United States



Abstract Title
Retrospective Study of the Relationship between Daily Oral Multivitamin Intake and Sleep Complaints in Post-Menopausal Women – An Analysis of NHANES Data (1999-2020)

Background
This study investigates whether daily oral multivitamin intake affects sleep patterns and sleep complaints in post-menopausal women. The hypothesis is that daily multivitamin intake may improve sleep quality in this demographic.

Methods
Data from the NHANES surveys (1999-2020) were analyzed to study the relationship between multivitamin use and sleep complaints. Dietary supplement usage, menopause status, and sleep data were extracted and pre-processed. Participants were categorized into two groups: those who took daily multivitamins and those who did not. Post-menopausal status was identified, and relevant sleep data from 2005-2020 was included. The final sample comprised 1,647 post-menopausal women who took daily multivitamins and 2,643 who did not.

The primary variable of interest was hours of sleep per night (SLD010/12). Outliers were removed, and the Shapiro-Wilk test was conducted to assess normality. Due to non-normal distributions (p &lt; 0.05), the Mann-Whitney U test was used to compare the sleep duration between groups.

The secondary variable was sleep complaints (SLQ050), evaluated using a Chi-Square test of independence to assess the association between multivitamin use and reported sleep troubles. A post-hoc Fisher’s Exact test was also performed to confirm the significance of the findings.

Results
The analysis revealed that post-menopausal women who took daily multivitamins had a significantly higher mean sleep duration (7.289 hours) compared to those who did not take multivitamins (6.946 hours), with a median of 7.0 hours for both groups. The Mann-Whitney U test indicated a significant difference in sleep duration between the groups (Z = -6.754, p &lt; 0.001). Additionally, there was a significant association between multivitamin use and reported sleep troubles, with the Chi-Square test showing (Χ² (1) = 4.167, p = .041) and the Fisher’s Exact test confirming a statistically significant difference (p &lt; 0.001). These findings suggest that while multivitamin intake may increase sleep duration, it is also associated with a higher incidence of reported sleep troubles among post-menopausal women.

Conclusion
Daily multivitamin use may increase the number of sleep hours per night but is also associated with reported sleep troubles. These findings highlight the importance of discussing multivitamin use with healthcare providers for post-menopausal women. Further research should consider additional confounding factors and the broader implications of multivitamin use on sleep quality.





AMA Research Challenge 2024 

Retrospective Study of the Relationship between Daily Oral Multivitamin Intake and Sleep Complaints

Abstract Title
Retrospective Study of the Relationship between Daily Oral Multivitamin Intake and Sleep Complaints in Post-Menopausal Women – An Analysis of NHANES Data (1999-2020)

Background
This study investigates whether daily oral multivitamin intake affects sleep patterns and sleep complaints in post-menopausal women. The hypothesis is that daily multivitamin intake may improve sleep quality in this demographic.

Methods
Data from the NHANES surveys (1999-2020) were analyzed to study the relationship between multivitamin use and sleep complaints. Dietary supplement usage, menopause status, and sleep data were extracted and pre-processed. Participants were categorized into two groups: those who took daily multivitamins and those who did not. Post-menopausal status was identified, and relevant sleep data from 2005-2020 was included. The final sample comprised 1,647 post-menopausal women who took daily multivitamins and 2,643 who did not.

The primary variable of interest was hours of sleep per night (SLD010/12). Outliers were removed, and the Shapiro-Wilk test was conducted to assess normality. Due to non-normal distributions (p < 0.05), the Mann-Whitney U test was used to compare the sleep duration between groups.

The secondary variable was sleep complaints (SLQ050), evaluated using a Chi-Square test of independence to assess the association between multivitamin use and reported sleep troubles. A post-hoc Fisher’s Exact test was also performed to confirm the significance of the findings.

Results
The analysis revealed that post-menopausal women who took daily multivitamins had a significantly higher mean sleep duration (7.289 hours) compared to those who did not take multivitamins (6.946 hours), with a median of 7.0 hours for both groups. The Mann-Whitney U test indicated a significant difference in sleep duration between the groups (Z = -6.754, p < 0.001). Additionally, there was a significant association between multivitamin use and reported sleep troubles, with the Chi-Square test showing (Χ² (1) = 4.167, p = .041) and the Fisher’s Exact test confirming a statistically significant difference (p < 0.001). These findings suggest that while multivitamin intake may increase sleep duration, it is also associated with a higher incidence of reported sleep troubles among post-menopausal women.

