OBJECTIVE:To describe the creation of a curated, shared repository of pharmacogenomics cases for pharmacy educators and highlight the lessons learned during the process. METHODS:The 2019-2020 American Association of Colleges of Pharmacy (AACP) Pharmacogenomics Special Interest Group (PGx SIG) established an ad-hoc committee tasked with creating a pharmacogenomics patient case repository for educational purposes. Following a needs assessment, a standardized case framework was developed based on the Pharmacists' Patient Care Process. A guidance document for case authors was also created. The maintenance of the repository and student involvement are further discussed. RESULTS:A total of 44 pharmacogenomics cases were accepted, categorized by difficulty: 17 introductory cases, 18 intermediate cases, and 9 advanced cases. These cases cover 9 therapeutic areas and are freely available through an online network and information-sharing platform (ie, AACP Connect). Over the last 36 months, the cases have been downloaded 427 times. CONCLUSION:The AACP Pharmacogenomics SIG successfully established a shared repository of educational pharmacogenomics cases using a standardized framework. This approach can serve as a model for other sections, SIGs, or educators wishing to develop case repositories in other fields of study. Future work will evaluate the direct outcomes of this resource in the academic setting.

Objective Incorporating diversity, equity, inclusion, and anti-racism principles into clinical and didactic education is essential because each influence cognitive and affective attitudes in pharmacy practice. Educators must learn from the past to enlighten the future. For example, race is a social construct, not a biological construct. However, it persistently acts as a surrogate for determining medical diagnoses and treatment. Findings Precision medicine and pharmacogenomics can serve as a basis for deconstructing social constructs surrounding race and other social determinants of health. Summary In this review, the authors highlight why using race in health education will lead to less-than-optimal clinical decisions and discuss best practices for incorporating diversity, equity, inclusion, and anti-racism into health education from a pharmacogenomic-based perspective.

Pharmacogenomics (PGx) utilizes a patient’s genome to guide drug treatment and dosing. The Accreditation Council for Pharmacy Education (ACPE) included PGx as a critical content area. Pharmacists are increasingly involved in providing this service, which necessitates training. Second-year pharmacy students at Samford University McWhorter School of Pharmacy have didactic training in the principles of PGx and managing drug therapy using PGx data. A clinical skills lab activity was developed to reinforce these principles and allow students to navigate resources to develop and communicate recommendations for drug therapy. The activity was initially planned as synchronous, but transitioned to asynchronous when students began remote learning in the spring of 2020 due to the COVID-19 pandemic. The investigators sought students’ perceptions of the PGx lab activity and the delivery of its content via a virtual format. This study gathered data from an anonymous, voluntary student survey through Samford University’s course management system, Canvas, in the spring of 2020 soon after completion of the virtual PGx learning activity. The investigators’ goal is to obtain the information and insights obtained from the students who participated in the PGx lab activity to provide guidance for the improvement of their PGx lab activity and for other schools of pharmacy to deliver a PGx lab activities using nontraditional teaching methodologies.

The purpose of the chapter is to illustrate instructional models that were implemented by Samford University McWhorter School of Pharmacy to comply with COVID-19 social distancing restrictions. While the second half of Spring 2020 was completely online (statewide shutdown), the university remained open in a hybrid manner for the 2020-21 academic year. There are three sections in the chapter: didactic, interprofessional, and advanced pharmacy practice experiences. The didactic section discusses course delivery methods and active learning, office hours, remote testing, student feedback, and contingency planning. The interprofessional section illustrates some of the school's synchronous and asynchronous interprofessional learning activities before and during the COVID-pandemic, as well as interprofessional education assessment methods. The last section of the chapter discusses how advanced pharmacy practice experience “direct patient care” was redefined, examples of the experiences, and contingency plans that were put into place to ensure on-time graduation for the classes of 2020 and 2021 pharmacy students.

