Abstract Introduction Restless legs syndrome (RLS) displays distinct clinical and genetic characteristics in East Asians, yet large-scale genomic data from China remain limited. To address this gap, we conducted the largest multicenter genome-wide association study of RLS in the Chinese population to define population-specific genetic architecture and phenotype–genotype relationships. Methods This multicenter study was led by Peking University People’s Hospital and included RLS patients from 25 accredited sleep laboratories across 16 provinces in China through the national RLS research network (RLSNC). Genome-wide association analyses, functional annotation, phenotype-wide association screening, genotype–phenotype stratification, and logistic regression models were performed to evaluate genetic effects on PLMI severity, sleep efficiency, and other RLS-relevant traits. Results We performed the largest multicenter GWAS of RLS in China, including 1,584 primary cases and 6,921 matched controls recruited from 25 sleep laboratories across 16 provinces. We identified six genome-wide significant susceptibility loci in the Chinese population, comprising three loci overlapping with signals previously reported in European-ancestry cohorts and three novel Chinese-specific loci—including variants near NTNG1 and additional signals in regulatory regions involved in synaptic function and neuronal excitability—and replicated BTBD9 and GLO1, whereas MEIS1 did not reach genome-wide significance, indicating marked trans-ethnic heterogeneity. NTNG1 (rs4603157) was strongly associated with sleep efficiency, showing a progressive genotype shift from normal to poor and severe categories. BTBD9 (rs3923809) showed a robust association with lower PLMI, with the G allele acting as a protective variant (OR = 0.59). Phenotype–genotype heatmaps revealed two major clusters—PLMI/fatigue (BTBD9/NCOA4) and sleep efficiency (NTNG1)—supporting genetically separable subtypes. These findings define the first high-resolution Chinese RLS genetic map and inform cross-population interpretation and subtype-based risk prediction. Conclusion This large multicenter Chinese GWAS identifies population-specific RLS susceptibility loci and reveals distinct genetic pathways underlying PLMI-dominant and sleep-fragmentation–dominant subtypes. These results refine trans-ethnic interpretation of RLS genetics and provide a foundation for subtype-based precision risk stratification in East Asians. Support (if any) This study was supported by the National Natural Science Foundation of China (NSFC) (Nos. 82400114 and 32441101).

BACKGROUND:Long-read sequencing and multi-omic analytical frameworks are increasingly being adopted in rare disease diagnostics. However, clinical workflows comprehensively integrating these methodologies remain uncommon. OBJECTIVE:This study aimed to assess the potential and limitations of integrating long-read genomic, transcriptomic, and proteomic analyses to characterize complex structural variants. METHODS:Two unrelated patients presenting with dystonia and comorbid neurological features underwent nanopore-based long-read DNA sequencing. In patient 1, complementary transcriptomic and proteomic analyses were performed. RESULTS:The workflow enabled the identification and characterization of two pathogenic complex structural variants: a homozygous AluY-mediated inversion disrupting PANK2, underlying neurodegeneration with brain iron accumulation (patient 1), and a heterozygous de novo 16p13.3 duplication-triplication event associated with an atypical dystonia-parkinsonism phenotype (patient 2). CONCLUSIONS:Our findings underscore the diagnostic potential of integrated long-read and multi-omic approaches for complex structural variant characterization, while illustrating persistent limitations of automated pipelines and highlighting unpredictable relationships between genomic, transcriptomic, and proteomic findings. © 2026 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

