ at the border of the amyloid plaque causes calcium (Ca 2+ ) influx in peri-plaque dystrophic neurites (DNs), resulting in microtubule disruption and axonal transport impairment (Figure 17) [Kuchibhotla et al., Neuron 59, 214-225, doi:10.1016/j.neuron.2008.06.008 (2008). PMC2578820; Sadleir et al., Acta Neuropathol 132, 235-256, doi:10.1007/s00401-016-1558-9 (2016). PMC4947125]. Preliminary results also indicate that annexin A6, a membrane resealing protein involved in muscle myofiber repair, reduced the formation of plaque-associated DNs and the accumulation of tau phosphorylated at Thr181(p-tau181) and Thr231 (p-tau231) in DNs (Figures 11C, 18, 23, and 24). p-tau181 and p-tau231, together with p-tau217, have emerged as important early cerebrospinal fluid (CSF) and plasma biomarkers of AD that track with amyloid pathology. Importantly, results presented herein show that annexin A6 repairs Aβ-damaged neuronal membranes and therefore represents a novel AD therapeutic. Additionally, DNs that surround amyloid plaques have been implicated in the seeding and spreading of pathologic AD tau, suggesting that the DN may act as the crucible in which Aβ-induced pathogenic tau is formed. The connection between Aβ and tau is one of the great unsolved mysteries of AD. While it is becoming clear that amyloid deposition precedes tau phosphorylation and neurofibrillary tangle (NFT) formation, the link between these processes is poorly understood. Aβ deposition in plaques occurs first, followed by the appearance of DNs containing neurotransmitter (suggesting pre-synaptic origin), then DNs with abnormal p-tau. Other studies support axonal origin of most DNs. It was hypothesized that DNs around plaques are sites of pathogenic tau phosphorylation and aggregation that play a role in AD tau seeding and spreading throughout the brain. CSF and plasma p-tau181, p-tau217, and p-tau231 effectively distinguished AD cases from controls and non-AD dementias and can predict which patients will develop disease over a decade before symptom onset. Increased p-tau181, p-tau217, and p-tau231 is one of the earliest pathologic tau changes associated with amyloid deposition. Results provided herein show that reducing Aβ-induced neurite membrane damage decreased Ca 2+ influx, microtubule disruption, axonal transport impairment, aberrant kinase activation, and the formation of pathologic p-tau, thus preserving neuronal function. Since abnormally phosphorylated and aggregated tau correlate with cognitive decline, it was critical to understand how amyloid deposition leads to AD tau seeding and spreading. Without wishing to be bound by any particular theory, disrupting the link between Aβ and tau pathologies may provide a therapeutic approach to AD by rendering amyloid plaques less able to form DNs and seed and spread pathologic tau. [0248] Experiments described in the present Example show that Aβ at the borders of plaques causes neurite membrane damage, Ca 2+ leakage, microtubule disruption, axonal transport impairment, and formation of DNs (Figure 17F and 17G), which provide the environment for pathogenic tau phosphorylation, seeding, and spreading. The present Example also explored membrane repair in neurons. All cells have membrane repair capacity, but it is highly developed in large, terminally differentiated cells with extensive surface area that undergo stress and Ca 2+ fluctuations, such as myofibers in muscle. In muscle, when the balance between membrane damage and repair is disrupted by genetic mutations, muscular dystrophies occur. Neurons are large post-mitotic cells with extensive plasma membrane area, and are likely more vulnerable to membrane damage due to multiple causes. Therefore, neurons must respond rapidly to repair membrane damage for preserving function and viability. Indeed, neurons express major membrane resealing proteins found in other cells, including annexin A6, Bin1, EHD proteins, and dysferlin, among others (Figure 18). Cell membrane changes and rigidity associated with aging could overwhelm membrane repair mechanisms and render neurons more susceptible to Aβ- induced membrane damage, which could partly explain why age is the primary risk factor for AD. In muscle myofibers, annexin A6 is the first membrane resealing protein that is recruited by Ca 2+ influx to the site of membrane damage (Figure 18). Other annexins and resealing proteins then follow to form the membrane cap complex that seals the membrane breach and allows repair to occur. Although well studied in muscle myofibers, this mechanism is virtually unexplored in neurons. Microglia appear to have a role in the protection of neurites against Aβ-induced damage, as exemplified by the dramatic increase in DNs in 5XFAD;TREM2-/- mice in which microglia fail to surround and wall-off plaques. [0249] Evidence suggests that the immediate vicinity of the amyloid plaque creates a locally toxic environment for neurons. Live imaging of 5XFAD brain slices loaded with ratiometric Ca 2+ dye Indo-1 showed elevated Ca 2+ in peri-plaque DNs (Figure 17A and 17B). EM of 5XFAD brain reveals axonal membrane breach in the vicinity of Aβ plaques (Figure 17C). Primary neurons treated with Aβ42 in vitro display axonal swellings that accumulate BACE1 and show tubulin disorganization, reminiscent of DNs in vivo (Figure 17D and 17E). Therefore, it was hypothesized that contact of axons with Aβ causes membrane disruption and Ca 2+ leak, which leads to aberrant kinase activation, microtubule disruption, impaired axonal transport, defective protein turnover, axonal swelling and DN formation, accumulation of amyloidogenic proteins like APP and BACE1, and elevated Aβ production in DNs (Figure 17F and 17G). Maintaining membrane integrity by enhancing repair mechanisms could reduce this toxic cascade in the vicinity of plaques, thus slowing disease progression. [0250] The annexins exhibit broad tissue distribution and function in membrane and actin remodeling, immune cell modulation, and wound repair. As described herein, annexin A6 plays a key role in membrane resealing in skeletal muscle and heart. Like other annexins, A6 binds negatively charged phospholipids such as phosphatidylserine in the presence of Ca 2+ , but it is unique in having 8 annexin repeats making it particularly sensitive to Ca 2+ (Figure 18A). Aβ has many deleterious effects on membranes, such as pore formation, detergent-like activity, deformation, thinning and increased rigidity, all of which can cause Ca 2+ leakage into the cell. Because it was hypothesized