Background: There is an increasing trend of colorectal cancer (CRC) incidence and mortality in individuals under the age of 50. The impact of age on the outcomes of CRC remains controversial. This study examined the characteristics and treatment trends of young-onset CRC by comparing patients < 50 years of age to those >50. Methods: Data were retrospectively obtained from one of the largest hospital systems in Virginia. The sample included patients diagnosed with CRC from 2008 to 2016. Bivariate analyses were used to describe patients' characteristics. Stratified and multivariate analyses were used to evaluate the association between treatments and age groups in different stages at diagnosis. Results: Approximately 11.6 % (n = 522) of the cohort were younger than 50 years old at diagnosis with a mean age of 42.7 (SD = 5.9) years. Compared to their older counterpart (50 and older), young-onset patients were more likely to be African American (28.7 % (n = 150) vs. 23.7 % (n = 944)), to own private insurance (68.5 % (n = 313) vs. 27.6 % (n = 1032)), to have never used tobacco products (50.4 % (n = 237) vs. 43.8 % (n = 1616)), and to be late stage at diagnosis (68.6 % (n = 358) vs. 52.5 % (n = 2090)) (all p < 0.05). For early stage diagnosis, over 98 % of the young-onset treatments were surgery. For late stage diagnosis, the cancer treatment for young onset patients were a combination of surgery (89.4 %), radiation (82.5 %), and chemotherapy (86.3 %). The results of the analyses also demonstrated that patients with young-onset CRC have higher odds for surgery [OR = 1.76, 95 %CI (1.26, 2.47)], radiation [OR = 1.31, 95 %CI (1.17, 1.47)], and chemotherapy [OR = 3.34, 95 %CI (2.62, 4.25)]. Conclusions: Findings confirmed late-stage prevalence among young-onset as well as significant demographic differences with patients' age >50. This study is one of few to explore the characteristics and assess treatment of young patients with CRC using U.S hospital data. Moreover, further studies need to clarify the effects of biological properties like genetic influences and environmental factors between races on cancer patient outcomes.

Personal genomic educational testing (PGET) has been suggested as a strategy to improve student learning for pharmacogenomics (PGx), but no randomized studies have evaluated PGET's educational benefit. We investigated the effect of PGET on student knowledge, comfort, and attitudes related to PGx in a nonblinded, randomized controlled trial. Consenting participants were randomized to receive PGET or no PGET (NPGET) during 4 subsequent years of a PGx course. All participants completed a pre-survey and post-survey designed to assess (1) PGx knowledge, (2) comfort with PGx patient education and clinical skills, and (3) attitudes toward PGx. Instructors were blinded to PGET assignment. The Wilcoxon Rank Sum test was used to compare pre-survey and post-survey PGx knowledge, comfort, and attitudes. No differences in baseline characteristics were observed between PGET (n = 117) and NPGET (n = 116) participants. Among all participants, significant improvement was observed in PGx knowledge (mean 57% vs. 39% correct responses; p < 0.001) with similar results for student comfort and attitudes. Change in pre/post-PGx knowledge, comfort, and attitudes were not significantly different between PGET and NPGET groups (mean 19.5% vs. 16.7% knowledge improvement, respectively; p = 0.41). Similar results were observed for PGET participants carrying a highly actionable PGx variant versus PGET participants without an actionable variant. Significant improvement in Likert scale responses were observed in PGET versus NPGET for questions that assessed student engagement (p = 0.020) and reinforcement of course concepts (p = 0.006). Although some evidence of improved engagement and participation was observed, the results of this study suggest that PGET does not directly improve student PGx knowledge, comfort, and attitudes.