OBJECTIVE:Genomic sequencing leaves >50% of dystonia-affected individuals without a diagnosis. Where DNA-oriented approaches remain insufficient, integrating multiomics is essential to advance genome interpretation. Herein, we incorporated RNA sequencing (RNA-seq) data from 167 patients with dystonia across a range of ages and presentations. METHODS:We leveraged an RNA-seq analysis pipeline, focused on the identification of expression and splicing aberrations, on RNA-seq from skin biopsies. The recruited patients had early-onset dystonia in 85.0%, non-focal dystonia in 92.2%, and coexisting features in 76.0%. Thirty-six patient samples with pre-identified variants (36/167, 21.6%) and 131 samples with no previously prioritized diagnostic candidates from genomic sequencing (131/167, 78.4%) were evaluated. RESULTS:We found that >80% of dystonia-associated genes were detected by fibroblast RNA-seq. Expression and splicing aberration analyses produced a manageable number of significant RNA defects affecting dystonia-associated genes. The approach was especially successful in validating pathogenic effects of loss-of-function variants, with disease-relevant RNA-underexpression detected for 66.7% (10/15). Studying aberrant expression and splicing in the context of other pre-identified variant types yielded relevant results in 28.6% (6/21 samples). We obtained a 6.9% (9/131) diagnostic uplift for patients without prior candidates, all of whom exhibited combined dystonia with autosomal recessive inheritance. The new diagnoses from RNA-seq and genomic reanalysis were based on previously neglected splice-region (3/9) and deep(er) intronic (6/9) variants. For the observed events, integration of new machine-learning scores predicted corresponding aberrant gene expression in the brain. INTERPRETATION:Fibroblast-based RNA-seq in our selected cohort improved variant interpretation and offered a modest yield in patients without prior candidate variants. ANN NEUROL 2026;99:1363-1378.

Hypertension (HTN) has been linked to changes in DNA methylation. However, longitudinal epigenome-wide analyses are still limited. We analyzed data from the KORA F4 and FF4 studies, conducted approximately 7 years apart. The dataset included 2614 participants, each with DNA methylation measured at least once. Leucocyte DNA methylation was profiled using the Illumina 450 k and EPIC arrays. Linear mixed-effects models were employed to identify associations between methylation sites and HTN status, systolic (SBP) and diastolic blood pressure (DBP). Interaction terms with follow-up time captured longitudinal methylation trajectories. We further examined CpG sites related to reversed, persistent, or progressive HTN and assessed their correlations with gene expression. One CpG site was associated with SBP and four with DBP, all representing novel loci, including RILP (cg08625564) and SVIL (cg15298791). Differential annual methylation changes were observed for 2, 23, and 12 CpG sites by HTN status, SBP, and DBP, respectively, highlighting genes such as RHPN2, CLDND1, ZNF69, and FKBP1B. Twenty CpG sites were associated with persistent HTN, including PLCB2 and MPPE1. In whole blood, 22 significant CpG–transcript pairs were detected, involving 14 CpG sites and 19 gene transcripts. This longitudinal epigenome-wide study identified novel CpG sites associated with blood pressure and persistent HTN. We observed differential DNA methylation trajectories over time linked to HTN, SBP, and DBP, with several changes correlating with gene expression, suggesting functional relevance. These findings underscore the dynamic role of DNA methylation in blood pressure regulation and provide new insights into epigenetic mechanisms of HTN.

Patients with suspected monogenic disorders often remain undiagnosed after exome sequencing. We report a family with two sisters affected by a complex spastic paraplegia. Initial exome sequencing had identified monoallelic pathogenic nonsense variants in AP4S1 and AP4B1, subunits of the adaptor protein complex 4 (AP-4), suggesting digenic inheritance. As digenic inheritance has not been established for AP-4-associated disorders, we applied a multiomics approach including genome sequencing, RNA sequencing and proteomics to clarify the genetic cause. By RNA sequencing a predicted synonymous variant (NM_006594.5:c.969G > A), compound heterozygous to the nonsense variant in AP4B1 and previously considered as benign, was re-prioritized as aberrant splicing was demonstrated. Proteomics showed reduced abundance of AP-4 components AP4B1 and AP4M1 and an upregulation of the cargo protein ATG9A, confirming AP-4 deficiency. Although the AP4S1 variant resulted in nonsense-mediated decay, the identification of biallelic causative variants in AP4B1 established the diagnosis of monogenic "Spastic paraplegia 47, autosomal recessive" while the initial hypothesis of digenic inheritance was refuted. This study illustrates the value of multiomics approaches in the diagnostic workflow of rare diseases and the potential for pathogenicity of synonymous variants.