Conclusion
Daily multivitamin use may increase the number of sleep hours per night but is also associated with reported sleep troubles. These findings highlight the importance of discussing multivitamin use with healthcare providers for post-menopausal women. Further research should consider additional confounding factors and the broader implications of multivitamin use on sleep quality.

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Background
Endothelial Notch signaling is a key player in regulating inflammation. While Notch1 has been extensively studied in the context of vascular inflammation, the role of endothelial Notch4, remains relatively unexplored. Growing evidence suggests that Notch4 plays critical roles in human endothelial inflammatory disorders. Polymorphisms in Notch4 are associated with endothelial dysfunction in preeclampsia, HIV-triggered glomerular injury, and severity of COVID-19 endothelial inflammation. Our recent work has shown that pharmacologic inhibition of endothelial Notch4 signaling using an anti-Notch4 antibody alters macrophage number and phenotype in mouse models of breast cancer, further supporting a distinct role for Notch4 in regulation of inflammatory targets. Our preliminary work has determined that Notch4 regulates an endothelial transcriptome distinct from Notch1, which is enriched for inflammatory genes such as CCL2 and IL6. However, all Notch proteins bind DNA via a common transcriptional co-factor, CSL, and the mechanism of how different Notch proteins regulate distinct transcriptional targets remains unclear. Better methods for detection of real-time and gene-specific activation of Notch signaling are critical for dissecting the roles of different Notch proteins in endothelium.

Methods
To examine gene-specific Notch transcriptional activity, we used the NanoBiT protein-protein-interaction system, a complementation-based luciferase reporter system composed of two split luciferase fragments, LgBiT and SmBiT. The NanoBiT PPI system allows for detection of protein:protein interactions through two subunits, Large BiT (LgBit) and Small BiT (SmBit), fused to two proteins of interest. Interaction between target proteins allows the subunits to come together resulting in luminescent signal that can be quantified in live cells. Real-time quantification allows for dynamic monitoring, capturing transient interactions and providing temporal resolution that homogenate testing lacks. We designed fusions of the active intracellular domain of Notch4 (ICN4) or Notch1 (ICN1) with SmBiT, and CSL with LgBiT and expressed the fusion proteins in HeLa cells. The resulting interactions between fusion proteins resulted in luminescent signal that was quantified using the SpectraMax L Microplate Reader. 

Results
We validated that NanoBiT CSL and ICN fusion proteins were expressed at high levels and retained their ability to induce Notch pathway targets. Co-expression of CSL-LgBiT with either ICN4-SmBiT or ICN1-SmBiT resulted in robust induction of luminescent signal. Interaction between CSL and ICN4 consistently yielded a higher luminescent signal than ICN1, suggesting that Notch4 may more strongly interact with CSL. 

Conclusion
We have designed and tested a novel method for real time measurement of gene-specific Notch pathway activation. Our preliminary findings suggest that Notch4 plays a distinct role in inflammatory signaling, possibly due to its robust interaction with CSL. Our NanoBiT-based assay may be used to determine protective targets in inflammatory diseases. 


Endothelial Notch4 regulates inflammatory signaling in a manner distinct from Notch1

AUTHORS: Dana Wang (2), Victor A. Lopez (1), Jessica Gannon (1), Sheryl Coutermarsh-Ott (3), Jeremy A. Brown (4), Adam Maxwell (1), Joanne Tuohy (5), Eli Vlaisavljevich (1)

(1) Biomedical Engineering and Mechanics, Virginia Tech 
(2) Virginia Tech Carilion School of Medicine, Virginia Tech 
(3) Biological Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine 
(4) School of Biomedical Engineering, Dalhousie University
(5) Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine 

BACKGROUND: Oral tumors are frequently diagnosed in both humans and dogs and have potential for malignancy. Current standard of care treatments like surgery, radiation, and chemotherapy are invasive, often leading to facial disfigurements and other adverse effects that decrease quality of life. There is a pressing need for less invasive treatments that preserve oral function and appearance.