Troubling racial inequities have emerged from the 2019 novel coronavirus (COVID-19) pandemic. While African Americans (AA) represent only about 13% of the US population, AA disproportionately account for about 1% of total COVID-19 deaths. Latinos, who make up 18 % of the population, account for 17.5 % of COVID-19 cases. Incontestably, these differences have been attributed to underlying health, social, and economic conditions that are more common among some racial and ethnic minorities than whites. To protect public health and mitigate transmission of COVID-19, public health officials have pleaded with the American public to practice good hygiene and social distancing. The aim of this research are to examine the underlying factors that influence intentions to engage in protective measures using the Protection Motivation Theory (PMT) in a Medically Underserved Area/Population. A survey questionnaire is used to assess intentions to comply with protective measures based on constructs from the PMT. Two sets of measurement items are used to assess protection motivation (i.e. hand washing and social distancing). Each set of measurement items is based on the two constructs of protection motivation. The constructs used to measure protection motivation include the threat and coping appraisals. Survey questions also include sociodemographic characteristics, COVID-19 experience, perceived COVID-19 threat. Descriptive statistics used to summarize all the variables. Bivariate and multivariate analyses are conducted to examine variable correlations and relationships. Statistical significance is defined as a two-tailed p-value less than 0.05. PMT variables were significant predictors of social distancing behavior during the COVID-19 pandemic. Fear, response-efficacy, and self-efficacy were all significant predictors of intention to engage in social distancing behavior. This study provides suggestions for future research to further examine the application of PMT to understand the factors influencing intention to adhere to precautionary behavior in times of COVID- 19 pandemic.

Background: Family history of prostate cancer (PCa) is a well-known risk factor, and both common and rare genetic variants are associated with the disease. Objective: To detect new genetic variants associated with PCa, capitalizing on the role of family history and more aggressive PCa. Design, setting, and participants: A two-stage design was used. In stage one, wholeexome sequencing was used to identify potential risk alleles among affected men with a strong family history of disease or with more aggressive disease (491 cases and 429 controls). Aggressive disease was based on a sum of scores for Gleason score, node status, metastasis, tumor stage, prostate-specific antigen at diagnosis, systemic recurrence, and time to PCa death. Genes identified in stage one were screened in stage two using a custom-capture design in an independent set of 2917 cases and 1899 controls. Outcome measurements and statistical analysis: Frequencies of genetic variants (singly or jointly in a gene) were compared between cases and controls. Results and limitations: Eleven genes previously reported to be associated with PCa were detected (ATM, BRCA2, HOXB13, FAM111A, EMSY, HNF1B, KLK3, MSMB, PCAT1, PRSS3, and TERT), as well as an additional 10 novel genes (PABPC1, QK1, FAM114A1, MUC6, MYCBP2, RAPGEF4, RNASEH2B, ULK4, XPO7, and THAP3). Of these 10 novel genes, all but PABPC1 and ULK4 were primarily associated with the risk of aggressive PCa. Conclusions: Our approach demonstrates the advantage of gene sequencing in the search for genetic variants associated with PCa and the benefits of sampling patients with a strong family history of disease or an aggressive form of disease. Patient summary: Multiple genes are associated with prostate cancer (PCa) among men with a strong family history of this disease or among men with an aggressive form of PCa. (C) 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Prostate cancer disproportionately affects men of African ancestry at nearly twice the rate of men of European ancestry despite the advancement of treatment strategies and prevention. In this review, we discuss the underlying causes of these disparities including genetics, environmental/behavioral, and social determinants of health while highlighting the implications and challenges that contribute to the stark underrepresentation of men of African ancestry in clinical trials and genetic research studies. Reducing prostate cancer disparities through the development of personalized medicine approaches based on genetics will require a holistic understanding of the complex interplay of non-genetic factors that disproportionately exacerbate the observed disparity between men of African and European ancestries.