Abstract Background It is an everyday observation that people of the same chronological age differ with respect to their physical and mental capacity. However, assessing these differences in biological age remains challenging. Methods Here, we aggregate 89 age-associated variables from the Berlin Aging Study II (BASE-II, n=1,631) to generate MultiAge, a new marker of biological age that summarizes information from ten domains reflecting organ health and global biological age. We then used methylation data obtained from an Illumina MethylationEPIC array and supervised machine learning to translate MultiAge into a DNA methylation signature, MultiAgeEpi (309 CpGs), which was subsequently validated in four independent external validation cohorts (KORA FF4, KORA Age, SHIP-TREND, BiDirect, total n=4,339). MultiAgeEpi results were compared with previously published epigenetic clocks (GrimAge, DunedinPACE, SystemsAge). Results We report that MultiAgeEpi showed similar, and in several cases, stronger associations with age-associated outcomes such as diabetes, metabolic syndrome, multimorbidity, frailty and mortality (q < 0.05) compared to the other clocks. Conclusions MultiAge and MultiAgeEpi thus provide a comprehensive assessment of biological age through aggregation of numerous age-associated variables and the use of the high-resolution methylomics data makes transfer of this marker to other cohorts possible.

To identify blood DNA methylation profiles related to liver steatosis, we performed an EWAS on the presence of ultrasonically-identified liver steatosis in the Young Finns Study (YFS) participants (n = 1529, 33–50y.), and on liver enzyme levels and fatty liver index (FLI) across three discovery cohorts: YFS, LURIC (n = 2371, 17–92y.) and KORA FF4 (n = 1872, 39–88y.). We further investigated the discovered associations across the longitudinal subset of YFS (n = 255), encompassing three follow-ups over 32 years, and the three-generational YFS-3G follow-up in 2018–2020. Finally, we examined the associations of the discovered CpGs with nearby genetic variation and whole blood expression of nearby genes. In YFS, the methylation levels of cg06690548 (SLC7A11) were lower in individuals with liver steatosis (Δbeta = − 0.011, FDR = 0.004). Methylation of 9 CpGs associated with GGT and 23 CpGs with FLI in at least two of the discovery cohorts. Methylation at cg06690548 (SLC7A11) and the majority of the CpGs associating with GGT or FLI had the strongest association in the two oldest generations of YFS-3G follow-up (ages 43–59y. and 59–93y.), with minor or non-significant association in the youngest generation (ages 6–36y.). Discovered meQTLs for the CpGs did not modulate the association between the methylation levels and GGT or FLI. The expression of the nearby genes mediated only the association between cg06500161 (ABCG1) and cg20544516 (SREBF1) and FLI. Our findings highlight the association between the methylation levels of cg06690548 (SLC7A11) and liver steatosis, describe the dynamic relationship between whole blood DNA methylation and MASLD, and contribute to a deeper understanding of the pathophysiology of liver diseases.

Next-generation sequencing has unraveled the genetic cause for many individuals with a rare disease, but a significant number of individuals remain undiagnosed using standard of care tests. It is anticipated that structural variants (SVs) have not been fully assessed in this context. Here, we performed optical genome mapping (OGM) for 57 trios and prioritized SVs using a two-step approach. First, we systematically identified all de novo SVs, and subsequently we studied all rare inherited SVs. Potential pathogenic SVs were confirmed using orthogonal methods. On average, we identified 6,289 SVs >500bp per proband, primarily insertions (69.8%) and deletions (27.1%). In total, we identified 13 de novo SVs, confirming a de novo mutation rate for large SVs of 0.23 or 1 in 4-5 cases. These de novo SVs impacted multiple (candidate) disease-associated genes, including NSF and FGF9. Additionally, on average per sample, we identified 11 rare inherited SVs overlapping with an established OMIM disease gene or its regulatory region, including a homozygous deletion affecting SCN9A causing congenital indifference to pain, a maternally inherited deletion in WWOX causing developmental and epileptic encephalopathy, and an interchromosomal insertion in the CMTX3 locus at Xq27.1 causing X-linked Charcot-Marie-Tooth disease. In total, we identified pathogenic SVs in three individuals and candidate disease-causing SVs in five other individuals. Overall, OGM enabled the accurate detection of challenging de novo and rare inherited SVs. Our results suggest a potential yield of disease-associated SVs in 5-14% of index cases, demonstrating that OGM can unravel previously hidden SVs in extensively tested individuals. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement TB was supported by the Kommission fur Klinische Forschung (KKF), TUM School of Medicine and Health, Technical University of Munich. MZ is supported by funding from the EJP RD (EJP RD Joint Transnational Call 2022) and the German Federal Ministry of Education and Research (BMBF, Bonn, Germany), awarded to the project PreDYT (PREdictive biomarkers in DYsTonia, 01GM2302). MZs is also supported by a Schlusselprojekt grant from the Else Kroner-Fresenius-Stiftung (2022_EKSE.185). In addition, MZ receives funding from the Federal Ministry of Education and Research (BMBF) and the Free State of Bavaria under the Excellence Strategy of the Federal Government and the Lander, as well as by the Technical University of Munich - Institute for Advanced Study. MZ has received research support from the German Research Foundation (DFG 458949627; ZE 1213/2-1). TMa received funding from the research council of Finland (338374, 360442) and Sigrid Juselius Foundation (220111). Some of the authors are a member of the European Reference Network on Rare Congenital Malformations and Rare Intellectual Disability ERN-ITHACA. ERN-ITHACA is funded by the European Union, under the grant agreement N.101156387. AH was supported by a ZonMW (The Netherlands Organization for Health Research and Development) Vici grant (No. 09150182310053). The project received funding (to KN, LELMV and AH) from the Dutch Ministry of Economic Affairs by means of a PPP Allowance made available by the Top Sector Life Sciences & Health to stimulate public-private partnerships. The aims of this study contribute to the ERDERA project (to BvdS, LELMV and AH, grant agreement N.220540), which received funding from the EU Horizon 2020 EU Horizon Europe research and innovation programs. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was approved by the Medical Review Ethics Committee Arnhem-Nijmegen under 2011/188 and 2020-7142 and the Ethics Committee of the Northern Ostrobothnia Hospital District (45/2015). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.

