Asta Literature Retrieval: Pathophysiology and clinical mechanisms of Costello Syndrome. Core disease mechanisms, molecular and cellular pathway...

This report is retrieval-only and is generated directly from Asta results.

• Papers retrieved: 20
• Snippets retrieved: 20

Relevant Papers

[1] HRAS germline mutations impair LKB1/AMPK signaling and mitochondrial homeostasis in Costello syndrome models

• Authors: L. Dard, C. Hubert, P. Esteves, W. Blanchard, Ghina Bou About et al.
• Year: 2022
• Venue: The Journal of Clinical Investigation
• URL: https://www.semanticscholar.org/paper/49640269f8c955e04c8700b1ffe476c4caddbb8a
• DOI: 10.1172/JCI131053
• PMID: 35230976
• PMCID: 9012293
• Citations: 15
• Influential citations: 1
• Summary: The findings highlight the importance of mitochondrial proteostasis and bioenergetics in the pathophysiology of RASopathies and suggest that patients with CS may benefit from treatment with mitochondrial modulators.
• Evidence snippets:
• Snippet 1 (score: 0.426) > Germline mutations that activate genes in the canonical RAS/MAPK signaling pathway are responsible for rare human developmental disorders known as RASopathies. Here, we analyzed the molecular determinants of Costello syndrome (CS) using a mouse model expressing HRAS p.G12S, patient skin fibroblasts, hiPSC-derived human cardiomyocytes, a HRAS p.G12V zebrafish model, and human fibroblasts expressing lentiviral constructs carrying HRAS p.G12S or HRAS p.G12A mutations. The findings revealed alteration of mitochondrial proteostasis and defective oxidative phosphorylation in the heart and skeletal muscle of CS mice that were also found in the cell models of the disease. The underpinning mechanisms involved the inhibition of the AMPK signaling pathway by mutant forms of HRAS, leading to alteration of mitochondrial proteostasis and bioenergetics. Pharmacological activation of mitochondrial bioenergetics and quality control restored organelle function in HRAS p.G12A and p.G12S cell models, reduced left ventricle hypertrophy in CS mice, and diminished the occurrence of developmental defects in the CS zebrafish model. Collectively, these findings highlight the importance of mitochondrial proteostasis and bioenergetics in the pathophysiology of RASopathies and suggest that patients with CS may benefit from treatment with mitochondrial modulators.

[2] Exploring the molecular mechanisms of subarachnoid hemorrhage and potential therapeutic targets: insights from bioinformatics and drug prediction

• Authors: Yi Liu, Yang Zhang, Huan Wei, Li Wang, Lishang Liao
• Year: 2025
• Venue: Scientific Reports
• URL: https://www.semanticscholar.org/paper/19a91d9c8cabec6a5a186729d545077e252ecb67
• DOI: 10.1038/s41598-025-97642-8
• PMID: 40229542
• PMCID: 11997208
• Summary: The findings not only elucidate the molecular mechanisms underlying SAH but also provide robust bioinformatics and experimental evidence supporting IRN as a promising therapeutic candidate, offering novel insights for future intervention strategies in SAH.
• Evidence snippets:
• Snippet 1 (score: 0.408) > involved in SAH pathology. As a result, our understanding of the cellular composition and microenvironment in SAH remains incomplete 8 . > Advances in bioinformatics provide powerful tools to analyze large-scale gene expression data and understand complex biological processes. By integrating transcriptomic data with immune cell infiltration analysis, we can gain a deeper understanding of the molecular mechanisms underlying SAH and identify potential key genes as therapeutic targets 9,10 . Previous studies have indicated that inflammation, oxidative stress, and cell death play crucial roles in the development of SAH, processes that are often closely associated with changes in specific cell types and immune responses 11 . > The goal of this study is to explore the molecular mechanisms of SAH, with a focus on immune cell infiltration and its role in disease progression. We aim to identify key genes and signaling pathways associated with SAH and investigate potential therapeutic strategies. Specifically, we will examine Isorhynchophylline (IRN) as a potential treatment for SAH and analyze its effects on relevant targets and signaling pathways. Through a comprehensive understanding of the pathological features of SAH, this study aims to provide valuable insights into future clinical interventions and treatment strategies.

[3] Changes in Serum Proteomic Profiles at Different Stages of Pregnancy Toxemia in Goats

• Authors: M. Uzti̇mür, C. N. Ünal, Gurler Akpinar
• Year: 2025
• Venue: Journal of Veterinary Internal Medicine
• URL: https://www.semanticscholar.org/paper/4b9c488b5dbd65d7b26fd2ad9aed70e8c4b59942
• DOI: 10.1111/jvim.70139
• PMID: 40492724
• PMCID: 12150350
• Summary: Understanding the serum proteome profiles of goats with pregnancy toxemia might help identify the proteomes and pathways responsible for the development of this disease and improve diagnosis and treatment.
• Evidence snippets:
• Snippet 1 (score: 0.394) > The pathophysiology and progression of this disease are not fully understood. > Traditional biomedical research has focused on the analysis of single genes, proteins, metabolites, or metabolic pathways in diseases. This molecular reductionist approach is based on the assumption that identifying genetic variations and molecular components will lead to new treatments for diseases [13][14][15][16]. However, many diseases are complex and multifactorial, and in order to determine the phenotype of such diseases, it is necessary to understand the changes that occur in more than one gene, pathway, protein, or metabolite at the cellular, tissue, and organismal levels [17][18][19]. Therefore, in recent years, proteomics, as one field of multi-omics technologies, has helped in evaluating the complex pathogenetic mechanisms of different diseases from a broad perspective and has made substantial contributions [20,21]. In veterinary medicine, proteomic analysis of metabolic diseases such as ketosis [16], hypocalcemia [22], and fatty liver [23] in dairy cows has contributed valuable insights for the definition of new pathophysiological pathways and new diagnosis and treatment protocols for these diseases. The proteomic approach can contribute importantly to a broad and detailed understanding of the changes that occur at the organismal level associated with the increase in BHBA concentration in goats with pregnancy toxemia. Our aim was to evaluate the serum protein profiles of goats with SPT or CPT using proteomic techniques to determine the proteomic profiles of these animals and to identify the relevant pathophysiological mechanisms.