Abstract Purpose: Prostate cancer is the most common cancer in males, with a ~1.5-2-fold higher incidence in African American men when compared with whites. Epidemiologic evidence supports a large heritable contribution to prostate cancer, with over 100 susceptibility loci identified to date that can explain ~33% of the familial risk. A portion of the undefined risk may be due to rare susceptibility variants. The African American Hereditary Prostate Cancer (AAHPC) Study, established in 1997, enrolled 77 African American families from seven clinical sites across the United States. The aim of this study is to identify rare, predictive, deleterious variants through exome sequencing of 99 cases from families selected from the AAHPC families and three 1000 Genome controls. Methods: To explore the contribution of rare variation in coding regions to prostate cancer risk, we sequenced the exomes of 99 AAHPC cases at a mean coverage of 30x. Post-variant calling quality control (QC) was implemented using Golden Helix SVS 8 software with filters set for removal of variants with Read Depth >10, Quality Score >10, and Quality Score: Read Depth Ratio > 0.5. Mendelian inconsistency was checked using PLINK. Prioritization of all candidate genes/variants was evaluated using online databases 1000 Genome and bioinformatics tool ANNOVAR for non-reference allele frequency and predictions of functional impact. Conclusions: Through exome sequencing of 99 AAHPC cases and three 1000 Genome controls, we identified 37 nonsynonymous single-nucleotide variants that are considered damaging by at least one predictive scoring tool in our candidate genes. Interesting candidate variants were found in known cancer susceptibility loci BRCA2, MSR1, PCNT, STAT3, WRN and ZFHX3. Future results are pending additional QC and analyses to determine which variants are shared by related individuals within each family compared to those not seen in the controls. Citation Format: Deyana D. Lewis, Shukmei Wong, Angela S. Baker, Joan E. Bailey-Wilson, John D. Carpten, Cheryl D. Cropp. Deleterious coding variants in African American Hereditary Prostate Cancer Study (AAHPC) families [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C050.

Purpose: Prostate cancer is the most common cancer in males, but also exhibits a ∼1.5-2-fold higher incidence in African American men compared with whites. Epidemiologic evidence supports a large heritable contribution to prostate cancer, with over 100 susceptibility loci identified to date that can explain ∼33 % of the familial risk. A portion of the undefined risk may be due to rare susceptibility variants. The African American Hereditary Prostate Cancer (AAHPC) Study, established in 1997, enrolled 77 AA families from seven clinical sites across the United States (Ann Epidemiol, 2000). The aim of this study is to identify rare, predictive, deleterious variants through exome sequencing of 99 cases from 26 families selected from the AAHPC families (2 to 3 affected men sequenced per family) and three female 1000 Genome controls. Methods: To explore the contribution of rare variation in coding regions of 38 known cancer-causing genes to prostate cancer risk (PCa), we sequenced the exomes of 99 AAHPC cases at a mean coverage of 30x. Post-variant calling quality control (QC) was implemented using Golden Helix SVS 8 software with filters set for removal of variants with Read Depth >10, Quality Score >10, and Quality Score: Read Depth Ratio > 0.5. Mendelian inconsistency was checked using PLINK. Prioritization of all candidate genes/variants were evaluated using online databases including 1000 Genomes and ANNOVAR for non-reference allele frequency and predictions of functional impact. Conclusions. Through exome sequencing of 99 AAHPC cases and 3 female 1000 Genome controls, we identified 37 non-synonymous single nucleotide variants that are considered damaging by at least one predictive scoring tool in our 38 candidate genes. However, most of these variants were common and thus unlikely to be causal. We observed three rare variants that were considered damaging by three predictive scoring tools in two known PCa genes, PCNT and ZFHX3. These 3 variants were each observed in a single different family (in 1 of 3 affected individuals). Interesting rare candidate variants (MAF ≤ 0.01) rs190517526 & rs114692729 were found in known cancer susceptibility loci (CD82 and EZH2). The CD82 variant was observed in all 3 sequenced affecteds in one family and the EZH2 variant was observed in 2 of 3 sequenced affecteds in a different family. These predicted damaging variants in these four genes represent potentially novel causal candidates for some of the 26 AAHPC families sequenced here. Future work will carefully analyze the remainder of the genome in the other 21 sequenced families including planned sequencing of additional family members. Citation Format: Deyana D. Lewis, Shukmei Wong, Angela S. Baker, Isaac Powell, John D. Carpten, Joan E. Bailey-Wilson, Cheryl Cropp. Rare candidate variants shared among affected family members in the African American Hereditary Prostate Cancer Study families [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4240.