Protein-truncating variants in the 3' region of a transcript, evading mRNA degradation and giving rise to aberrant truncated proteins, are an underrecognized cause in Mendelian diseases. Here, we report two individuals with heterozygous de novo nonsense variants in the penultimate and last exon of NUSAP1, both presenting with early-onset refractory epilepsy, global developmental delay, congenital microcephaly, and a recognizable facial gestalt. RNA sequencing performed in one individual did not show a reduction in expression, compatible with escape of aberrant transcripts from nonsense mediated mRNA decay (NMD). We systematically analyzed gnomAD population data to delineate a critical region at the 3' region of NUSAP1, where nonsense variants introduce a premature termination codon and escape NMD. Such variants are absent from healthy controls, while frameshift variants producing C-terminal elongations appear tolerated. This position-dependent model provides guidance for diagnostic variant interpretation.

The dystonin gene (DST) encodes three major isoforms, DST-a, DST-b and DST-e. Biallelic pathogenic variants in DST have previously been associated with two allelic monogenic disorders: hereditary sensory and autonomic neuropathy type VI (caused by a loss of DST-a) and epidermolysis bullosa simplex 3 (caused by a loss of DST-e). We investigated patients diagnosed with congenital myopathy using exome or genome sequencing. In 19 affected individuals from 14 unrelated families, we identified nine different variants in biallelic state located in exons 40-41, specific to DST-b. Affected individuals presented with severe neonatal myopathy characterized by arthrogryposis, hypotonia and dilated cardiomyopathy. Postnatal CPAP ventilation was required in nine patients, and seven died within the first three years of life. Survivors showed an improvement of symptoms, with the oldest three patients, now over 25 years old, exhibiting normal cognition and being ambulatory. RNA analyses demonstrated that transcripts encoding DST-b are predominantly expressed in skeletal muscle, heart tissue and cultured fibroblasts, but not in brain, matching the phenotypic spectrum. Patient-derived fibroblasts exhibited reduced DST mRNA expression. Proteomic analysis confirmed a reduction of DST protein levels due to an absence of the DST-b isoform. Muscle biopsies from four patients aged 1 month to 3 years revealed mild, non-specific myopathic changes. Ultrastructural analysis in three individuals showed mild and focal myofibrillar disruption and non-specific undulating nuclear membranes, with these changes observed in two cases each. Additionally, we identified two homozygous variants affecting both DST-a and DST-b isoforms in four patients from two unrelated families; all presented with severe arthrogryposis and died intrauterine or shortly after birth. Genotype-phenotype correlation in these patients and previously published cases with respective variants resulted in the definition of a DST-associated lethal congenital contracture syndrome. Our findings demonstrate that biallelic variants exclusively affecting DST-b cause an autosomal recessive congenital myopathy. Variants that also impact DST-a besides DST-b result in a more severe, lethal congenital contracture syndrome. The location of the variant within DST allows for phenotype prediction. We propose redefining DST as a disease-associated gene linked to four distinct allelic disease phenotypes.