that Aβ causes membrane damage leading to Ca 2+ influx, dysregulated kinase pathways, microtubule instability and impaired vesicular transport, the present Example explored the role of annexin A6 in membrane resealing in vitro and in vivo. [0251] Upon acute membrane injury, annexin A6 initiated the formation of a repair cap protein complex, recruiting annexins A1 and A2 to the site of damage (Figure 18B). Annexin A6 and the other proteins in this complex, annexins A1 and A2, and the shoulder proteins BIN1, dysferlin, and the EHD family proteins, are all expressed in brain. Importantly, mutations in BIN1 are some of the strongest genetic risk factors associated with AD, suggesting that the membrane repair function of BIN1 may be compromised by these mutations in AD. Annexin A6 is key to initiating and forming the repair cap complex, since a truncation mutant consisting of only the N-terminal 32 amino acids of annexin A6, N32, and a missense mutation that is deficient in Ca 2+ binding, E233A, both exert a strong dominant- negative effect on repair cap assembly and membrane repair. Previously, it was shown that recombinant annexin A6 or A5 reduced dye leakage from liposomes induced by Aβ and various membrane disruptors. Injection of exogenous recombinant annexin A2 was protective in a traumatic brain injury model by decreasing BBB permeability and promoting angiogenesis, and annexin A5 protected choroid plexus cells from damage by Aβ42. Injection of human recombinant annexin A1 acutely decreased blood brain barrier permeability in young 5XFAD and Tau P301L mice as well, further suggesting beneficial effects of annexins in neurological disease. Although annexin A6 constitutive knockout (KO) mice were shown to have normal immune and cardiac function, more recently they were found to have increased sensitivity to painful mechanical stimuli due to loss of annexin A6 interaction with the Piezo2 channel. These in vivo results are intriguing, but do not directly address how annexin A6 plays a role in membrane resealing of neurons in the brain, nor the role of membrane repair in AD. [0252] To investigate annexin A6 in membrane repair, a knockin mouse expressing GFP- tagged A6 (A6-GFP) from the endogenous mouse locus by CRISPR-Cas9 genome editing (Anxa6em1(GFP) mice) was generated. In primary cortical neurons cultured from Anxa6em1(GFP) mouse embryos, A6-GFP increased as neurons matured in vitro (Figure 2C and 2D), suggesting an important neuronal function. Laser injury of Anxa6em1(GFP) primary neurons showed that A6-GFP accumulated within seconds at the site of membrane damage (Figure 19A), very similar to the well-established muscle laser injury paradigm. In skeletal and heart muscle cells, exogenous recombinant annexin A6 localizes rapidly to the site of laser injury and enhances membrane repair. Similarly, exogenous recombinant tdTomato-tagged annexin A6 colocalized with genomically expressed A6-GFP at the laser injury site in both the neuronal cell body (Figure 19B) and neurite (Figure 19C) in Anxa6em1(GFP) primary neurons, suggesting that exogenous recombinant A6 may mediate neuronal membrane repair. To determine whether annexin A6 localizes to sites of membrane damage caused by Aβ, Anxa6em1(GFP) primary neurons were treated with oligomeric Aβ42 followed by anti-GFP and anti-Aβ immunofluorescence microscopy (Figure 19D). It was found that A6-GFP accumulated at sites where Aβ42 contacted the membrane, suggesting recruitment of A6-GFP to sites of Aβ-induced membrane injury. [0253] Next, Anxa6em1(GFP) mouse brain sections were analyzed by immunofluorescence microscopy, which showed A6-GFP expression in neurons of cortex (Figure 20A) and other brain regions, but not in microglia or astrocytes, indicating that neurons are major cell types that express annexin A6 in the brain. Anxa6em1(GFP) mice were then crossed to 5XFAD mice74, which are a well-established early onset model of amyloid pathology. In addition to neuronal soma and dendrites, A6-GFP accumulated in DNs around amyloid plaques of Anxa6em1(GFP);5XFAD mice, as shown by colocalization with the DN marker BACE1 (Figure 20B). [0254] To confirm that A6-GFP localizes similarly to endogenous A6, 5XFAD brains were stained with an annexin A6 antibody. As with A6-GFP localization in Anxa6em1(GFP);5XFAD brain, endogenous annexin A6 in 5XFAD brain was localized at the plasma membrane of neurons and DNs around plaques (Figure 21A). Immunoblot analysis of wild-type primary mouse neurons treated for 72 hours with Aβ42 oligomers showed increased annexin A6 (4X) and DN markers BACE1, LAMP1, and LC3B-II (Figure 21B and 21C). In human AD hippocampus, annexin A6 also localized to the membrane of neurons and to BACE1-containing DNs near amyloid plaques (Figure 21D and 21E). Together, these results demonstrated that annexin A6 is localized to mouse and human neurons and DNs around amyloid plaques, and that Aβ increased annexin A6 and other proteins associated with DNs. [0255] To test whether annexin A6 increases membrane repair and reduces DN formation, A6-GFP was overexpressed in 5XFAD mouse brain from an AAV8 vector driven by the neuron-specific human synapsin (syn) promoter77 (VectorBuilder). On P0, 5XFAD pups were ICV-injected with either syn-GFP AAV or syn-A6-GFP AAV, then aged to 4 months and brains harvested. GFP fluorescence revealed A6-GFP expression in neurons and a large number of DNs, similar to the endogenous A6 pattern (Figure 22A). A6-GFP colocalized with BACE1 in DNs, indicating A6-GFP reached the correct location to repair membrane damage. Immunoblot analysis showed that A6-GFP was expressed approximately 8 fold higher than endogenous A6 (Figure 22B and 22C), which mice tolerated well with no obvious ill effects. To determine the effects of A6-GFP on amyloid pathology and DN formation, sections were stained with antibodies against Aβ42 and LAMP1, a well-established DN marker (Figure 23A). Nikon NIS-Elements software was used to define each plaque and its associated DN halo and determine the ratio of the respective areas stained for LAMP1 and Aβ42 (Figure 23B). Smaller amyloid plaques grow at a faster rate and have proportionally greater amounts of neuritic dystrophy, so plaques were stratified based on Aβ core size before averaging the ratios. As expected, smaller plaques had a higher LAMP1:Aβ42 ratio than larger plaques. Importantly, a significant decrease of the LAMP1:Aβ42 ratio of smaller plaques was observed in hippocampus and cortex of 5XFAD brains injected with A6-GFP AAV compared to