Results from association studies are traditionally corroborated by replicating the findings in an independent data set. Although replication studies may be comparable for the main trait or phenotype of interest, it is unlikely that secondary phenotypes will be comparable across studies, making replication problematic. Alternatively, there may simply not be a replication sample available because of the nature or frequency of the phenotype. In these situations, an approach based on complementary pairs stability selection for genome-wide association study (ComPaSS-GWAS), is proposed as an ad-hoc alternative to replication. In this method, the sample is randomly split into two conditionally independent halves multiple times (resamples) and a GWAS is performed on each half in each resample. Similar in spirit to testing for association with independent discovery and replication samples, a marker is corroborated if its p-value is significant in both halves of the resample. Simulation experiments were performed for both nongenetic and genetic models. The type I error rate and power of ComPaSS-GWAS were determined and compared to the statistical properties of a traditional GWAS. Simulation results show that the type I error rate decreased as the number of resamples increased with only a small reduction in power and that these results were comparable with those from a traditional GWAS. Blood levels of vitamin pyridoxal 5 '-phosphate from the Trinity Student Study (TSS) were used to validate this approach. The results from the validation study were compared to, and were consistent with, those obtained from previously published independent replication data and functional studies.

Inherited variations in UDP-glucuronosyltransferase 1A1 (UGT1A1) are associated with an increased breast cancer risk in women of African ancestry. The UGT1A1*28 promoter polymorphism is characterized by the presence of 7 TA repeats in the TATA box sequence and results in reduced UGT1A1 gene expression and enzymatic activity. In this study, we investigated associations between the UGT1A1*28 polymorphism and breast cancer risk among African American (AA) women in Memphis, Tennessee, a city with increased breast cancer mortality rates among AA women. Saliva was collected from 352 AA women, including breast cancer cases (n=82) and controls (n=270) between June 2016 to June 2017. DNA was isolated and sequenced for the UGT1A1*28 polymorphism. The odds ratio for cases with the low UGT1A1 activity alleles (TA)7/8 repeat genotypes versus 5/5, 5/6, and 6/6 genotypes was 1.46 [95% CI, 0.65-3.31; P = 0.36] in premenopausal women and 1.10 (95% CI, 0.52-2.38; P = 0.79) in postmenopausal women. Further analysis of TCGA RNA-seq data showed that UGT1A1 mRNA was significantly lower among estrogen receptor (ER)-negative breast cancers from AA as compared to non-Hispanic white women with ER-negative breast cancer. Larger epidemiological studies are needed to determine the functional consequence of the UGT1A1*28 polymorphism on breast cancer risk in AA women.

Interprofessional practice between pharmacists and nurses can involve pharmacokinetic dosing of medications in a hospital setting. This study describes student perceptions of an interprofessional collaboration pharmacokinetics simulation on the Interprofessional Education Collaborative (IPEC) 2016 Core Competencies. The investigators developed a simulation activity for senior undergraduate nursing and second-year pharmacy students. Nursing and pharmacy students (n = 54, 91 respectively) participated in the simulation using medium-fidelity manikins. Each case represented a pharmacokinetic dosing consult (vancomycin, tobramycin, phenytoin, theophylline, or lidocaine). Nursing students completed head-to-toe assessment and pharmacy students gathered necessary information and calculated empiric and adjusted doses. Students communicated using SBAR (Situation, Background, Assessment, and Recommendation). Students participated in debrief sessions and completed an IRB-approved online survey. Themes from survey responses revealed meaningful perceptions in all IPEC competencies as well as themes of safety, advocacy, appreciation, and areas for improvement. Students reported learning effectively from the simulation experience. Few studies relate to this type of interprofessional education experience and this study begins to explore student perceptions of interprofessional education (IPE) in a health sciences clinical context through simulation. This real-world application of nursing and pharmacy interprofessional collaboration can positively affect patient-centered outcomes and safety.