[4] The hyperornithinemia–hyperammonemia-homocitrullinuria syndrome

• Authors: D. Martinelli, D. Diodato, Emanuela Ponzi, M. Monné, S. Boenzi et al.
• Year: 2015
• Venue: Orphanet Journal of Rare Diseases
• URL: https://www.semanticscholar.org/paper/ed033868ee677da141e5c926bc7c93cac242ea06
• DOI: 10.1186/s13023-015-0242-9
• PMID: 25874378
• PMCID: 4358699
• Citations: 92
• Influential citations: 5
• Summary: The clinical phenotype of HHH syndrome is extremely variable and its severity does not correlate with the genotype or with recorded ammonium/ornithine plasma levels, suggesting the need for a better understanding of the still unsolved pathophysiology of the disease.
• Evidence snippets:
• Snippet 1 (score: 0.391) > Although the disease responds well to treatment with low risk of relapse of hyperammonemia [38], slowly progressive pyramidal signs characterize the chronic course, as also seen in argininemia [89]. However, the mechanism(s) of pyramidal dysfunction in HHH syndrome still remains to be elucidated. Creatine deficiency may contribute to the pathogenetic mechanism of the syndrome, as creatine is relevant for mitochondrial energy metabolism, regulation of glycolysis, proteins synthesis, membrane stabilization and neuromodulation [77,78,85]. This could be in line with the finding of abnormally shaped mitochondria at electron microscopy studies in skin fibroblasts, hepatocytes and muscle biopsy from HHH syndrome patients [11,23,82]. Furthermore, a mitochondrial dysfunction has been recently related to the effects of ornithine and homocitrulline in causing oxidative stress and disturbed mitochondrial homeostasis [79,80]. > A further mechanism that can be involved in the pathophysiology of HHH syndrome is related to polyamines metabolism. Shimizu and colleagues reported increased total and fractional (putrescine, cadaverine, spermine, spermidine) polyamines in one HHH syndrome patient [30]. Indeed, the clinical similarities between HHH syndrome and argininemia, which has been associated to an abnormal polyamine metabolism [91,92], may suggest a common pathogenetic mechanism causing pyramidal dysfunction. > Overall, the pathogenesis of HHH syndrome is complex and not completely understood. It is likely that different mechanisms, including the impact of low mitochondrial ornithine on UC flux, the presence of hyperammonemic crises and the disturbance of other pathways in major organs play a role in determining the heterogeneous clinical presentation of ORC1 deficiency. > In addition, as molecular studies failed to disclose a correlation between type of mutations or ornithine transport capacity and disease severity, an effect of genetic modifiers, such as ORC genes redundancy, seems to be likely, but further studies are certainly needed to clarify this point.

[5] Renal ciliopathies: promising drug targets and prospects for clinical trials

• Authors: L. Devlin, Praveen Dhondurao Sudhindar, J. Sayer
• Year: 2023
• Venue: Expert Opinion on Therapeutic Targets
• URL: https://www.semanticscholar.org/paper/ab2155b6e12caba53d57ac0e8ce28860d69ec9fd
• DOI: 10.1080/14728222.2023.2218616
• PMID: 37243567
• Citations: 10
• Summary: The advances in basic science and clinical research into renal ciliopathies which have yielded promising small compounds and drug targets are reviewed, within both preclinical studies and clinical trials.
• Evidence snippets:
• Snippet 1 (score: 0.378) > Although renal ciliopathies can be classified into distinct syndromes, causative mutations in genes encoding proteins involved in the primary cilium or centrosome mean they may share overlapping mechanisms of disease, which may be amenable for therapeutic intervention (Figure 2). Abnormal functioning of proteins involved in ciliogenesis, such as CEP164, can prevent proper cilia formation, which will effect a myriad of downstream ciliary signaling pathways. Additionally, mutations in genes encoding for proteins involved in cargo trafficking or regulation, such as CEP290, will have implications for signal pathway transduction, as well as mutations in components of signaling pathways themselves, such as PKD1. In regard to renal ciliopathies, abnormalities in signaling pathways such as cAMP, Shh, Wnt, mTOR, and AMPK, likely cause misoriented cellular divisions, increased proliferation, increased fluid secretion and subsequent cystogenesis, consequently leading to further kidney damage. Ciliary and centriolar proteins which have roles in DDR and cell cycle regulation may also be driving a renal cystogenesis phenotype alongside increased fibrosis and apoptosis. Increased inflammation and dysfunctional mitochondria are also byproducts of dysregulated signaling pathways have been shown to contribute to the progression of renal ciliopathies. Extensive reviews of mechanisms of renal ciliopathy diseases have recently been performed [23,24]. Importantly, due to the wide range of cellular processes that primary cilia regulate, it is likely that in each syndrome there are multiple pathogenic drivers of disease. In some ways, this is advantageous as it offers many points for potential therapeutic targets. However, the cross talk between pathways and feedback loops introduces complications of changing one pathway without negatively affecting another. Further challenges arise with core biological pathways, such as Shh signaling, in which modification in vitro may be beneficial, but systemic treatment is unrealistic due to the expected severe side effects [18,24,116].