those injected with GFP AAV (Figure 23B). Smaller plaques are thought to be undergoing the most rapid growth and causing the greatest neurotoxicity, so reduction of dystrophic neurites around smaller plaques is likely to have beneficial effects. The total percent area positive for LAMP1 in the cortex was significantly decreased, while that of Aβ42 was unchanged (Figure 23C), indicating that A6-GFP specifically reduced dystrophic neurites with minimal effects on Aβ deposits. Using higher magnification confocal images, it was observed that the area of individual GFP+ DNs was significantly reduced in A6-GFP AAV injected mice compared to those injected with GFP AAV (Figure 23D). A6-GFP overexpression did not appear to affect microglial or astrocytic responses to amyloid plaques, as the ratio of microglial marker Iba1 to the amyloid stain MeXO4 and astrocyte marker GFAP to MeXO4 in the area within 15μm of the plaque core was unchanged (Figure 23E). Together, these results showed that annexin A6 overexpression reduced the formation of DNs but did not affect Aβ pathology. [0256] Previous work has suggested that plaques and associated neuritic dystrophy play a key role in pathologic tau seeding and spreading [He, Z. et al. Nat Med 24, 29-38; Leyns, C. E. G. et al. Nat Neurosci 22, 1217-1222; Parhizkar, S. et al. Nat Neurosci 22, 191-204]. Additionally, new phospho-tau biomarkers have been identified that track closely with A ^ pathology and predict AD years in advance [Barthelemy et al., J Exp Med 217, doi:10.1084/jem.20200861 (2020). PMC7596823; Barthelemy, N. R. et al. Nat Med 26, 398- 407; Suarez-Calvet, M. et al. EMBO Mol Med 12, e12921, doi:10.15252/emmm.202012921 (2020); Mattsson-Carlgren, N. et al. Sci Adv 6, eaaz2387, doi:10.1126/sciadv.aaz2387 (2020)]. Using specific antibodies for p-tau231 (Figure 24A) or p-tau181 (Figure 24B), it was observed that p-tau231 and, even more noticeably, p-tau181 accumulated in DNs of 5XFAD brains, as shown by colocalization with LAMP1 and BACE1 (Figure 24A, 24B, and 24D). No signal for p-tau 231 or p-tau181 was detected in 5XFAD;Tau-/- brain (Figure 24A and 24B). Since A6-GFP overexpression reduced DNs in 5XFAD brain (Figure 23), it was hypothesized that A6-GFP would also decrease p-tau associated with DNs. Indeed, a significant reduction in the ratio of p-tau181 to amyloid was observed in 5XFAD mice injected with syn-A6-GFP AAV compared to those injected with syn-GFP AAV (Figure 24C). It was hypothesized that increased kinase activity in DNs could be responsible for p-tau accumulation. Activated, phosphorylated forms of two kinases, CaMKII and c-jun kinase (JNK), known to phosphorylate p-tau181, p-tau217, and p-tau23181,82, were colocalized with p-tau181 in 5XFAD DNs (Figure 24D-24F). In human AD brain, p-tau181 colocalized with total tau, BACE1, and APP in DNs around plaques (Figure 24G-24I) and p-tau 231 colocalized with p-JNK and the DN marker APP (Figure 24J). These results showed that DNs are sites of early tau phosphorylation associated with amyloid pathology and that decreasing DN formation via annexin A6 overexpression will reduce p-tau181, a biomarker that predicts AD, and perhaps other pathologic p-tau isoforms. [0257] It has been shown in muscle that not only cellular overexpression of annexin A6, but exogenous recombinant A6 is able to enhance membrane repair [Demonbreun, A. R. et al. J Clin Invest 129, 4657-4670, doi:10.1172/JCI128840 (2019). PMC6819108] (Figure 25). Overexpressed and exogenous recombinant annexin A6 promote myofiber membrane resealing after laser injury and reduce dye influx to an equivalent amount [Demonbreun, A. R. et al. J Clin Invest 129, 4657-4670, doi:10.1172/JCI128840 (2019). PMC6819108]. This strongly suggested that recombinant annexin A6 could serve as a therapeutic agent, since it can home to sites of membrane damage from the extracellular space [Demonbreun, A. R. et al. J Clin Invest 129, 4657-4670, doi:10.1172/JCI128840 (2019). PMC6819108]. Recombinant A6 is also effective in acute (lytic damage from cardiotoxin injection) and chronic (muscular dystrophy due to sarcoglycan mutation) muscle injury models [Demonbreun, A. R. et al. J Clin Invest 129, 4657-4670, doi:10.1172/JCI128840 (2019). PMC6819108]. Importantly, following ICV injection into 5XFAD brain, HIS-tagged recombinant A6 (A6-HIS) localized to membranes of BACE1+ DNs (Figure 25). Materials and Methods [0258] AAV mediated A6-GFP expression. VectorBuilder cloned the mouse Annexin A6 cDNA (NM_013472.5) into an AAV expression vector with a C-terminal eGFP tag under control of the neuronal promoter synapsin (syn). They prepared serotype 8 AAV expressing either A6-GFP or GFP alone. Genomic titer was determined by quantitative PCR.5XFAD transgene positive males were crossed to SJL/B6 hybrid females in timed matings to generate transgene negative and positive littermates. On P0, each pup in a litter was cryoanesthetized and 2 μl containing 2x10 10 viral genomes of A6-GFP AA8 or GFP AAV8 was injected into the ventricle of each hemisphere using a 10μl Hamilton syringe. Pups were placed in home cage on a heating pad to recover, then reunited with their mother. At 4.5 months of age, they were anesthetized with a lethal dose of ketamine/xylazine and transcardially perfused with PBS containing protease and phosphatase inhibitors. One hemibrain was dissected into hippocampus, cortex and midbrain which were snap-frozen separately. The other hemibrain was drop fixed in 10% buffered formalin overnight at 4°C, then transferred to 20% w/v sucrose in 1xPBS for 24 hours, then stored in 30% w/v sucrose in 1xPBS with azide. All animal work was done with the approval of the Northwestern University IACUC. [0259] Immunofluorescence and microscopy.10% formalin-fixed hemibrains were sectioned coronally at 30μm on a freezing sliding microtome and collected in cryopreserve (30% w/v sucrose, 30% ethylene glycol in 1X PBS). Three sections were stained and imaged per mouse. [0260] For quantification of the ratio between LAMP1 and Aβ42 the following staining protocol was used.1:2000 rat monoclonal anti-LAMP1 (clone 1D4B, DSHB) and 1:2000 rabbit monoclonal anti-Aβ42 antibody (clone H31L21, Invitrogen, #700254) in 1% BSA TBS 0.1% triton at 4°C overnight. Following 3 TBS washes, sections were incubated for 2 hours at room temperature with secondary antibodies: 1:750 donkey anti-rat Alexa 568 (abcam), donkey anti-rabbit 647(ThermoFisher Scientific), 300 nM DAPI. [0261] For quantification of the ratio between p-Tau 181 and Thiazine red plaque