Numerous correlational and group comparison studies have demonstrated robust associations between sleep health (SH) and large-scale brain organization. However, individual differences play a critical role in this relationship, highlighting the need for person-specific analyses. In this study, we aimed to explore whether multiple brain imaging features could predict various SH-related traits at the individual level using machine learning (ML) techniques. We utilized data from 28 088 participants in the UK Biobank, extracting 4677 structural and functional neuroimaging markers. These features were then used to predict a range of self-reported sleep characteristics, including insomnia symptoms, sleep duration, ease of waking in the morning, chronotype, napping behaviour, daytime sleepiness and snoring. For each of these seven traits, we trained both linear and nonlinear ML models to evaluate how well brain imaging data could account for individual differences. Our analyses involved extensive computational resources, equivalent to over 200 000 core-hours (equivalent to 25 years of compute time). Despite this, the predictive performance of brain features was consistently low across all models, with balanced accuracy scores ranging from 0.50 to 0.59. The highest accuracy achieved (0.59) came from a linear model predicting the ease of getting up in the morning. Notably, models using only demographic variables such as age and sex achieved comparable performance, suggesting that these basic characteristics may largely explain the observed variability. These findings indicate that, even when using a large, well-powered sample and advanced ML techniques, multi-modal brain imaging features provide limited predictive value for SH at the individual level. This low predictability underscores the complexity of the relationship between self-reported sleep and brain structure/function. It also suggests that other biological, environmental or psychological factors-possibly not captured by current imaging modalities-may play a more substantial role in shaping sleep-related behaviours.

Polygenic risk scores (PRS) aggregate the effects of common genetic variants into a single metric of disease predisposition. Many neurological disorders exhibit a polygenic architecture, thereby providing a rationale for the application of PRS in risk prediction, biological subtyping, and stratification of patients to inform clinical decision-making. Here, we use restless legs syndrome (RLS) as an informative translational model to discuss both opportunities and current constraints of PRS use in neurology. RLS has a well-characterized polygenic component with 164 GWAS risk loci, a PRS with moderate case-control discrimination (AUC 0.73) when used alone, but showing potential for higher performance (AUC 0.82-0.91) in machine-learning models incorporating non-genetic variables. We discuss how multi-omics integration, PRS-based clinical subgrouping, and rare variant penetrance modification can advance PRS development and application in RLS and contextualize these developments within the wider landscape of PRS in neurological disorders.

STUDY OBJECTIVES:Our study introduced the 2023 UK Biobank sleep questionnaire and described variation in sleep health dimensions and the prevalence of disordered sleep. METHODS:A questionnaire comprising validated measures and bespoke items was developed to capture key self-reported domains of sleep health and symptoms of sleep disorders. We quantified cohort prevalence of operationally defined sleep disorders and assessed the patterning of sleep health dimensions across key sociodemographic and clinically relevant variables. RESULTS:A total of 183 704 individuals completed at least one module of the questionnaire after email invitation (representing 56 per cent of those with an active email address), and an additional 1352 individuals completed via the participant website. In total 185 056 individuals were included in the analysis. Respondents were predominantly from a White ethnic background (96.8%), had a mean age of 69.9 (SD, 7.5) years, 57.9 per cent were female, and 25.5 per cent were in employment. Compared to non-respondents, respondents were more likely to be female, tended to be better educated, healthier, and exhibit lower levels of socioeconomic deprivation, although baseline sleep variables were similar between respondents and non-respondents. Around 40 per cent of respondents reported sleep duration less than 7 h, and 49 per cent reported poor sleep quality (Pittsburgh Sleep Quality Index >5). Approximately one-quarter (25.2%) met the criteria for at least one operationally defined sleep disorder, with insomnia being the most common (14.4%) followed by obstructive sleep apnea (8.0%), restless legs syndrome (4.1%), and frequent nightmares (3.7%). Sleep disorders were associated with higher levels of anxiety, depression, fatigue, and cognitive complaints. CONCLUSIONS:Poor sleep quality and operationally defined sleep disorders are common in the UK Biobank cohort. Sleep questionnaire data can now be integrated with a range of biomedical information to advance understanding of sleep.