[6] Aberrant NLRP3 Inflammasome Activation Ignites the Fire of Inflammation in Neuromuscular Diseases

• Authors: Christine Péladeau, J. Sandhu
• Year: 2021
• Venue: International Journal of Molecular Sciences
• URL: https://www.semanticscholar.org/paper/763a36db080236fca8cde89b2afcdf056f3584d0
• DOI: 10.3390/ijms22116068
• PMID: 34199845
• PMCID: 8200055
• Citations: 17
• Influential citations: 1
• Summary: Whether therapeutic targeting of the NLRP3 inflammasome components is a viable approach to alleviating the detrimental phenotype of neuromuscular diseases and improving clinical outcomes is examined.
• Evidence snippets:
• Snippet 1 (score: 0.376) > Despite a large number of mechanisms that have been identified in muscle degeneration and nerve cell loss, none have proven to be the primary cause of the disease. There is much need for a deeper understanding of the biology of the pathogeneses and the molecular mechanisms that are activated early in the diseases in order to identify "druggable" targets and disease-modifying treatments for these devastating diseases. > Human iPSC technologies are emerging as useful platforms for disease modeling to study pathogenic mechanisms and discover novel therapeutics for neuromuscular diseases [211,237]. Indeed, patient-derived iPSCs are being used to create a "patient-in-adish" disease model to derive relevant cell types for testing potential therapeutics, paving the way towards personalized medicine. This approach allows drug screening in a dish prior to administration to patients and "bench-to-bedside" translation of potential therapies. Additionally, iPSCs may also be used to stratify patients with various phenotypes and guide future clinical trials for bringing improved therapies to patients. Since multiple cell types are involved in disease pathogenesis, future research efforts need to be focused on deciphering "disease-specific signatures" at single-cell resolution, and not only in neuronal cells but also in non-neuronal cells. The application of modern technologies, including single-cell RNA sequencing and spatial transcriptomics, to neuromuscular diseases, will allow to ascertain cellular vulnerability and cell-specific mechanisms during various stages of disease progression. > The vital roles of the NLRP3 inflammasome in neuromuscular diseases such as DMD, LGMD and ALS, reveal that targeting this pathway is indeed a promising therapeutic strategy. Dysregulation of the NLRP3 inflammasome in muscle tissues by muscle damage, membrane instability, extracellular ATP and Ca 2+ ions or signals from infiltrating immune cells, clearly impacts the progression of neuromuscular and neurodegenerative disorders. Thus, modulation of these pathways involved with activation and assembly of NLRP3 inflammasome could be truly beneficial.

[7] 18O-assisted dynamic metabolomics for individualized diagnostics and treatment of human diseases

• Authors: E. Nemutlu, Song Zhang, N. Juranic, A. Terzic, S. Macura et al.
• Year: 2012
• Venue: Croatian Medical Journal
• URL: https://www.semanticscholar.org/paper/880f053c7f060db4b990e447d0a22c4b69372ddb
• DOI: 10.3325/cmj.2012.53.529
• PMID: 23275318
• PMCID: 3541579
• Citations: 28
• Summary: The potential use of dynamic phosphometabolomic platform for disease diagnostics currently under development at Mayo Clinic is described and discussed briefly.
• Evidence snippets:
• Snippet 1 (score: 0.369) > Living cells represent an integrated and interacting network of genes, transcripts, proteins, small signaling molecules, and metabolites that define cellular phenotype and function. Traditionally the focus of biomedical research was on individual genes, single protein targets, single metabolites, and metabolic or signaling pathways. This "molecular reductionist" paradigm was based on the assumption that identifying genetic variations and molecular components would lead to discovery of cures for human diseases. However, most of diseases are complex and multi-factorial and the disease phenotype is determined by the alterations of multiple genes, pathways, proteins and metabolites (at cellular, tissue, and organismal levels). Therefore, an integrated "omics" approach is more viable direction for uncovering alterations in metabolic networks, disease mechanisms, and mechanisms of drug effects. > Recent advent of large-scale metabolomics and fluxomic (metabolite dynamics and metabolic flux analysis) completed the "omics revolution" (Figure 1), where genomics, transcriptomics, proteomics, metabolomics, and fluxomics all together complement phenotype determination of living organism. Such integrated "omics" cascades provide a framework for advances in system and network biology, integrative physiology, and system medicine as well as system pharmacology and regenerative medicine. Noteworthy is the "reverse omic" approach or "metabolomicsinformed pharmacogenomics, " where discovery of specific metabolite changes have led to discovery of genetic alterations (2). Therefore, bringing new "omics" technologies to clinical practice will improve disease diagnostics and treatment by targeting drugs and procedures for each unique transcriptomic and metabolomic profiles.

[8] New therapeutic targets in rare genetic skeletal diseases

• Authors: M. Briggs, Peter A. Bell, M. Wright, K. A. Pirog
• Year: 2015
• Venue: Expert Opinion on Orphan Drugs
• URL: https://www.semanticscholar.org/paper/1363107f71ae6d2d60abca471cddf3da5d13644b
• DOI: 10.1517/21678707.2015.1083853
• PMID: 26635999
• PMCID: 4643203
• Citations: 37
• Influential citations: 1
• Summary: An overview of disease mechanisms that are shared amongst groups of different GSDs and potential therapeutic approaches that are under investigation are described to generate critical mass for the identification and validation of novel therapeutic targets and biomarkers.
• Evidence snippets:
• Snippet 1 (score: 0.368) > proteins of the cartilage ECM such as type II collagen [50]. However, emerging knowledge suggests that the primary genetic defect may be less important than the cells' response to the expression of the mutant gene product [107]. Moreover, the largely overlooked response of a cell (i.e. chondrocyte) to the abnormal extracellular environment is also important for disease progression as illustrated by several GSDs discussed in this review. > It is important that 'omics'-based approaches and technologies are systematically applied to the study of rare GSDs so that definitive reference profiles and disease signatures are generated for each phenotype. These can then be used in a Systems Biology approach to identify both common and dissimilar pathological signatures and disease mechanisms. This approach is entirely dependent upon relevant in vitro and in vivo models (and also novel 'disease-mechanism phenocopies' [107]) for testing new diagnostic and prognostic tools and for determining the molecular mechanisms that underpin the pathophysiology so that effective therapeutic treatments can be developed and validated. This approach will eventually lead to personalized treatments and care strategies centred on shared disease mechanisms with the use of relevant biomarkers to monitor the efficacy of treatment and disease progression. > It is vital that all relevant stakeholders are involved from the outset in defining the appropriate outcomes of any potential therapeutic regime. The perceptions of a successful therapy can differ widely between the clinical academic community and the relevant patient-support groups and it is vital that there is engagement on all these issues. > In summary, the identification of causative genes and mutations for GSDs over the last 20 years, coupled with the generation and in-depth analysis of a plethora of relevant cell and mouse models, has derived new knowledge on disease mechanisms and suggested potential therapeutic targets. The fast-evolving hypothesis that clinically disparate diseases can share common disease mechanisms is a powerful concept that will generate critical mass for the identification and validation of novel therapeutic targets and biomarkers.