cores, the following staining protocol was used.1:300 rabbit monoclonal anti-p-tau181 (clone D9F46, cell signaling #12885) in 1% BSA TBS 0.1% triton at 4°C overnight. Following 3 TBS washes, sections were incubated for 2 hours at room temperature with secondary antibodies: donkey anti-rabbit 647(ThermoFisher Scientific), 300 nM DAPI and 1:15,000 dilution of 1 mg/ml Thiazine Red. [0262] All sections were mounted with Prolong Gold (Molecular Probes) and images acquired on a Nikon Ti2 Eclipse widefield microscope with a 10x objective, using NIS Elements software high content method to capture and tile whole sections. All image acquisition settings were maintained the same between treatment groups and genotypes. For image analysis, regions of interest (ROIs) were drawn in cortex and hippocampus. Using the General Analysis tool, thresholding was set to distinguish Aβ42, and LAMP1 positive regions, or p-Tau181 and Thiazine red positive regions, then the percent area covered by each stain from the hippocampal or cortical ROI was calculated. Using the same sections, thresholding in the General Analysis tool was used to define sub-ROIs that correspond to individual plaques having both Aβ42 and LAMP1 or p-Tau181 and ThR positive pixels within cortical and hippocampal ROIs. The General Analysis tool was used to measure area covered by Aβ42 and by LAMP1 in a given sub-ROI (plaque) and the ratio between LAMP1:Aβ42 was calculated in Excel. [0263] Statistics. Student's two-tailed t-test and ANOVA were performed using InStat software (GraphPad Software, Inc., San Diego, CA) to compare means of the various genotypes, genders, and treatment groups. * 0.05 > p > 0.01 ** 0.01 > p > 0.001 *** 0.001 > p > 0.0001; Error bars = S.E.M. [0264] A6-HIS Ventricle injection. A6-HIS was purified from E. coli using standard methods. A 5 month old 5XFAD male mouse was anesthetized with isoflurane in stereotaxic frame, a central incision made to expose skull. On the left side of brain, a small hole was drilled with 25 gauge needle at the site to target ventricle (B-L or A-P: -0.60mm; M-L: +1.30mm) then a 10 μl Hamilton syringe was used to inject 3 μl of 21mg/ml A6-HIS at a depth of -2.00mm, 3 times with 2-3 min break in between for a total of 9 μl, containing 189μg A6-HIS, a dose of 6.3 mg/kg for a 30 gm mouse. After injection, the incision was stapled shut and the mouse recovered from anesthesia. [0265] Three hours after surgery, the mouse was anesthetized with a lethal dose of ketamine/xylazine and transcardially perfused with PBS containing protease and phosphatase inhibitors. Both hemibrains were drop fixed in 10% buffered formalin overnight at 4°C, then transferred to 20% w/v sucrose in 1xPBS for 24 hours, then stored in 30% w/v sucrose in 1xPBS with azide. [0266] 10% formalin-fixed hemibrains were sectioned sagittally at 30μm on a freezing sliding microtome and collected in cryopreserve (30% w/v sucrose, 30% ethylene glycol in 1X PBS). Three sections were stained and imaged per mouse. [0267] To image A6-HIS localization, sections were antigen retrieved for 40 min at 80°C in 1mM sodium citrate at pH 9, then stained as follows: 1:500 chicken anti-NeuN (Millipore), 1:300 mouse monoclonal anti-BACE1 (clone 3D5) and 1:300 rabbit monoclonal anti-HIS (clone D3I1O, Cell signaling, #12698) in 1% BSA TBS 0.1% triton at 4°C overnight. Following 3 TBS washes, sections were incubated for 2 hours at room temperature with secondary antibodies: 1:750 donkey anti-chicken Alexa 405 (Jackson Immunologicals), donkey anti-mouse 488 (ThermoFisher Scientific) donkey anti-rabbit 568 (ThermoFisher Scientific), Methoxy XO420μM. [0268] All sections were mounted with Prolong Gold (Molecular Probes) and images acquired on a Nikon A1R confocal microscope with a 60x objective, using NIS Elements software. EXAMPLE 4 [0269] In this Example, the role of annexin A6 in DN formation is investigated. It is hypothesized that neuronal annexin A6 maintains membrane integrity during amyloid plaque growth, reducing Ca 2+ influx, stabilizing microtubules and reducing DN formation. It is further hypothesized that overexpressed A6 will reduce Aβ-induced DN formation, while A6 deficiency or dominant negative A6 will increase DN pathology. [0270] Whether overexpression of wild type or dominant negative (E233A) annexin A6 increases or decreases membrane repair, respectively, following laser injury in primary mouse neurons, as assessed by membrane-impermeant dye penetration and Ca 2+ sensor imaging, is determined. The role of other repair cap components in neuronal membrane repair is also determined. [0271] C57BL/6 E15.5 mouse primary neurons are isolated and plated in coverslip bottom dishes for imaging (MatTek) and 12-well plates for biochemical analysis. An AAV PHP.eB (blood-brain barrier penetrant AAV55; Figure 26) vector is engineered to express syn-GFP, syn-A6-GFP, or syn-A6(E233A)-GFP (VectorBuilder). Dominant negative A6(E233A) has been studied and found to strongly inhibit membrane repair [Demonbreun, A. R. et al. J Clin Invest 129, 4657-4670, doi:10.1172/JCI128840 (2019)]. AAV vectors are added to neurons (1x10 8 VG/µl; MOI=100-1000) and cultured for 7-14d. Parallel cultures are infected with AAV vectors that express shRNA constructs to knockdown repair cap shoulder proteins annexins A1 and A2, Bin1, and dysferlin. In addition, for annexins A1 and A2, primary neurons are infected with AAV vectors expressing dominant negative A1 and A2 (A1(D171A), A2(D161A)). At 7-14 days in vitro (DIV), neurons will undergo laser injury as described herein on a Nikon A1R-multiphoton confocal microscope with a Chameleon Vision titanium sapphire laser (690-1040nm) and a 25x (1.1 NA) water immersion lens. To measure Ca 2+ influx, neurons are co-infected with AAV expressing Ca 2+ sensors jRCaMP1 or jRGECO185 (AddGene). To measure dye influx, the membrane-impermeant dye FM 4-64 (ThermoFisher) is added to the bath immediately before laser injury. Ca 2+ influx and dye penetration are imaged on the same Nikon A1R-multiphoton confocal microscope used to cause the laser injury and quantified in time-series images using NIS-Elements software to assess the effect of A6 constructs on membrane resealing efficiency. [0272] It is also determined whether overexpression of wild type or dominant negative annexin A6 increases or decreases membrane repair, respectively, in primary mouse neurons treated with Aβ42 oligomers and fibrils, as assessed by dye penetration, Ca 2+ influx, neuritic beading, axonal transport, caspase 3 activation, and