BACKGROUND:SRRM4 is an exclusively neural-expressed splicing-factor gene not yet associated with a monogenic condition. OBJECTIVE:We sought to delineate movement disorders caused by SRRM4 variants. De novo splice-donor-site variants at position +2 of intron 5 of SRRM4 (c.464+2T>C, c.464+2T>A) occurred in three unrelated patients with dystonia and chorea. We present detailed phenotypic information on these individuals and characterize the effect of the splice-site alteration. METHODS:Exome and genome sequencing were used to identify SRRM4 variants. To assess the consequence of a mutant +2 residue at the affected splice donor of SRRM4, we performed transcriptomic analyses using short-read and long-read RNA-sequencing in patient fibroblasts in which SRRM4 expression was induced by genome editing. RESULTS:Clinical presentations were characterized by infantile combined dystonic and choreatic syndromes or chorea-predominant disease. Studies in SRRM4 expression-activated cells revealed two variant-specific SRRM4-mRNA isoforms including one that was characterized by a 69-nucleotide in-frame insertion without creation of a premature termination codon, suggestive of a mechanism other than loss-of-function. Additionally, we uncovered altered splicing patterns of known SRRM4 downstream mRNA-substrates in patient cells compared to SRRM4 expression-activated control fibroblasts, such as a conserved AP1S2 microexon. AP1S2 is linked to a monogenic syndrome with abnormal movements and missplicing of its microexon is a well-established outcome in neural models of SRRM4 disruption. CONCLUSIONS:We conclude that the patients' phenotypes are caused by a previously undiagnosed SRRM4-related disorder, offering a basis for improved understanding of mechanistic convergence in genetic movement disorders and potential therapeutic targeting of the misregulated splicing events. © 2026 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Objective(s): Genetic generalized epilepsy (GGE) is a common subtype of epilepsy characterized by generalized seizure types, with an unclear etiology and recognized genetic contribution to its susceptibility. Although genetic factors play a significant role, the precise mechanisms and causative variants underlying GGE remain poorly understood. This study aimed to identify the genetic basis of GGE. Materials and Methods: Whole exome sequencing (WES) was performed in eight consanguineous GGE families. Sanger sequencing was conducted to validate the WES findings and confirm variant segregation within the families. RNA-seq data (GSE185632) and in silico analyses were used to assess gene expression and variant pathogenicity. Results: A rare nonsense variant in exon 13 of Calpain 7 (CAPN7, NM_014296.3: c.1454G>A; p.Trp485Ter) was identified and determined to be pathogenic according to the American College of Medical Genetics and Genomics (ACMG) criteria (PVS1, PM2, PP4, and PP1). The variant cosegregated with the disease in the family. RNA-seq analysis of epilepsy transcriptomes revealed significant down-regulation of this gene (log2FC= -0.84, padj = 0.016). Complementary computational analyses demonstrated strong evolutionary constraint and pathogenic signatures, further supporting its disease association. CAPN7 negatively perturbate endometrial stromal cell decidualization in epithelial-mesenchymal transition via AKT pathway. The proteolytic activity of CAPN7 is associated with degradation of EGFR. Conclusion: This study provides novel insight on the association of CAPN7 in GGE, highlighting its potential contribution to epilepsy pathogenesis. Further research is required to gather additional evidence and elucidate the molecular mechanisms underlying the clinical manifestations associated with CAPN7 variants.