[9] Cardiomyocytes Derived from Induced Pluripotent Stem Cells as a Disease Model for Propionic Acidemia

• Authors: Esmeralda Alonso-Barroso, B. Pérez, L. Desviat, E. Richard
• Year: 2021
• Venue: International Journal of Molecular Sciences
• URL: https://www.semanticscholar.org/paper/da649a0f04477c53b448c5ac5f873f8762235290
• DOI: 10.3390/ijms22031161
• PMID: 33503868
• PMCID: 7865492
• Citations: 16
• Influential citations: 1
• Summary: The novel results show that PA iPSC-cardiomyocytes represent a promising model for investigating the pathological mechanisms underlying PA cardiomyopathies, also serving as an ex vivo platform for therapeutic evaluation.
• Evidence snippets:
• Snippet 1 (score: 0.367) > The study of the mechanisms involved in disease physiopathology has been mainly performed using the hypomorphic PA mouse model that mimics the biochemical and clinical phenotype [5]. Using this model, bioenergetic failure, oxidative damage and deregulation of miRNAs induced by accumulating propionyl-CoA have been described as potential mechanisms contributing to PA physiopathology [6][7][8]. The limitations of animal models for the study of cardiac energy metabolism [9] and of the commonly available cellular human models such as fibroblasts, underline the importance of generating new relevant cell models to provide deeper insight into the underlying mechanisms of disease. The use of in vitro models with human cellular context is highly recommended and, in this sense, induced pluripotent stem cells (iPSCs) have certain advantages since they provide the genetic background of the patient and represent an unlimited source of biological material for the study of pathophysiology and treatment effectiveness [10]. We have previously generated an iPSC line from a PA patient with defects in the PCCA gene that showed full pluripotency, differentiation capacity and genetic stability [11]. > In the present study, we aimed to establish a platform that served as a disease model to study the cellular and molecular alterations operating in cardiac tissue affected by PA disease. We described the characterization of cardiomyocytes derived from the PCCA iPSC line (PCCA iPSC-CMs) and the analysis of specific pathways potentially involved in cardiac PA physiopathology.

[10] Computational drug discovery approaches identify mebendazole as a candidate treatment for autosomal dominant polycystic kidney disease

• Authors: P. Brownjohn, A. Zoufir, Daniel J O’Donovan, Saatviga Sudhahar, A. Syme et al.
• Year: 2024
• Venue: Frontiers in Pharmacology
• URL: https://www.semanticscholar.org/paper/a595e78572ca02b8cb2897bfc4a989a2b021b279
• DOI: 10.3389/fphar.2024.1397864
• PMID: 38846086
• PMCID: 11154008
• Citations: 2
• Summary: It is determined that the anthelmintic mebendazole was a potent anti-cystic agent in human cellular and in vivo models of ADPKD, and is likely acting through the inhibition of microtubule polymerisation and protein kinase activity.
• Evidence snippets:
• Snippet 1 (score: 0.367) > Targets and molecules were ultimately filtered for validation based on biological and chemical insights, and the potential for clinical translation.Earlier this year, Wilk et al., 2023 applied a similar transcriptomic approach to us, in that case making use of publicly available transcriptomic datasets to create Pkd2-specific ADPKD disease signatures, from which signature reversion was sought from the Library of Integrated Network-based Cellular Signatures (LINCs) drug signature database in order to identify drug repurposing candidates.While one group has previously made use of a knowledge graph-based approach to prioritise preclinically active compounds with the highest chance of clinical translation (Malas et al., 2019), to our knowledge, the current study provides the first combined application of transcriptomic and machine-learning approaches to identify and prioritise putative treatments for ADPKD, and further deconvolute potential mechanisms of action for experimental validation. > In summary we report, using computational, in vitro and in vivo approaches, that the anthelmintic drug mebendazole ameliorates disease-relevant phenotypes in cellular and animal models of ADPKD.We further show that this effect is likely primarily due to the inhibitory effect of mebendazole on the polymerisation of microtubules, which underlie cellular processes important in ADPKD, including cell proliferation, transport, and cilia signalling, and extends previous work linking the importance of the microtubule network to ADPKD pathophysiology.We also describe the inhibitory profile of mebendazole on known and novel protein kinase targets, some of which have previously been implicated in ADPKD, suggesting mebendazole may be acting via polypharmacology to impact disease mechanisms.We acknowledge that further experimental efforts will be required to confirm the actions of mebendazole on these putative targets in relevant disease model systems.It would be particularly informative to investigate these mechanisms in dedicated in vivo studies, where the effects of mebendazole on a wider range of ADPKD-relevant cell types and phenotypes could be evaluated.