Histotripsy is a non-invasive, non-thermal, and non-ionizing image-guided focused ultrasound technique. It utilizes acoustic cavitation to break down tissue into acellular debris by producing high-pressure ultrasound pulses that converge at the transducer focus to generate a cavitation bubble cloud for mechanical tissue ablation. While current clinical histotripsy systems are large, cart-based devices operating between 500kHz to 1MHz for deep tissue treatments like the liver, this study aims to develop miniaturized high-frequency histotripsy transducers for targeting smaller, superficial structures like oral tumors.

METHODS: CT images of canines with oral tumors were segmented and analyzed in MATLAB to identify accessible acoustic windows with histotripsy treatment. A ray-sphere intersection approach was used to guide transducer designs based on predicted acoustic windows. 2MHz and 6.3MHz single-element transducers were developed and tested on excised canine oral tumors, producing bubble cloud diameters of approximately 2mm and 0.25mm, respectively. Excised canine oral tumors were degassed, embedded in 1% agarose gel, and underwent treatment with both transducers using a pulse repetition frequency of 1kHz and 2,000 pulses per point. Real-time ultrasound imaging was used for treatment monitoring and post-treatment ablation was quantified histologically with hematoxylin and eosin stain. 

RESULTS: CT acoustic window analysis produced a matrix showing where ultrasound pulses could reach the tumor unimpeded by the skull. This visual representation illustrated the spatial relationship between the acoustic window, skull, and oral tumor. During ex-vivo treatments, real-time ultrasound imaging indicated that both 2MHz and 6.3MHz transducers generated well-confined bubble clouds. After treatment, hypoechoic regions observed within the tissue suggested tumor ablation and liquefaction. Histological analysis confirmed complete, delineated ablation and decellularization of the tissue within the treated area. The 2MHz transducer demonstrated faster ablation rates, approximately 7.4 times quicker than the 6.3MHz transducer.

CONCLUSIONS: Preliminary acoustic window analysis informed optimal transducer positioning for targeting oral tumors effectively with a smaller transducer system. Both the 2MHz and 6.3MHz transducers successfully ablated excised canine oral tumors. Overall, this study shows the feasibility of ablating oral tumors with histotripsy for the first time and provides insight on optimizing histotripsy devices for oral tumor treatment.

Histotripsy for the Treatment of Oral Tumors: A Canine Ex-Vivo Feasibility Study

Abstract Title
Hodgkin-Huxley Algorithm to Diagnose Channelopathies from Empirical Action Potentials

Background
Human channelopathies are diagnosed by symptom profile or genetic testing which fail to provide a mechanistic basis for patients’ experiences. This project aims to develop an algorithm that decomposes a patient’s electrophysiology data into clinically relevant values that would better focus treatment efforts. Our model system for variation in action potential pathology are garter snakes (Thamnophis spp.) that have evolved resistance to their neurotoxic prey (Taricha spp.). The toxin, tetrodotoxin, occludes the pore of voltage-gated sodium channels that conduct sensory and motor impulses. However, resistance mutations observed in snake skeletal muscle voltage-gated sodium channels significantly reduce channel function by limiting sodium conductance. Our model aims to reproduce that level of mechanistic detail from action potentials recorded in vivo directly in the target tissue rather than by complicated whole-cell electrophysiology techniques.

Methods
To observe sodium channel conductivity deficits, we collected action potentials from known healthy and pathological samples and then trained a model based on this dataset. We recorded from muscles carrying tetrodotoxin-sensitive sodium channels (NaV1.4⁺, N=9) from Thamnophis atratus as well as from snakes with mildly resistant channels (A1281P, N=11) suffering mild deficits. We then tailored the Hodgkin-Huxley model of the action potentials to fit skeletal muscle recordings. We deployed the model to decompose action potentials into distinct, molecularly-based mathematical parameters, including sodium channel conductance (GNa), sodium channel activation (m), and inactivation (h). We generated representative action potentials based on averages of each group. Then, R was used to fit a parameter set to each group to assess differences in molecularly-based parameters between groups (e.g. GNa).