Background: Despite a growing understanding of the somatic landscape of breast tumors from BRCA1 and BRCA2 mutation carriers, less is known about breast tumors from carriers of germline mutations in other homologous recombination and DNA repair pathway genes such as ATM, CHEK2, and PALB2. Methods: We identified 44 clinically annotated breast cancer cases that included carriers of germline mutations in BRCA1 (n=9), BRCA2 (n=9), ATM (n=5), CHEK2 (n=7), and PALB2 (n=6) from the Hereditary Cancer Risk Program at BUMC. Sporadic breast cancers cases (n=8) were also collected. Genomic DNA and RNA were extracted from macro-dissected FFPE tumor sections, adjacent normal FFPE tissue, along with constitutional genomic DNA from blood. Expanded whole exome sequencing (WES) was performed on normal/tumor pairs and RNA-seq from tumors for each case. Bioinformatics analysis was performed using industry standard methods for somatic characterization. Results: All germline mutations were confirmed by WES. Somatic mutational analysis and copy number profiling from WES revealed the greatest similarities among BRCA1 and CHEK2 carriers. As expected, TP53 mutations were found in 8 of 9 BRCA1 carriers as all were triple negative subtype. We also detected somatic TP53 mutations in tumors from 4 of 7 CHEK2 carriers. Somatic TP53 mutations were found in only 1 of 7 BRCA2 tumors and 1 of 4 PALB2 tumors tested. Furthermore, BRCA1 and CHEK2 tumors showed trends of having higher mutation burden. Analysis of copy number BRCAness demonstrated stronger similarities between BRCA1, ATM, CHEK2, and PALB2 tumors. BRCA2 tumors were unique with fewer events and characterized by specific amplifications including 11q23 (CCND1) and 17q23 (BRIP1). Hierarchical clustering of RNA-seq data revealed strong clustering of BRCA1 tumors compared to all other tumors, predominantly attributed to breast cancer subtype. Furthermore, pathway analysis of genes that distinguish BRCA1 mutation positive versus non-BRCA mutated tumors showed strong correlation to pro-inflammatory and immune pathway signatures. Conclusions: Molecular analysis of 44 breast cancers from individuals with inherited predisposition to breast cancer via BRCA1, BRCA2, ATM, CHEK2, and PALB2 germline mutations demonstrated strongest somatic similarities between BRCA1 and CHEK2 tumors although all BRCA1 were TNBC and all CHEK2 tumors were ER positive. Marked differential gene expression differences in RNA expression patterns were observed in BRCA1 mutation carriers compared with all other groups analyzed. Our study is among the first to interrogate the profile of non-BRCA mutated hereditary breast cancers. Citation Format: Blum JL, Wong S, Pearson EJ, Nair A, Snipes GJ, Briones N, Baker A, Cropp CD, Carpten JD. Molecular analysis of breast cancers from individuals with hereditary cancer syndromes secondary to mutations in BRCA1, BRCA2, ATM, CHEK2, and PALB2 [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-04-02.

Background: Genetic polymorphisms can explain some of the population- and individual-based variations in nutritional status biomarkers. Objective: We sought to screen the entire human genome for common genetic polymorphisms that influence folate-status biomarkers in healthy individuals. Design: We carried out candidate gene analyses and genome-wide association scans in 2232 young, healthy Irish subjects to evaluate which common genetic polymorphisms influence red blood cell folate, serum folate, and plasma total homocysteine. Results: The 5,10-methylenetetrahydrofolate reductase (MTHFR) 677C -> T (rs1801133) variant was the major genetic modifier of all 3 folate-related biomarkers in this Irish population and reached genome-wide significance for red blood cell folate (P = 1.37 x 10(-17)), serum folate (P = 2.82 x 10(-11)), and plasma total homocysteine (P = 1.26 x 10(-19)) concentrations. A second polymorphism in the MTHFR gene (rs3753584, P = 1.09 x 10(-11)) was the only additional MTHFR variant to exhibit any significant independent effect on red blood cell folate. Other MTHFR variants, including the 1298A -> C variant (rs1801131), appeared to reach genome-wide significance, but these variants shared linkage disequilibrium with MTHFR 677C -> T and were not significant when analyzed in MTHFR 677CC homozygotes. No additional non-MTHFR modifiers of red blood cell or plasma folate were detected. Two additional genome-wide significant modifiers of plasma homocysteine were found in the region of the dipeptidase 1 (DPEP1) gene on chromosome 16 and the Twist neighbor B (TWISTNB) gene on chromosome 7. Conclusions: The MTHFR 677C -> T variant is the predominant genetic modifier of folate status biomarkers in this healthy Irish population. It is not necessary to determine MTHFR 677C -> T genotype to evaluate folate status because its effect is reflected in concentrations of standard folate biomarkers. The MTHFR 1298A -> C variant had no independent effect on folate status biomarkers. To our knowledge, this is the first genome-wide association study report on red blood cell folate and the first report of an association between homocysteine and TWISTNB.