[11] Lactate metabolism and lactylation in kidney diseases: insights into mechanisms and therapeutic opportunities

• Authors: Yuhua Cheng, Linjuan Guo
• Year: 2025
• Venue: Renal Failure
• URL: https://www.semanticscholar.org/paper/6208b88884af543f7c97d2e70ed6b727dcfb4f58
• DOI: 10.1080/0886022X.2025.2469746
• PMID: 40012230
• PMCID: 11869332
• Citations: 9
• Summary: A review examines the role of lactate esters, especially lactylation, in kidney diseases, with a focus on their regulatory mechanisms and potential as therapeutic targets.
• Evidence snippets:
• Snippet 1 (score: 0.361) > Lactate metabolism and its post-translational modifications, particularly lactylation, play critical roles in the pathophysiology of various kidney diseases, including AKI, DKD, and ccRCC (Figure 1). The kidney's ability to metabolize lactate is crucial for maintaining renal function under normal conditions. However, in pathological states, impaired lactate metabolism leads to its accumulation, exacerbating renal dysfunction and disease progression. For more details on lactate metabolism and kidney diseases, refer to previous reviews [2,3,25]. > Lactylation influences gene transcription, protein function, and cellular metabolism, contributing to inflammatory responses, mitochondrial dysfunction, and tumor progression. > Understanding the mechanisms of lactate metabolism and lactylation in kidney diseases opens new avenues for therapeutic interventions. Targeting these metabolic pathways could mitigate renal injury and improve patient outcomes. Future research should focus on elucidating the specific pathways and molecular targets affected by lactate and lactylation and developing inhibitors to modulate these processes. Clinical trials are necessary to validate the efficacy and safety of these therapies. Overall, the lactate-lactylation axis is a promising target for novel therapeutic strategies aimed at treating kidney diseases and improving renal health.

[12] Rare Monogenic Diseases: Molecular Pathophysiology and Novel Therapies

• Authors: I. Condò
• Year: 2022
• Venue: International Journal of Molecular Sciences
• URL: https://www.semanticscholar.org/paper/6aece75e6947f102b657851b74e8b96df5e654c1
• DOI: 10.3390/ijms23126525
• PMID: 35742964
• PMCID: 9223693
• Citations: 14
• Influential citations: 2
• Summary: A rare disease is defined by its low prevalence in the general population and its presence in a very small number of people.
• Evidence snippets:
• Snippet 1 (score: 0.361) > The selective expression or the particular role of specific genes in a single tissue explains the appearance of organ-specific inherited diseases. This is the case of genetic disorders of the kidney, which include dominant and recessive forms of cystic diseases, and renal tubulopathies. Mutations in polycystin-1 (PKD1) or -2 (PKD2) genes lead to autosomaldominant polycystic kidney disease (ADPKD), whose gender-dependent phenotype was analyzed in the study by Talbi et al. [9]. These results, obtained in mice lacking PKD1 expression, show the involvement of intracellular Ca2+ levels in the more severe phenotype affecting male ADPKD animals. Altogether, identification of the molecular mechanisms underlying enhanced Ca2+ signaling and proliferation in cells from male kidneys may contribute to develop novel therapeutics for ADPKD [9]. The autosomal-recessive form of polycystic kidney disease (ARPKD) mostly arises from defects in the gene named polycystic kidney and hepatic disease 1 (PKHD1), whereas a minority of cases is linked to a second causative gene DZIP1L. To examine the still unclear molecular pathophysiology of ARPKD, Cordido et al. recapitulate known molecular disease mechanisms and possible therapeutic approaches, from cellular and animal models to clinical trials [10]. The knowledge of ARPKD pathogenic pathways, involving the epidermal growth factor receptor (EGFR) axis, the production of adenylyl cyclase adenosine 3 ,5 -cyclic monophosphate (cAMP) and the activation of several protein kinases, begins to stimulate possible pharmacological interventions [10]. Inherited loss of function in various electrolyte transport proteins located along the nephron leads to two types of kidney tubulopathy with overlapping clinical symptoms: Gitelman and Bartter syndromes. The review by Nuñez-Gonzalez et al. aims to explain the different molecular basis of these difficult to diagnose monogenic syndromes. Moreover, the authors provide an overview of current therapeutic approaches and highlight the presence of common and specific options for Gitelman and Bartter patients [11].

[13] Mitochondrial Dysfunction in Diabetes: Shedding Light on a Widespread Oversight

• Authors: F. Iheagwam, A. J. Joseph, E. D. Adedoyin, Olawumi Toyin Iheagwam, Samuel Akpoyowvare Ejoh
• Year: 2025
• Venue: Pathophysiology
• URL: https://www.semanticscholar.org/paper/dbf8042761c1a5fc50f8cd894cc498505abac7cb
• DOI: 10.3390/pathophysiology32010009
• PMID: 39982365
• PMCID: 12077258
• Citations: 23
• Summary: This review aims to elucidate the complex link between mitochondrial dysfunction and diabetes, covering the spectrum of diabetes types, the role of mitochondria in insulin resistance, highlighting pathophysiological mechanisms, mitochondrial DNA damage, and altered mitochondrial biogenesis and dynamics.
• Evidence snippets:
• Snippet 1 (score: 0.358) > The landscape of DM research is continuously evolving, with emerging technologies and approaches offering new insights into the pathophysiology of the disease and potential therapeutic targets. Advancements in omics technologies, encompassing genomes, transcriptomics, proteomics, and metabolomics, have transformed the molecular mechanisms underlying DM [134]. High-throughput sequencing techniques enable comprehensive analysis of genetic variants, gene expression profiles, protein abundance, and metabolite levels associated with DM and its complications [135]. Single-cell omics approaches provide unprecedented resolution and granularity, allowing researchers to dissect cellular heterogeneity and identify novel cell types, subpopulations, and signalling pathways involved in DM pathogenesis. Integrating multi-omics data sets offers a systems-level perspective of DM, unravelling complex networks of molecular interactions and regulatory circuits underlying disease progression [136]. > In addition to omics technologies, advances in imaging modalities, such as MRI, PET, and optical imaging, enable non-invasive visualisation and quantification of metabolic, functional, and structural changes. Molecular imaging probes targeting specific biomarkers and metabolic pathways provide valuable insights into disease mechanisms and treatment responses in preclinical and clinical settings [85]. Despite significant progress in DM research, numerous unanswered questions and knowledge gaps persist, hindering the ability to develop effective prevention and treatment strategies. Key areas requiring further investigation include the role of epigenetics, environmental factors, and the microbiome in DM susceptibility and progression. Moreover, the interaction between environmental cues and genetic predisposition remains incompletely understood, highlighting the need for comprehensive multi-omics studies and large-scale epidemiological analyses to identify gene-environment interactions and modifiable risk factors for DM [137]. Furthermore, the heterogeneity of DM phenotypes and clinical outcomes poses a challenge for personalised medicine approaches, necessitating robust biomarkers and predictive models to stratify patients based on disease subtypes, prognosis, and treatment response [138].