Results
The model reproduced the expected negative correlation between sodium channel mutations and channel conductance (e.g. reduced GNa). Furthermore, it revealed significant decreases in two kinetic subparameters, m and h, providing an additional explanation of reduced conductance. These data validate our model against peer-reviewed research (del Carlo et al., 2024)

Conclusion
This model offers the first estimate of sodium channel function in native snake skeletal muscle. Our model produced results congruent with findings of peer-reviewed reports using gold-standard methods. However, the model currently lacks sufficient specificity to evaluate patient-level data. Ongoing work aims to expand this model as a diagnostic tool by training it on even more extreme snake channelopathies. With further refinement, this model could be a clinically useful tool for the differential diagnosis of human channelopathies, advancing personalized medicine for inherited disorders.

Hodgkin-Huxley Algorithm to Diagnose Channelopathies from Empirical Action Potentials

The nicotinic acetylcholine receptor (nAChR) has been shown to play a functionally distinct role in the development of the adolescent brain through the modulation of neurotransmitter release across various neurodevelopmental milestones. CHRNA2 encodes for the α2 nicotinic acetylcholine receptor associated with CA1 oriens lacunosum moleculare GABAergic interneurons and is associated with learning and memory. Prior literature consistently supports the finding that chronic nicotine exposure during adolescence leads to an impairment in learning in adulthood. Previously, we found that adolescent male hypersensitive (CHRNA2 L9'S/L9'S) mice had impairments in learning and memory during a pre-exposure-dependent contextual fear conditioning task that could be rescued by low-dose nicotine exposure. In this study, female adolescent CHRNA2 L9'S/L9'S mice and wild-type (WT) littermate controls were exposed to saline or nicotine (0.09 mg/kg) using a hippocampus-dependent task of pre-exposure-dependent contextual fear conditioning. Alterations in freezing behavior—an indication of learning—were compared between CHRNA2 L9'S/L9'S and WT female adolescent mice as well as against adolescent male CHRNA2 L9'S/L9'S and WT mice. We found that nicotine-treated adolescent WT female mice had significantly greater freezing behavior than both saline-treated WT mice and nicotine-treated CHRNA2 L9'S/L9'S female mice. Nicotine-treated adolescent CHRNA2 L9'S/L9'S female mice did not have enhanced freezing behavior on context test (CT) day when compared with saline-treated CHRNA2 L9'S/L9'S female mice. These results indicate that hypersensitivity of the CHRNA2 gene in female adolescent mice produces deficits in nicotine-dependent learning and memory in the hippocampus. These results are contrasted with the results obtained in the previously published male data where we found that male hypersensitive (CHRNA2 L9'S/L9'S) mice had impairments in learning and memory that could be rescued by low-dose nicotine exposure. Thus, nicotine exposure mediates a sexually dimorphic pattern of learning and memory in WT and CHRNA2 L9'S/L9'S adolescent mice exposed to a pre-exposure-dependent contextual fear conditioning paradigm. At present, the mechanism driving sexual dimorphisms between nicotine-exposed adolescent CHRNA2 L9'S/L9'S mice is unknown. Further research must be conducted in both in-vitro and in-vivo studies examining the role of α2- expressing nAChR signaling mediating sex-dependent effects.

Hypersensitivity of the nicotinic acetylcholine receptor subunit (CHRNA2 L9’S) in female adolescent mice produces deficits in learning and memory that are not rescued by nicotine


Background 

Tumor cells in the tumor microenvironment (TME) are known to upregulate endoplasmic reticulum (ER) stress as a survival mechanism and ER stress transmission to the mitochondria is associated with tumorigenesis. We studied the mitochondrial unfolded protein response (mtUPR) associated Lon protease 1 (LONP1) in tumor cells undergoing ER stress. Our hypothesis is LONP1 inhibition during ER stress promotes immunogenic cell death (ICD) in melanoma cells.

Methods 

To simulate the TME, we used murine B16 melanoma cells that were treated with thapsigargin, a compound known to induce ER stress. Then, some cells were co-treated with both thapsigargin and CDDO-Me, a pharmacological inhibitor of LONP1. RT-PCR was used to assess potential targets associated with mt-UPR. TIMER is a database we used to assess the clinical significance of LONP1 in skin cutaneous melanoma patients. MitoProbe DIOC assay was used to assess mitochondrial membrane potential. Annexin V/PI assay was used to determine the proportion of apoptotic cells. Calreticulin exposure assay was used to determine the expression level of cell-surface calreticulin. CellTiter-Glo assay was used to determine both the intracellular and extracellular concentrations of ATP.