Dystonia is a rare disease trait for which large-scale genomic investigations are still underrepresented. Genetic heterogeneity among patients with unexplained dystonia warrants interrogation of entire genome sequences, but this has not yet been systematically evaluated.To significantly enhance our understanding of the genetic contribution to dystonia, we (re)analysed 2874 whole-exome sequencing (WES), 564 whole-genome sequencing (WGS), as well as 80 fibroblast-derived proteomics datasets, representing the output of high-throughput analyses in 1990 patients and 973 unaffected relatives from 1877 families. Recruitment and precision-phenotyping procedures were driven by long-term collaborations of international experts with access to overlooked populations.By exploring WES data, we found that continuous scaling of sample sizes resulted in steady gains in the number of associated disease genes without plateauing. On average, every second diagnosis involved a gene not previously implicated in our cohort. Second-line WGS focused on a subcohort of undiagnosed individuals with high likelihood of having monogenic forms of dystonia, comprising large proportions of patients with early onset (81.3%), generalized symptom distribution (50.8%) and/or coexisting features (68.9%). We undertook extensive searches for variants in nuclear and mitochondrial genomes to uncover 38 (ultra)rare diagnostic-grade findings in 37 of 305 index patients (12.1%), many of which had remained undetected due to methodological inferiority of WES or pipeline limitations. WGS-identified elusive variations included alterations in exons poorly covered by WES, RNA-gene variants, mitochondrial-DNA mutations, small copy-number variants, complex rearranged genome structure and short tandem repeats. For improved variant interpretation in WGS-inconclusive cases, we employed systematic integration of quantitative proteomics. This aided in verifying diagnoses related to technically challenging variants and in upgrading a variant of uncertain significance (3 of 70 WGS-inconclusive index patients, 4.3%). Further, unsupervised proteomic outlier analysis supplemented with transcriptome sequencing revealed pathological gene underexpression induced by transcript disruptions in three more index patients with underlying (deep) intronic variants (3/70, 4.3%), highlighting the potential for targeted antisense-oligonucleotide therapy development. Finally, trio-WGS prioritized a de novo missense change in the candidate PRMT1, encoding a histone methyltransferase. Data-sharing strategies supported the discovery of three distinct PRMT1 de novo variants in four phenotypically similar patients, associated with loss-of-function effects in in vitro assays.This work underscores the importance of continually expanding sequencing cohorts to characterize the extensive spectrum of gene aberrations in dystonia. We show that a pool of unresolved cases is amenable to WGS and complementary multi-omic studies, directing advanced aetiopathological concepts and future diagnostic-practice workflows for dystonia. Using whole-genome sequencing and proteomics, Zech et al. have shown that many patients with suspected monogenic dystonia carry mutations that are undetectable with exome analysis alone. Complementary approaches, such as RNA sequencing and functional studies, can improve rates of diagnosis.

The molecular basis for accelerated cognitive decline seen in Alzheimer's Disease (AD) cases presenting with cortical alpha-Synuclein (⍺-Syn) co-pathology is not well understood. We show that such co-pathology brains express higher levels of microtubule- associated protein tau and that increasing ⍺-Syn expression is sufficient to drive tau accumulation. Our results reveal a hitherto unknown link between the pathogenesis of AD and Parkinson's Disease whereby tau and ⍺-Syn synergistically drive dementia-related pathology. ### Competing Interest Statement The authors have declared no competing interest.

Background and Objectives:Exome sequencing (ES) is increasingly used in the diagnostic workup of epilepsies. While its utility has been extensively demonstrated in children, its role in adults remains to be defined. In this study, we evaluate the outcomes of a holistic exome-based approach in adults with epilepsy. Methods:We included 106 adults with epilepsy and a presumed genetic etiology between January 2015 and December 2023 at the Medical University of Vienna, Austria. Diagnostic ES, including copy number variation (CNV) and mitochondrial analyses, was performed. We report on diagnostic outcomes, phenotype expansions, and research findings. Furthermore, we compared the diagnostic outcomes with 3 comprehensive gene panels. Results:In our cohort, the diagnostic yield was 30.2%, outperforming all 3 simulated gene panels. A developmental and epileptic encephalopathy phenotype was associated with receiving a genetic diagnosis. Overall, 27 distinct molecular etiologies were identified. Eight patients had pathogenic CNVs, and 2 had mitochondrial DNA variants. Molecular diagnoses had potential clinical implications in 8 of 32 solved cases (25%), which were eventually exerted in 5 patients (15.6%). Tailored treatment changes were successfully applied in SCN1A-related epilepsy (discontinuation of sodium channel blockers) and GLUT1 deficiency (ketogenic diet). Three patients with mitochondrial diseases were referred for preventive screening investigations after the genetic diagnosis. Our findings expand the clinical spectrum of 3 known epilepsy genes. In addition, explorative variant prioritization identified heterozygous truncating variants in CLASP1 in 2 unrelated patients with focal epilepsy, suggesting it as a candidate gene. Discussion:Our study strongly supports the use of holistic genetic approaches, encompassing CNV and mitochondrial analyses, in adults with epilepsy. Similar to pediatric cohorts, results may inform clinical care. Moreover, we report on phenotype expansions and a candidate gene discovery.