LDH release. [0273] Primary neurons are prepared as described herein and plated on coverslip bottom dishes for imaging (MatTek) and 12-well plates for biochemical analysis. AAV PHP.eB expressing syn-GFP, syn-A6-GFP or syn-A6(E233A)-GFP is added to neurons and cultured for 7-14d, then treated with oligomeric or fibrillar Aβ42 (rPeptide) preparations, as per previous methods [Sadleir et al. Acta Neuropathol 132, 235-256, doi:10.1007/s00401-016- 1558-9 (2016); Sadleir et al., J Biol Chem 287, 7224-7235, doi:10.1074/jbc.M111.333914 (2012)]. A high [Aβ42] (10μM) is used to simulate the high local [Aβ] experienced by peri- plaque DNs. For Ca 2+ imaging, neurons is co-infected with AAV expressing jRCaMP1or jRGECO185, then subjected to live imaging 0-6 hrs after Aβ42 addition. To measure neuritic beading, neurons are transfected with BacMam RFP-tubulin (ThermoFisher) two days before Aβ42 addition, then imaged 0-16 hours following Aβ42 treatment. To measure axonal transport, LysoTracker DeepRed (ThermoFisher) and MitoTracker (Cell Signaling) are added prior to Aβ42 addition, then imaged 0-16 hours following Aβ42 treatment. Imaging is performed on a Nikon W1 Dual CAM Spinning Disk confocal using a 40x objective. Cell viability is measured by cleaved caspase 3 immunoblot analysis, imaging propidium iodide uptake, and lactate dehydrogenase activity (Promega) in media. [0274] It is determined whether overexpression of wild type or dominant negative (E233A) A6 in 5XFAD mice decreases or increases DN formation and glial activation around plaques, respectively. Dye penetration, Ca 2+ influx, caspase 3 activation, behavior, and EM for microtubule integrity is assessed. [0275] The AAV PHP.eB vector was able to cross the blood brain barrier and achieve widespread long-term expression of proteins in the brain (Figure 26)).5XFAD mice receive single tail vein injections of 1x10 12 VG of AAV PHP.eB syn-A6-GFP, AAV PHP.eB syn- A6(E233A)-GFP, and control AAV PHP.eB syn-GFP to express wild type and dominant negative A6-GFP fusion proteins in the brain.5XFAD mice are well-established models of early Aβ pathology, with plaque deposition starting at 2 months of age, gene expression changes that are similar to those seen in human AD brain [Neuner et al., Neuron 101, 399- 411 e395, doi:10.1016/j.neuron.2018.11.040 (2019). PMC6886697; Heuer et al., Learn Mem 27, 355-371, doi:10.1101/lm.051839.120 (2020)], and neuron loss with age [Oakley et al., J Neurosci 26, 10129-10140 (2006); Eimer et al., Molecular neurodegeneration 8, 2, doi:10.1186/1750-1326-8-2 (2013)]. [0276] In an AD prevention paradigm, 5XFAD mice (n=20/group; 10 males, 10 females) are tail vein-injected with AAV vectors at 1.5 months of age and harvested 3 or 8 months later to assess the effects of annexin A6-GFP fusion proteins on the formation of DNs and Aβ plaques. In an AD treatment paradigm, 5XFAD mice (n=20/group; 10 males, 10 females) are tail vein-injected at 4 months of age and harvested 5 months after injection. Before brain harvest, behavioral analyses is performed in the Northwestern Behavioral Phenotyping Core Facility. Behavioral assays include: 1) Novel object recognition, which assesses declarative memory by measuring the ratio of time spent exploring a novel object compared to a familiar one90, 2) Spontaneous alternation in the Y-maze, which tests working memory by measuring the amount of spontaneous alternation between the three arms of the maze for 5 min [Oakley et al., J Neurosci 26, 10129-10140 (2006)], 3) contextual and cued fear conditioning to measure the animal’s ability to associate a space or tone with a foot shock, a test of hippocampal dependent memory, 4) Morris water maze, a sensitive test of spatial memory in which the animal learns to remember the location of a hidden platform in a tank of opaque water [Gobeske et al., PLoS One 4, e7506, doi:10.1371/journal.pone.0007506 (2009)]. [0277] At brain harvest, mice are transcardially perfused with PBS, the left hemibrain fixed in 10% PFA and cryopreserved in 30% sucrose/PBS for immunofluorescence microscopy, and the right hemibrain sub-dissected into cortex, hippocampus, and cerebellum (negative control) and flash frozen in LN2 for biochemical analysis. Floating coronal sections (30μm) from fixed hemibrains are stained for amyloid pathology using anti-Aβ42 antibody (Thermofisher), anti-Aβ 3D6 antibody (Elan), amyloid dyes Thiazine red (ThR; Sigma) or MethoxyXO4 (MeXO4; HelloBio). DNs are assessed using antibodies recognizing the DN markers LAMP1 (1D4B clone), BACE1 (Abcam), APP (Abcam), and reticulon 3 (RT3; Millipore). Microglia and astrocytes are assessed using antibodies recognizing Iba1 (all microglia), CD68 (activated microglia), GFAP (all astrocytes) and C3 (activated astrocytes). Using NIS-Elements software, the area ratio of DNs to Aβ plaques in cortex and hippocampus is determined as shown in Figure 23 [Sadleir et al., PLoS One 17, e0263332, doi:10.1371/journal.pone.0263332 (2022); Sadleir et al., Curr Alzheimer Res 18, 283-297, doi:10.2174/1567205018666210713125333 (2021)]. Areas immunostained for Iba1, CD68, GFAP, and C3 are quantified in the peri-plaque region within 15μm of the plaque core and in the cortex and hippocampus overall. Aβ+ percent area, plaque number, and plaque size is also quantified to determine the effects of A6-GFP and A6(E233A)-GFP overexpression on Aβ pathology. For mice aged to 9.5 months (late prevention paradigm timepoint), NeuN staining is quantified in the subiculum and layer 5 of the cortex to determine if A6-GFP and A6(E233A)-GFP decreases and increases neuron loss, respectively, in 5XFAD mice. Immunostaining with an antibody to activated cleaved caspase 3 (Cell Signaling Technologies), which increases with age in 5XFAD mice89, is performed to determine if A6- GFP and A6(E233A)-GFP decreases and increases apoptosis, respectively. [0278] To address the mechanism by which membrane repair mediated by A6 decreases DNs, Ca 2+ imaging is performed to determine if overexpression of A6 decreases resting Ca 2+ levels in DNs. 5XFAD mice (n=20/group; 10 males, 10 females) receive single tail vein injections of 1x10 12 VG of AAV PHP.eB syn-A6-TdTomato, AAV PHP.eB syn-A6(E233A)- TdTomato, and control AAV PHP.eB syn-TdTomato at 1.5 months of age. At 4 months, brains are cut into 350μm coronal slices on a vibratome and maintained at 37°C in aerated artificial CSF (aCSF) for live multiphoton imaging. Brain slices are loaded with ratiometric Ca 2+ -sensitive dye Indo-1 AM (Invitrogen) and the far-red amyloid dye NIAD4 (Nomadics, Inc.) to mark plaques and Ca 2+ imaging is performed on a Nikon A1R-multiphoton confocal microscope with Chameleon Vision titanium sapphire laser (690-1040nm) and 25x (1.1 NA) water immersion lens (Figure 17A). 