Results

RT-PCR showed that Lonp1 is expressed in response to ER stress. TIMER showed that expression of LONP1 is negatively correlated with the infiltration of cytotoxic CD8+ T cells, CD4+ T cells and activated NK cells. MitoProbe DIOC assay of co-treated cells showed the lowest mitochondrial membrane potential. Annexin V/PI assay of those cells showed an increase in apoptosis versus all other conditions. Calreticulin exposure assay of co-treated cells showed an increase in cell-surface calreticulin exposure versus all other conditions. CellTiterGlo assay showed both decreased intracellular ATP and increased extracellular ATP in cotreated cells only.

Conclusion

B16 melanoma cells undergoing ER stress in the absence of LONP1 function showed higher cell-surface calreticulin, higher extracellular ATP release, increased entry into late apoptosis and their mitochondrial membrane potential was significantly reduced. We conclude that inhibition of LONP1 in the presence of ER stress induced ICD in our cells, suggesting LONP1 as a potential target for cancer immunotherapy.

Inhibiting LONP1 Promotes Immunogenic Cell Death in Melanoma Cells Undergoing Endoplasmic Reticulum Stress

Background
Laser powder bed fusion (LPBF) is a 3D printing technique that rapidly and selectively melts metal powder via laser irradiation which then solidifies in the prescribed pattern before a new layer of powder is spread across the surface and the process repeats. LPBF is the most common 3D printing method used with stainless 316L alloys. It offers advantages in the biomedical field by improving mechanical properties such as fracture toughness and strength, enabling complex, patient-specific geometries and reducing material waste, crucial for applications like stents and implants. Nevertheless, consideration of corrosion behavior is crucial in assessing the longevity of these materials in aqueous environments. 

Methods
Various corrosion tests were conducted on LPBF-produced stainless steel alloys. These tests included polarization scans in acidic environments to assess corrosion resistance, mass loss testing in ferric chloride and sodium chloride solutions to measure susceptibility to localized corrosion, and galvanostatic etching in ammonium persulfate to identify microstructural sites prone to selective attack. Transmission electron microscopy was used to analyze local chemical composition differences at a microscale. Scanning electron microscopy and optical microscopy characterized the microstructure, focusing on features susceptible to localized corrosion.

Results
Corrosion testing showed lower rates for LPBF-produced material compared to conventionally processed stainless steel, suggesting enhanced corrosion resistance. However, post-test analysis revealed various localized corrosion forms, including dissolution through cellular structures formed during the rapid solidification inherent to LPBF. Transmission electron microscopy uncovered local variations in elements critical to corrosion resistance like chromium and molybdenum, impacting corrosion behavior. These findings emphasize the complexity of corrosion mechanisms in LPBF materials and the importance of detailed microstructural analysis.

Conclusion
The study identified lower corrosion rates in LPBF-produced stainless steel alloys but also highlighted localized corrosion pathways through cellular structures, pores formed due to inadequate metal fusion, and other microstructural features inherent to the LPBF process. Advanced microscopy techniques revealed elemental variations influencing corrosion behavior. Future research should explore diverse environments, long-term corrosion performance, and predictive models linking microstructure to corrosion behavior. Addressing these challenges is vital for developing corrosion-resistant materials for biomedical applications and enhancing device performance in clinical settings.

Investigating Corrosion Behavior in 3D Printed Laser Powder Bed Fusion Stainless Steel 316L Alloys - Insights into Material Behavior Relevant for Biomedical Applications