[14] Mitochondria and the future of RASopathies: the emergence of bioenergetics.

• Authors: M. Kontaridis, Saravanakkumar Chennappan
• Year: 2022
• Venue: The Journal of clinical investigation
• URL: https://www.semanticscholar.org/paper/7b39a31a51522aa5293be61180e7461a201b8df8
• DOI: 10.1172/JCI157560
• PMID: 35426371
• Citations: 7
• Summary: RASopathies are a family of rare autosomal dominant disorders that affect the canonical Ras/MAPK signaling pathway and manifest as neurodevelopmental systemic syndromes, including Costello syndrome (CS). In this issue of the JCI, Dard et al. describe the molecular determinants of CS using a myriad of genetically modified models, including mice expressing HRAS p.G12S, patient-derived skin fibroblasts, hiPSC-derived human cardiomyocytes, an HRAS p.G12V zebrafish model, and human lentivirally in...
• Evidence snippets:
• Snippet 1 (score: 0.357) > RASopathies, a group of syndromic disorders caused by germline mutations in genes that affect the canonical Ras/MAPK signaling pathway, include Noonan syndrome (NS), NS with multiple lentigines (NSML), Costello syndrome (CS), cardiofaciocutaneous syndrome (CFCS), neurofibromatosis type 1 (NF1), and other clinically related diseases (Figure 1A and ref. 1). Though individually rare, collectively, this family of disorders constitutes one of the world's largest groups of congenital diseases. Germline pathogenic variants result in similar yet distinct syndromes, the phenotypic characteristics of which can include facial abnormalities, short stature, cardiac defects, hematopoietic defects, skeletal malformations, and certain types of cancer (1)(2)(3). These characteristics can be severe and life-threatening and may be present at birth or develop throughout one's lifetime. Unfortunately, effective targeted therapies for RASopathies remain elusive, with limited to no options available for most patients. Therefore, there is a critical need to identify effective treatments. Indeed, understanding the causal mechanisms associated with the development of each disease uniquely, through identification of the distinct point mutations within common genes, the panoply of signaling pathways affected by the genetic anomalies, and the potential molecular targets associated with each, may help us find targeted and personalized approaches to treating patients (4). > The Ras/MAPK signaling pathway is critical for cellular homeostasis, cell differentiation, proliferation, and survival. Gainof-function mutations and/or increased Ras and MAPK activities are associated with development of RASopathies and many other diseases, including cancer. However, because Ras/MAPK signaling is required for a multitude of cellular processes, identifying the appropriate inhibitors and their required level of inhibition to provide therapeutic efficacy without intolerable side effects, remains challenging. > A myriad of animal model systems developed to study RASopathies has helped identify many (or most) of the causal genes associated with this group of disorders. The pioneering studies also helped determine aberrant molecular functions of gene mutations, identifying possible therapeutic targets.

[15] Cardiac Phenotype and Gene Mutations in RASopathies

• Authors: M. Faienza, G. Meliota, D. Mentino, R. Ficarella, Mattia Gentile et al.
• Year: 2024
• Venue: Genes
• URL: https://www.semanticscholar.org/paper/a4087d3b73d20a6e2f46b7fb87eed4017ec9a9be
• DOI: 10.3390/genes15081015
• PMID: 39202376
• PMCID: 11353738
• Citations: 8
• Influential citations: 1
• Summary: The molecular mechanisms underlying the development of cardiac diseases associated particularly with NS are clarified, and the main morphological and clinical characteristics of the two most frequent cardiac disorders, namely pulmonary valve stenosis (PVS) and HCM are discussed.
• Evidence snippets:
• Snippet 1 (score: 0.357) > Cardiac involvement is a major feature of RASopathies, a group of phenotypically overlapping syndromes caused by germline mutations in genes encoding components of the RAS/MAPK (mitogen-activated protein kinase) signaling pathway. In particular, Noonan syndrome (NS) is associated with a wide spectrum of cardiac pathologies ranging from congenital heart disease (CHD), present in approximately 80% of patients, to hypertrophic cardiomyopathy (HCM), observed in approximately 20% of patients. Genotype–cardiac phenotype correlations are frequently described, and they are useful indicators in predicting the prognosis concerning cardiac disease over the lifetime. The aim of this review is to clarify the molecular mechanisms underlying the development of cardiac diseases associated particularly with NS, and to discuss the main morphological and clinical characteristics of the two most frequent cardiac disorders, namely pulmonary valve stenosis (PVS) and HCM. We will also report the genotype–phenotype correlation and its implications for prognosis and treatment. Knowing the molecular mechanisms responsible for the genotype–phenotype correlation is key to developing possible targeted therapies. We will briefly address the first experiences of targeted HCM treatment using RAS/MAPK pathway inhibitors.

[16] Recombinant growth hormone therapy in a girl with costello syndrome: a 4-year observation