Mitochondria (MT), the major site of cellular energy production, are under dual genetic control by 37 mitochondrial DNA (mtDNA) genes and numerous nuclear genes (MT-nDNA). In the CHARGEmtDNA+ Consortium, we studied genetic associations of mtDNA and MT-nDNA associations with body mass index (BMI), waist-hip-ratio (WHR), glucose, insulin, HOMA-B, HOMA-IR, and HbA1c. This 45-cohort collaboration comprised 70,775 (insulin) to 170,202 (BMI) pan-ancestry individuals. Validation and imputation of mtDNA variants was followed by single-variant and gene-based association testing. We report two significant common variants, one in MT-ATP6 associated (p ≤ 5E-04) with WHR and one in the D-loop with glucose. Five rare variants in MT-ATP6, MT-ND5, and MT-ND6 associated with BMI, WHR, or insulin. Gene-based meta-analysis identified MT-ND3 associated with BMI (p ≤ 1E-03). We considered 2,282 MT-nDNA candidate gene associations compiled from online summary results for our traits (20 unique studies with 31 dataset consortia's genome-wide associations [GWASs]). Of these, 109 genes associated (p ≤ 1E-06) with at least 1 of our 7 traits. We assessed regulatory features of variants in the 109 genes, cis- and trans-gene expression regulation, and performed enrichment and protein-protein interactions analyses. Of the identified mtDNA and MT-nDNA genes, 79 associated with adipose measures, 49 with glucose/insulin, 13 with risk for type 2 diabetes, and 18 with cardiovascular disease, indicating for pleiotropic effects with health implications. Additionally, 21 genes related to cholesterol, suggesting additional important roles for the genes identified. Our results suggest that mtDNA and MT-nDNA genes and variants reported make important contributions to glucose and insulin metabolism, adipocyte regulation, diabetes, and cardiovascular disease.

Vitamin B12 deficiency is common in older individuals. Circulating vitamin B12 concentration can be used to diagnose deficiency, but this test has substantial false positive and false negative rates. We conducted genome-wide association studies (GWAS) in which we resolved total serum vitamin B12 into the fractions bound to transcobalamin and haptocorrin: two carrier proteins with very different biological properties. We replicated reported associations between total circulating vitamin B12 concentrations and a common null variant in FUT2. This allele determines the secretor phenotype in which blood group antigens are found in non-blood body fluids. Vitamin B12 bound to haptocorrin (holoHC) remained highly associated with FUT2 rs601338 (p.Trp154Ter). Transcobalamin bound vitamin B12 (holoTC) was not influenced by this variant. HoloTC is the bioactive the form of the vitamin and is taken up by all tissues. In contrast, holoHC is only taken up by the liver. Using holoHC from individuals with known FUT2 genotypes, we demonstrated that FUT2 rs601338 genotype influences the glycosylation of haptocorrin. We then developed an experimental model demonstrating that holoHC is transported into cultured hepatic cells (HepG2) via the asialoglycoprotein receptor (ASGR). Our data challenge current published hypotheses on the influence of genetic variation on this clinically important measure and are consistent with a model in which FUT2 rs601338 influences holoHC by altering haptocorrin glycosylation, whereas B12 bound to non-glycosylated transcobalamin (i.e. holoTC) is not affected. Our findings explain some of the observed disparity between use of total B12 or holoTC as first-line clinical tests of vitamin B12 status.