P21-activated kinase 1 (PAK1) is a serine/threonine protein kinase that plays a crucial role in cardiomyocyte survival in response to various stresses. However, the underlying cardioprotective mechanisms of PAK1 remain unclear. Autophagy is a lysosome degradation pathway essential for cellular homeostasis. In the present study, we showed the ability of PAK1 to regulate autophagy in cardiomyocytes and identified p62 as a potential downstream mediator. PAK1 is silenced in H9c2 cardiac myoblasts by siRNA or overexpressed by adenovirus. Autophagy flux was determined by LC3-II protein levels and a fluorescent autophagy reporter with and without the lysosomal protease inhibitors Pepstatin A (pepA) and Aloxistatin (E64d). Downregulation of PAK1 reduced LC3-II levels in whole cell lysates, which was not affected by pepA and E64d, suggesting that PAK1 knockdown reduced autophagy flux. Conversely, PAK1 overexpression increased LC3-II levels, which were further elevated by pepA and E64d, suggesting that PAK1 is sufficient to promote autophagy. Interestingly, the protein expression of p62, a ubiquitin-binding autophagy adaptor, was increased by PAK1 overexpression and reduced by PAK1 knockdown. Importantly, overexpression of p62 rescued the defective autophagy flux in the absence of PAK1, suggesting that p62 may mediate PAK1-dependent autophagy. RT-qPCR assay showed that the p62 mRNA levels were unchanged by either overexpression or knockdown of PAK1 in vitro and in vivo. The cells were treated with the protein synthesis inhibitor cycloheximide (CHX) and p62 protein levels were measured over time in both PAK1-silencing and overexpressing conditions. The results showed that p62 degradation was mitigated by PAK1 overexpression and accelerated by PAK1 knockdown. Together, these results suggest that PAK1 is sufficient and necessary to maintain autophagy in cardiomyocytes, which is likely mediated by its ability to affect p62 protein stability.

PAK1 regulates cardiomyocyte autophagy through p62

Kv7 channels are potassium ion channels expressed in the nervous system. Kv7 channels function to control the excitability of neurons by reducing the rate of action potential firing. The Kv7.2 channel has been shown to play a particularly crucial role in neurodevelopment. Five different KCNQ genes encode Kv7 subunits, which form a tetrameric Kv7 channel. Loss of function mutations in the KCNQ2 gene have been shown to result in neurologic dysfunction, including neonatal epilepsy. Therefore, regulation of Kv7.2 is essential for normal neuronal function. Calmodulin (CaM) is a calcium (Ca2+)-binding protein shown to interact with the C-terminus of Kv7.2, particularly with its intracellular regulatory domain. This region contains several hotspots for pathological mutations, suggesting their importance in regulating the function of Kv7.2. The regulatory domain of KCNQ2 is composed of two regions of importance to this study: the A helix (Q2A) and B helix (Q2B) (Fig. 1 & 2). CaM binds to each Kv7 subunit by interacting with Q2A and Q2B. The amino acid sequence of Q2B contains phosphorylation sites at serines S520 and S527 which could potentially contribute to the regulation of Kv7.2 function. This study aims to characterize the Ca2+-dependent binding interactions between CaM and the regulatory domain of Kv7.2. It is also investigating whether phosphorylation of Q2B interferes with CaM interactions and how CaM modifies its binding to the regulatory domain. Binding interactions were studied by electrophoretic mobility shift assay (EMSA) and isothermal calorimetry (ITC). Results from the ITC show that CaM has a higher affinity for Q2B (Kd = 0.243 μM) than Q2A (Kd = 5.27 μM). Compared to the binding affinity between CaM and an extended Q2B sequence (Kd = 0.05 μM), the binding affinity is 42x lower when Q2B is phosphorylated at S520 (Kd = 2.1 μM) and only 5x lower when phosphorylated at S527 (Kd = 0.25 μM). EMSA shows a degree of CaM binding to Q2B phosphorylated at S527 but demonstrates no binding when phosphorylated at S520. These findings indicate that Q2B phosphorylation at S520 blocks CaM interactions in the presence of Ca2+.

Phosphorylation of Kv7.2 Potassium Channel's Regulatory Domain Alters Binding Interactions with Calmodulin

Background
An individual’s healthcare costs can provide an objective measure of overall morbidity. Quantifying the impact of genetic variation on healthcare costs can inform public health policies and help identify genetic determinants of mortality. 

Methods
We estimated inpatient, outpatient, primary care and prescription-related costs, from the perspective of healthcare systems, for a total of 1.3 million individuals across 8 different healthcare systems. The median per-patient annual healthcare cost (expressed in 2019 prices) had substantial range across countries, from €483/year in the Estonian Biobank to €458,455/year in the Mass General Brigham Biobank. 