• Authors: E. Blachowska, E. Petriczko, A. Horodnicka-Józwa, A. Skórka, M. Pelc et al.
• Year: 2016
• Venue: Italian Journal of Pediatrics
• URL: https://www.semanticscholar.org/paper/1cd4e664fa0145ffcd3205cd9a10f056c2ce849c
• DOI: 10.1186/s13052-015-0209-4
• PMID: 26812928
• PMCID: 4729164
• Citations: 8
• Summary: The possibility of growth hormone (GH) treatment can be considered in cases of documented GH deficiency in patients with Costello syndrome, but only under close oncologic and cardiologic supervision.
• Evidence snippets:
• Snippet 1 (score: 0.357) > Costello syndrome (CS, OMIM #218040) is caused by heterozygous germline mutations in the proto-oncogene HRAS that cause dysfunction of the Ras-MAPK signaling pathway. To date, 15 mutations in HRAS have been identified. The birth prevalence of this disease is estimated at 1:1,230,000 to 1:300,000 [1][2][3][4]. Clinically, CS is characterized by polyhydramnios, high birth weight, postnatal growth retardation, relative macrocephaly, coarse facial features, loose skin, especially of the hands and feet, hyperpigmentation, hypertrophic cardiomyopathy, atrial arrhythmias, papillomata, developmental delay or mental retardation, and predisposition to malignancies. In the newborn and neonatal periods, the presence of suggestive facies and severe feeding difficulties leading to failure to thrive and hypoglycemia help make the correct diagnosis [5][6][7]. Furthermore, cases of Costello syndrome patients with endocrine disorders such as adrenal insufficiency and endogenous growth hormone deficiency have also been documented in the literature [8][9][10][11]. > Due to the complex nature of the discussed syndrome, patients require multidisciplinary care (provided by cardiologists, speech therapists, gastroenterologists, orthopedic surgeons) along with early stimulation and developmental support. Because of the short stature and growth hormone deficiency in this condition, growth hormone therapy is often considered. For decades there has been great debate on the anticipated risk of carcinogenesis and cardiomyopathy weighted against the potential benefits resulting from recombinant human growth hormone (rhGH) therapy. To date, there are no conclusive data showing a negative role of rhGH therapy in the development of these diseases. > Here we report a six-year-old patient with Costello syndrome, who has been successfully treated with rhGH for 42 months.

[17] Future research trends in understanding the mechanisms underlying allergic diseases for improved patient care

• Authors: H. Breiteneder, Z. Diamant, T. Eiwegger, W. Fokkens, C. Traidl‐Hoffmann et al.
• Year: 2019
• Venue: Allergy
• URL: https://www.semanticscholar.org/paper/e19b0755c4f4903f68377333676edebf9bd73c89
• DOI: 10.1111/all.13851
• PMID: 31056763
• PMCID: 6973012
• Citations: 90
• Influential citations: 3
• Summary: Recent developments in research and patient care and future trends in the discipline are reviewed and topics on food allergy, biologics, small molecules, and novel therapeutic concepts in allergen‐specific immunotherapy for airway disease are highlighted.
• Evidence snippets:
• Snippet 1 (score: 0.356) > The past decades have witnessed extensive progress in unraveling cellular and molecular mechanisms of immune regulation in asthma, allergic diseases, organ transplantation, autoimmune diseases, tumor biology, and chronic infections. 1,2 Consequently, a better understanding of the functions, the reciprocal regulation, and the counterbalance of subsets of immune and inflammatory cells but also structural cells-for example, epithelial and vascular cells, airway smooth muscle cells, neuroendocrine system-that interact via various intercellular messengers will indicate avenues for immune interventions and novel treatment modalities of allergic diseases and immunological disorders. It is generally expected that drug development in the next decades will show a significant shift from chemicals to biologicals. > After more than 20 years without any breakthrough drug becoming available for patients, several disciplines including allergology are now experiencing extraordinary times with the recent licensing of several major biological drugs and novel allergen-specific immunotherapy (AIT) vaccines. Several biological modifiers of the immune response targeting intracellular messengers or their receptors have been developed to date. [3][4][5][6][7][8] In addition, a number of promising small molecule drugs and vaccines are in the development pipeline. [9][10][11] This new era is now calling for the development of biomarkers and phenoand endotyping of diseases for customized patient care, which is termed stratified medicine, precision medicine, or personalized medicine. 4 Distinguishing phenotypes of a complex disease covers the observable clinically relevant properties of the disease but does not show a direct relationship to disease etiology and pathophysiology. In a complex condition, such as asthma, different pathogenetic mechanisms can induce similar clinical manifestations; however, they may require different treatment approaches. 12,13 These pathophysiological mechanisms underlying disease subgroups are addressed by the term "endotype." [12][13][14] Classification of complex diseases based on the concept of endotypes provides advantages for epidemiological, genetic, and drug-related studies. Accurate endotyping by using reliable biomarkers reflects the natural history of the disease and aims to predict the response to (targeted) treatments. 15 Recent studies have focused on better understanding

[18] From molecular signatures to predictive biomarkers: modeling disease pathophysiology and drug mechanism of action

• Authors: A. Heinzel, P. Perco, G. Mayer, R. Oberbauer, A. Lukas et al.
• Year: 2014
• Venue: Frontiers in Cell and Developmental Biology
• URL: https://www.semanticscholar.org/paper/36d6c03a528c1358c0ae5b667cca5ce73b2fbee5
• DOI: 10.3389/fcell.2014.00037
• PMID: 25364744
• PMCID: 4207010
• Citations: 23
• Summary: This work exemplifies a computational workflow for expanding from statistics-based association analysis toward deriving molecular pathway and process models for characterizing phenotypes and drug mechanism of action, in turn providing precision medicine hypotheses utilizing predictive biomarkers.
• Evidence snippets:
• Snippet 1 (score: 0.356) > In such scenario a biomarker needs to serve as proxy of key mechanistic factors characterizing and driving a disease on a patient-specific level, combined with educating on the specific interference of disease mechanism with drug mechanism of action. For capturing these constraints a detailed molecular map of a clinical phenotype and its interference with a drug mechanism of action is needed, and here integration of Omics profiling adds to identifying such mechanisms (Fechete et al., 2011;Mühlberger et al., 2012). > An a priori stratification of patients based on an appropriately chosen biomarker panel reflecting the pathophysiology of a given patient (group) allowing to determine a match with a specific drug's mechanism of action appears as promising approach. As recently discussed by Himmelfarb et al. fresh approaches are critical in finding therapies to kidney disease benefiting patients, outlining the importance of improving the translational aspect in clinical research (Himmelfarb and Tuttle, 2013). Here, omics technologies have added significantly to the data landscape characterizing chronic kidney disease, however, in a first instance mainly expanding the candidate set of apparently relevant processes and pathways, going in hand with a large number of biomarker candidates, which individually hamper clinically relevant assessment on disease progression (Fechete et al., 2011;Hellemons et al., 2012). > Integrative approaches in the realm of Systems Biology have been proposed for reaching a consensus description of chronic kidney disease pathophysiology, including molecular models of DN as well as of the reno-cardial axis (He et al., 2012;Komorowsky et al., 2012;Mayer et al., 2012;Heinzel et al., 2013). Still, a translation process needs to be followed, joining disease pathophysiology, stratification markers allowing enrichment strategies, combined with on a molecular mechanistic level matching drugs for allowing precision medicine (Mirnezami et al., 2012). In this work we exemplify such procedure on DN being the major clinical presentation leading to end stage renal disease.