400nm (blue, Ca 2+ bound):475nm (green, Ca 2+ free) ratio will be converted to [Ca 2+ ]i as described [Oh et al., J Neurosci 33, 7905-7911, doi:10.1523/JNEUROSCI.5457-12.2013 (2013)] for individual DNs near plaques. Since overexpressed A6 in DNs are marked with red TdTomato fluorescence, Ca 2+ bound:Ca 2+ free ratios are compared between TdTomato-positive and TdTomato-negative DNs within individual animals. Additional 5XFAD mice are transduced with AAV vectors as described and brains prepared for EM to assess microtubule ultrastructure and density in peri-plaque DNs in cortex and in white matter tracts, following previously published procedures [Kandalepas et al., Acta Neuropathol 126, 329-352, doi:10.1007/s00401-013-1152-3 (2013)]. [0279] Based on results described herein (see Figures 23 and 24) showing that A6-GFP overexpression reduced DNs and p-tau181 in 5XFAD mice, and that endogenous or exogenous A6 was rapidly recruited to the site of laser injury in primary neurons, it is expected that overexpression of wild-type A6-GFP and dominant negative A6(E233A)-GFP in neurons will increase and decrease membrane repair, respectively, after laser injury. [0280] Based on annexin A6 being the initiating protein in muscle membrane repair cap formation, it is expected that A6(E233A)-GFP will have the strongest inhibitory effect on membrane resealing, while knockdown or dominant negative constructs of annexins A1 and A2, Bin1, and dysferlin may have smaller but measurable effects on membrane repair. It is also expected that wild-type A6-GFP will reduce Ca 2+ influx, microtubule depolymerization, and neuritic beading in Aβ42-treated primary neurons to improve axonal transport and neuronal survival. Data provided herein show that A6-GFP overexpression from birth reduces DN formation (Figure 23). Therefore, it is expected that a decrease and increase in DNs will be seen with tail vein injection of AAV PHP.eB syn-A6-GFP and AAV PHP.eB syn- A6(E233A)-GFP, respectively, at 1.5 months, the time at which plaques are rapidly growing. It is further expected that overexpression of A6-GFP starting at 4 months, when numerous plaques have already formed, will still reduce the area ratio of DN to Aβ plaque, but not as strongly since plaques formed before 4 months of age may have irreversible membrane damage. As at 1.5 months, overexpression of A6(E233A)-GFP starting at 4 months is expected to exacerbate DN formation in 5XFAD mice. It is also expected that mice harvested at 8 months after AAV PHP.eB syn-A6-GFP injection at 1.5 months may have reduced Aβ burden, since BACE1 reduction in DNs around plaques should lead to slower rates of Aβ production and less plaque seeding [Peters et al., Acta Neuropathol 135, 695- 710, doi:10.1007/s00401-017-1804-9 (2018). PMC5904228]. EXAMPLE 5 [0281] In this Example, the roles of annexin A6 and dystrophic neurites in the accumulation of pathologic phosphorylated tau proteoforms and the seeding and spreading of pathologic AD tau is determined. [0282] It is determined whether membrane repair via annexin A6 protects against DN formation and accumulation of p-tau181 and other pathologic tau proteoforms in DNs resulting in decreased AD tau seeding and spreading. Whether dominant negative A6 increases DN formation leading to increased p-tau and elevated tau seeding and spreading is also determined. It is further determined if overexpression of wild type or dominant negative A6 decreases or increases p-tau accumulation and AD tau seeding and spreading, respectively, in DNs around plaques in 5XFAD mice. [0283] AD tau seeds are isolated from severe human AD brain tissue obtained from the Northwestern Alzheimer’s Disease Research Center. Briefly, frontal cortex gray matter is homogenized with a dounce homogenizer in 9 volumes (v/w) of high salt buffer with 0.1% sarkosyl and 10% sucrose, then centrifuged at 10,000g. Pellets are re-extracted twice, supernatants combined, sarkosyl concentration increased to 1% and supernatant centrifuged at 45,000g. Following PBS washes, the pellet is centrifuged at 250,000g, resuspended in PBS via sonication, and centrifuged at 100,000g. This pellet, containing 60- 70% of tau, is resuspended in PBS via sonication, centrifuged at 10,000g, and the final supernatant collected as AD Tau. Total protein concentration is assessed with BCA assay and tau concentration measured by ELISA.15-30μg tau per gram of tissue at 10-28% purity can be obtained with this method. When injected into brains of an amyloid mouse model such as 5XFAD, AD tau leads to the appearance of AT8+ DNs on the ipsilateral and contralateral sides, with greater plaque burden leading to increased AT8+ DNs and tau spreading [He et al., Nat Med 24, 29-38, doi:10.1038/nm.4443 (2018)]. While AT8 staining is a hallmark of human AD, this marker is very low in amyloid mouse models in the absence of injected AD tau. To verify that seeding-competent AD tau is successfully isolated, AD tau is injected into 5XFAD mice at 3 months, and tau seeding and spreading is assessed by AT8 immunostaining (ThermoFisher antibody MN1020) at 6 months. [0284] To perform tau seeding experiments, cohorts of 5XFAD mice (n = 20/group; 10 males, 10 females) are tail-vein injected with AAV PHP.eB syn-GFP, syn-A6-GFP or syn- A6(E233A)-GFP at 1.5 months, followed by unilateral stereotaxic injection at 3 months of 1 µg AD tau into the dentate gyrus (bregma, −2.5 mm; lateral, −2.0 mm; depth, −2.2 mm) and 1µg AD tau into the overlying cortex (bregma, −2.5 mm; lateral, −2.0 mm; depth, −1.0 mm) using a syringe (Hamilton; syringe 80265-1702RNR and needle 7803-07)35. As a negative control, tau purified from a cognitively unimpaired, healthy brain without tau pathology is injected. Mouse brains are harvested at 6 months or 9 months of age (3 or 6 months after AD tau injection) after transcardial perfusion of PBS with protease and phosphatase inhibitors (Calbiochem). Whole brains are fixed 24-48 hrs in 4% PFA, then cryopreserved with 30% sucrose/PBS and sectioned coronally at 30μm. The left cortex is nicked on the surface of the piriform cortex so that ipsilateral and contralateral sides can be identified during staining and imagining. Tau spreading is detected via AT8 immunostaining. DNs are quantified via immunostaining with antibodies recognizing