A GWAS meta-analysis identified 27 and 106 significant, independent loci for inpatient and medication costs, respectively. Effects were overall modest, the most significant inpatient signal (rs6938239 near ILRUN) was associated with ~1% increased cost per year, per allele. Following stratified analyses, 33% of inpatient loci had sex-specific effects while 22% had an age-specific effect. E.g. homozygous carriers of variant rs62236881 in the 3’ UTR of ZNRF3 had 9% higher costs in females compared with 4% in males, potentially due to an increased risk of breast cancer.

Results
Despite differences in tariff structure and cost reimbursement across healthcare systems, we observed strong genetic correlations between inpatient studies (median rg=0.88) and 95% of significant loci did not show heterogeneity across studies. PheWAS indicated that significant loci may impact healthcare costs via either common risk factors (e.g. BMI) or chronic diseases risk (e.g. asthma, depression).

Leveraging whole-exome sequencing data from the UK Biobank (UKB), we estimated the cost for putative loss of function (pLOF) burdens for 83 clinically relevant genes. The largest effects were observed for BRCA1/2, MSH2 and APC. Annual inpatient costs were ~1.8 times higher in individuals carrying one pLOF in BRCA2 than in non-carriers. We estimated that the total annual inpatient costs attributed to BRCA2 pLOF mutations amongst those aged 40-69 in the UK would be about €26 million.

Polygenic scores (PGS) for various risk factors and diseases were linked to higher healthcare costs. In UKB, the top 10% with the highest BMI PGS had a median annual cost of €414, compared to €329 for those in the middle 40-60%. Using polygenic weights from GenCost data, PGS for ~11,000 individuals in Genomics England showed that the top 10% incurred ~€250 more than those in the middle 40-60%.

Conclusion
Genetic variation across individuals influences healthcare expenditure. Our findings are applicable across various healthcare systems and help better understanding global morbidity.

Quantifying the impact of genetic variation on healthcare cost across 1.3 million individuals from 11 studies and 8 countries: The GenCost Consortium

Background: Hirschsprung disease is a congenital neurocristopathy that affects 1 in 5000 newborns. The disease involves fetal gut aganglionosis due to the defective migration and differentiation of neural crest cells in the intestines. The condition is associated with intractable constipation, megacolon ileus and the need for colectomy in childhood. While it was previously known that gestational exposures such as maternal vitamin A deficiency, ibuprofen intake, and BP-3 sunscreen use had implications on the development of Hirschsprung, we found that these variables share effects common to the RET proto-oncogene pathway.
Methods: An initial systematic review was done on the NIH library, PubMed and Scorpus databases to evaluate existing literature on maternal gestational exposures tied to Hirschsprung disease. Search queries involved keywords “Hirschsprung disease”, “maternal exposure” and “developmental pathway”. Inclusion criteria for accepted studies were: peer reviewed status, sample size greater than twenty, human models, discussion of developmental mechanisms, and published within the past twenty years. Based on these studies, we categorized the maternal exposure variables and further reviewed the specific biologic pathways impacted. From this list of pathways, the mechanism common between the highest number of categories was selected for this report. 
Results: This study explores how maternal exposures to vitamin A deficiency, BP-3, and ibuprofen increase the risk of Hirschsprung disease by affecting the RET proto-oncogene, which is essential for neural crest cell migration and implicated in at least 20% of all Hirschsprung cases. Retinoic acid, the active form of vitamin A, upregulates RET transcription. As a result, low vitamin A levels can downregulate RET and impair neural crest cell migration. Benzophenone-3 (BP-3), a sunscreen ingredient, reduces RET levels by disrupting fetal enteric neuron development and neural crest cell migration via the SLIT2/ROBO1-miR-218-RET/PLAG1 pathway. While ibuprofen does not directly affect RET, it may affect RET signaling by increasing acetylcholinesterase (AchE) activity, as suggested by studies showing co-expression of RET and choline acetyltransferase in enteric ganglia.
Conclusion: 
Our study found that vitamin A deficiency, BP-3, and ibuprofen increase the risk of Hirschsprung disease via different pathways, with the RET proto-oncogene being the most commonly implicated gene. Vitamin A deficiency and BP-3 exposure both affect the RET signaling pathway, while ibuprofen appears to indirectly increase risk through a separate mechanism. These findings highlight the need to monitor and mitigate maternal exposures to reduce Hirschsprung disease risk and suggest the RET proto-oncogene as a potential target for treatment and prevention.



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