BACE1, LAMP1, p-tau181, and RT3, and amyloid plaques via staining for Aβ42, 3D6, ThR or MeXO4 as described herein. Other p-tau proteoforms associated with the early Aβ-phase of AD (e.g., p-tau217, p-tau231) will also be assessed, as will known Tau kinases, such as p-JNK, p-CaMKII, p-ERK, and CDK5. It is expected that decreased DNs in A6-GFP overexpressing mice will result in reduced p-tau181, p-tau 231, phosphorylated tau kinases, and AT8 staining in DNs and decreased spread of AT8 immunoreactivity to the contralateral side. Iba1, GFAP, and NeuN immunostaining is also analyzed to assess whether expression of wild type or dominant negative A6-GFP affects microglial and astrocytic responses to plaques and neurodegeneration (at 9 months) in the context of seeding with human AD tau. [0285] As indicated above, it is determined whether overexpression of wild type annexin A6 decreases DNs, p-tau, and the seeding and spreading of AD tau in 5XFAD;TREM2 -/- mice in the absence of TREM2 signaling in microglia. [0286] Using approaches described herein, the effect of A6-GFP overexpression on the seeding and spreading of AD tau is investigated in 5XFAD;TREM2 -/- mice compared to 5XFAD;TREM2 +/+ mice. TREM2 -/- mice (JAX, strain 027197) are crossed with 5XFAD mice to generate 5XFAD;TREM2 -/- and 5XFAD;TREM2 +/+ littermate mice (n=20/group; 10 males, 10 females), which are then tail vein-injected with AAV PHP.eB syn-A6-GFP or control AAV PHP.eB syn-GFP at 1.5 months, followed by unilateral stereotaxic injection at 3 months with 1 µg AD tau each into dentate gyrus and overlying cortex. Mice are harvested at 6 months or 9 months of age (3 or 6 months after AD tau injection) and whole brains processed for immunofluorescence microscopy. All analyses are performed as described herein. It is expected that even in TREM2 -/- mice, A6-GFP overexpression is able to decrease DNs, p- tau181, AT8, and other p-tau proteoforms in DNs and reduce the spread of AD tau in the ipsilateral and contralateral sides of the brain, demonstrating a role for DNs in pathologic tau formation and spread. [0287] Annexin A6 is also correlated with DNs, p-tau proteoforms, tau kinases, microtubule density, activated microglia and astrocytes, and amyloid and tau pathologies in human AD compared to 5XFAD brains. Fixed and frozen frontal cortex, hippocampus and cerebellum (as a control) from non-cognitively impaired amyloid negative (NCI-), NCI amyloid positive (NCI+), mild cognitively impaired amyloid positive (MCI+), and mild, moderate, and severe AD cases (n=10 cases/stage) are obtained from the NU ADRC. Frozen tissue is processed for immunoblot analysis for annexin A6, p-tau181, p-tau217, p- tau231, total tau (Tau5), AT8, p-JNK, p-CaMKII, p-ERK, CDK5, APP/Aβ (6E10 antibody), LAMP1, BACE1, reticulon 3, Iba1, CD68, GFAP, and C3. Immunoblots are quantified on a ProteinSimple blot imager and levels of the above proteins correlated with annexin A6 using Pearson’s coefficient. Fixed tissue is cut into 30μm floating sections and immunostained with antibodies recognizing the proteins above and stained with ThR or MeXO4 to label Aβ plaques and tau tangles and imaged on Nikon T1 widefield and A1 confocal microscopes. Images are quantified using NIS Elements software, immunostained areas calculated as described herein above, and correlated with annexin A6 levels using Pearson’s coefficient. [0288] Based on data provided herein showing a clear reduction in DN:amyloid ratio, DN area, and p-tau181:amyloid in DNs (Figures 23 and 24), it is expected that in the experiments described above, A6-GFP overexpression in neurons will reduce DNs, p-tau accumulation, and the spread of pathologic tau, whereas overexpression of dominant negative A6(E233A)-GFP will increase these phenotypes. While TREM2 KO increases tau spreading, TREM2 deficiency is not expected to prevent A6-GFP overexpression from decreasing DNs, p-tau, and AD tau seeding and spreading. Because increased p-tau181 in CSF and plasma is one of the earliest tau changes in AD, it is also expected that p-tau181+ DNs appear early in NCI+ brains, while AT8+ DNs appear late in MCI+ and AD brains, which have tau pathology and cognitive decline. It is further expected that A6 will have increased localization to DN membranes, especially in NCI+ brains with early-stage Aβ plaques. EXAMPLE 6 [0289] In this Example, it is determined whether exogenous recombinant annexin A6 targeted to the brain is able to restore Ca 2+ homeostasis and decrease pathologic p-tau, AD tau seeding and spreading, and dystrophic neurite formation around amyloid plaques in 5XFAD mice. Exogenous recombinant annexin A6 targeted to the brain is expected to promote neuronal membrane repair and decrease DN formation, p-tau accumulation, and pathologic tau seeding and spreading, rendering amyloid plaques less toxic to surrounding neurites, thus slowing disease progression. [0290] It is also determined whether recombinant A6-HIS localizes to sites of Aβ42 oligomer or fibril contact with mouse primary neurons and reduces neuronal membrane damage, Ca 2+ and dye influx, and neuritic beading. Site directed mutatgenesis is used to generate A6(E233A) with 6-HIS (pCMV6-AC-His backbone, PS100002, Origene) and TdTomato tags (PS10010, Origene) as described herein and then A6-HIS, A6(E233A)-HIS, A6-TdTomato, and A6(E233A)-TdTomato is expressed and purified in ExpiCHO or Expi293 cells at the Northwestern Recombinant Protein Production Core as described [Demonbreun et al., J Clin Invest 129, 4657-4670, doi:10.1172/JCI128840 (2019) and herein]. Primary neurons are isolated from E15.5 mouse cortex, cultured for 7 and 14 DIV, and then treated with oligomeric or fibrillar Aβ42 (10μM) in the presence of A6-HIS or A6(E233A)-HIS (1, 10, 33, 100 μM). A similar experiment using A6-TdTomato and A6(E233A)-TdTomato is conducted for live-imaging time course studies of neuritic beading and axonal trafficking. After 1 hr of Aβ42 exposure, neurons are treated with fluorescently-conjugated wheat-germ agglutinin to label membranes, then fixed and stained with antibodies to Aβ42 and the 6-HIS tag (Cell Signaling, 12698). It is expected that A6-HIS will colocalize with Aβ42 at puncta on the cell membrane (Figure 19D) in a A6-HIS concentration-dependent manner, similar to binding to injured muscle cells. A6(E233A)-HIS is expected to show greatly reduced localization to the membrane at sites of Aβ42 contact due to its inability to bind phospholipids in the presence of Ca 2+ [Demonbreun et al., J Clin Invest 129, 4657-4670, doi:10.1172/JCI128840 (2019)]. Correlation of A6-HIS and A6(E233A)-HIS with Aβ42 is determined by Pearson’s Correlation coefficient in NIS-Elements. The effects of A6-HIS and A6(E233A)-HIS on Aβ42-induced Ca2+ and dye influx, microtubule disorganization, lysosome trafficking, accumulation of DN markers LAMP1 and BACE1, and viability is also determined, as described herein for neurons overexpressing A6-GFP or A6(E233A) from AAV. It is expected that adding exogenous A6-HIS will reduce Ca 2+ and dye influx, neuritic beading, and accumulation of markers of DNs and apoptosis, while A6(E233A)-HIS will not be protective and may even have a detrimental effect. If the effects of exogenous A6-HIS are similar to those of overexpressed A6-GFP, however, then the protective effects of A6 likely derive from its membrane resealing properties, not from some other cellular function. [0291] It is further determined whether recombinant annexin A6-HIS brain infusion via ICV injection or mini-pump implantation results in membrane localization on DNs around plaques in 5XFAD mice. It has been shown that A6 does not need to be expressed in the cell undergoing damage to improve membrane repair in mouse models of acute (cardiotoxin injection) or chronic (muscular dystrophy) muscle injury [Demonbreun et al., J Clin Invest 129, 4657-4670, doi:10.1172/JCI128840 (2019)]. Indeed, exogenous recombinant A6 binds to sites of membrane damage and facilitates membrane repair in muscle [Demonbreun et al., J Clin Invest 129, 4657-4670, doi:10.1172/JCI128840 (2019)]. Additionally, it is shown herein that exogenous recombinant A6 colocalizes with genomically expressed A6 at sites of laser damage in primary neurons (Figure 19B and 19C). To determine the minimal dose required for widespread A6-HIS membrane localization, single ICV injections in 5XFAD mice (5/group) of lower doses of A6-HIS and A6(E233A)-HIS (0.1mg/kg, 0.33mg/kg, 0.66mg/kg, 1 mg/kg) are performed, harvested at longer timepoints (3, 6 and 18 hours), and then anti-HIS immunohistochemistry is conducted. A6-HIS staining intensities are compared at all doses and timepoints to find the membrane saturating dose. A short-term Alzet pump implantation (1-2 weeks; 5 mice/group) is then performed to administer a daily dose corresponding to the saturating dose, and 2-fold higher and lower, and the mice are harvested for immunohistochemistry. [0292] For ICV injections, 5XFAD mice are anesthetized by isofluorane inhalation (ISOTHESIA, ndc 11695-6776-2, Henry Schein) delivered with a Basic Small Animal Anesthesia Device model R500IE (RWD Life Science Co. Ltd). The right lateral ventricle is located using the following stereotaxic coordinates: AP: -0.6; ML: +1.2; DV: -2.0. A small hole is drilled in the skull and the needle of a Hamilton syringe (80265-1702RNR, needle 7803-07) filled with A6-HIS or A6(E233A)-HIS lowered into the right lateral ventricle. For placement of the Alzet pump, mice are prepared the same, but instead a cannula from Brain infusion kit 3 (cat # 0008851, Alzet) is inserted and the brain infusion kit cemented on the skull. A small subcutaneous pouch on the back of the mouse is made to fit Alzet mini- osmotic pump 2006 connected to the brain infusion kit. [0293] As a functional test of the A6 saturating dose, 5XFAD mice (5/group) are implanted with mini-osmotic pumps to infuse A6-TdTomato or A6(E233A)-TdTomato at the saturating dose for 1-2 weeks. Mice are harvested for live-slice imaging with the Indo-1 Ca 2+ sensor, as described herein. The Indo-1400nm/475nm ratio is quantified in TdTomato positive and negative DNs, and it is expected that those with A6-TdTomato will have reduced Ca 2+ , while those with A6(E233A)-TdTomato will have increased Ca 2+ , compared to TdTomato negative DNs. [0294] Whether osmotic minipump administration of recombinant A6-HIS decreases elevated Ca 2+ , p-tau accumulation, AD tau seeding and spreading, and DN formation in 5XFAD mice is also determined. Osmotic minipumps are used to chronically deliver recombinant A6-HIS into the lateral ventricle of 5XFAD mice. Osmotic minipumps have been successfully used for long-term administration a variety of proteins into the brain, such as antibodies [Dang et al., Cell Rep 27, 1073-1089 e1075, doi:10.1016/j.celrep.2019.03.084 (2019); Furuyama et al., Nature 567, 43-48, doi:10.1038/s41586-019-0942-8 (2019); Mastrella et al., Cancer Res 79, 2298-2313, doi:10.1158/0008-5472.CAN-18-0881 (2019); Roy et al., Immunity, doi:10.1016/j.immuni.2022.03.018 (2022)] and NGF [Benitez et al., Front Endocrinol (Lausanne) 12, 636600, doi:10.3389/fendo.2021.636600 (2021); Kawasaki et al., J Pharmacol Sci 140, 1-7, doi:10.1016/j.jphs.2019.02.011 (2019)], among others. The effect of A6-HIS is tested from 3 to 4.5 months of age, a time of very active Aβ plaque seeding and growth. At 3 months of age, groups of 205XFAD mice (10 males, 10 females) are implanted with osmotic minipumps (model 2006, Alzet) containing A6-HIS, A6(E233A)- HIS, or vehicle (artificial CSF). During the last week of infusion, mice undergo behavioral testing (Y-maze, fear conditioning, novel object recognition), and following 42 days of continuous infusion, mice are harvested for brain analysis. As described herein for analysis of mice overexpressing A6-GFP, brains are stained for amyloid plaques and DN markers and ratios (e.g., LAMP1:Aβ42) determined using NIS-Elements software. If extracellular recombinant A6-HIS functions similarly to intracellular AAV-expressed A6-GFP, a reduction in the DN:amyloid ratio is exptected. Reduction of p-tau proteoforms is confirmed by immunohistochemistry as described herein and Ca 2+ imaging is performed with Indo-1 in brain slices as described herein. It is also determined if osmotic minipump administration of A6-HIS reduces AD tau seeding and spreading.5XFAD mice will undergo osmotic minipump infusion of A6-HIS, A6(E233A)-HIS, or vehicle into the right lateral ventricle for 42 days, after which minipumps are replaced with new pumps and fresh A6 proteins. Mice are then injected with AD tau into the left dentate gyrus and overlying cortex as described herein. Following another 42 days of annexin A6 infusion, mice are harvested for brain analysis to determine the extent of AD tau seeding and spreading as described herein. [0295] It is expected that recombinant A6-HIS will decrease Ca 2+ influx, neuritic beading, and cell death in primary neuron cultures and reduce DNs, p-tau, and AD tau seeding and spreading in 5XFAD brain. 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