[19] Mechanistic Models of Signaling Pathways Reveal the Drug Action Mechanisms behind Gender-Specific Gene Expression for Cancer Treatments

• Authors: C. Çubuk, F. Can, M. Peña-Chilet, J. Dopazo
• Year: 2020
• Venue: Cells
• URL: https://www.semanticscholar.org/paper/e40f7a3b8f72ba01374ba00fbf308a47a3fa5dd4
• DOI: 10.3390/cells9071579
• PMID: 32610626
• PMCID: 7408716
• Citations: 9
• Summary: Despite the existence of differences in gene expression across numerous genes between males and females having been known for a long time, these have been mostly ignored in many studies, including drug development and its therapeutic use. In fact, the consequences of such differences over the disease mechanisms or the drug action mechanisms are completely unknown. Here we applied mechanistic mathematical models of signaling activity to reveal the ultimate functional consequences that gender-s...
• Evidence snippets:
• Snippet 1 (score: 0.355) > Therefore, a proper interpretation of the effect that differences in gene expression have over phenotypes, such as drug response or disease progression, involves understanding the mechanisms of the disease or the mode of action of drugs, which can be interpreted through mechanistic models of cell signaling [12] or cell metabolism [13]. Mechanistic models have helped to understand the disease mechanisms behind different cancers [14,15], including neuroblastoma [16,17], breast cancer [18], rare diseases [19], complex diseases [20], the mechanisms of action of drugs [21,22], and other biologically interesting scenarios such as the molecular mechanisms that explain how stress-induced activation of brown adipose tissue prevents obesity [23] or the molecular mechanisms of death and the post-mortem ischemia of a tissue [24]. Among the few available proposals of mechanistic modeling algorithms that model different aspects of signaling pathway activity, Hipathia has demonstrated having superior sensitivity and specificity [12]. > Here, we propose the use of mechanistic models [13,14] of signaling activity related with cancer hallmarks [25], other cancer-related signaling pathways, and some extra relevant cellular functions to understand the functional consequences of the gender bias in gene expression. Such mechanistic models use gene expression data to produce an estimation of profiles of signaling or metabolic circuit activity within pathways [13,14]. An interesting property of mechanistic models is that they can be used not only to understand molecular mechanisms of disease or of drug action but also to predict the potential consequences of gene perturbations over the circuit activity in a given condition [26]. Actually, in a recent work, our group has successfully predicted therapeutic targets in cancer cell lines with a precision over 60% [15]. Therefore, we will use this mechanistic framework to understand what is the molecular basis of the different effects of cancer drugs by directly simulating their effect in the patients. This approach has recently been used by us to understand the generation of resistances in cancer at the single cell level in glioblastoma [27].

[20] Novel Approaches to Studying SLC13A5 Disease

• Authors: Adriana S. Beltran
• Year: 2024
• Venue: Metabolites
• URL: https://www.semanticscholar.org/paper/8469c534cd81d96f84b61e2d963dead12088feb7
• DOI: 10.3390/metabo14020084
• PMID: 38392976
• PMCID: 10890222
• Citations: 2
• Summary: Current technologies for generating patient-specific induced pluripotent stem cells (iPSCs) and their inherent advantages and limitations are discussed, followed by a summary of the methods for differentiating iPSCs into neurons, hepatocytes, and organoids.
• Evidence snippets:
• Snippet 1 (score: 0.355) > The precise pathophysiology underlying how SLC13A5 loss-of-function results in epilepsy refractory to treatment is a subject of open and ongoing research. Several hypotheses suggest SLC13A5 alters metabolic pathways, leading to neuronal dysfunction. Conversely, therapeutic inhibition of NaCT in the liver is a target to improve metabolic diseases, including non-alcoholic fatty liver disease, obesity, and insulin resistance. Thus, functionally accurate modeling and characterization of the mechanisms involved in citrate transport disruption are critical for understanding its role in human disease. > IPSC-derived cellular systems are a powerful tool for modeling rare human genetic diseases, such as SLC13A5 (Figure 5). IPSCs derived from patients containing the genetic information of the disease can overcome the limitations of animal models, providing access to relevant human cell types that recapitulate the disease phenotype. For instance, patient-derived iPSCs differentiated into neurons or hepatocytes can be used to investigate molecular and cellular mechanisms, including citrate transport and accumulation, energy metabolism, oxidative stress, and other cellular processes. They can also be used to define the spectrum of the disease and how different mutations might lead to various disease severities, screen for potential therapeutic compounds that can restore the transporter function or ameliorate the symptoms, and enable personalized medicine approaches that can tailor treatments to individual patients based on their genetic background and disease severity. > transport disruption are critical for understanding its role in human disease. > IPSC-derived cellular systems are a powerful tool for modeling rare human genetic diseases, such as SLC13A5 (Figure 5). IPSCs derived from patients containing the genetic information of the disease can overcome the limitations of animal models, providing access to relevant human cell types that recapitulate the disease phenotype. For instance, patient-derived iPSCs differentiated into neurons or hepatocytes can be used to investigate molecular and cellular mechanisms, including citrate transport and accumulation, energy metabolism, oxidative stress, and other cellular processes.

Notes

• This provider combines search_papers_by_relevance with snippet_search.
• No synthesis or second-stage model call is performed.

Disorder

• Name: Costello Syndrome
• Category: Mendelian
• Existing deep-research providers: falcon
• Existing evidence reference count in YAML: 6

Key Pathophysiology Nodes

• Constitutive RAS-MAPK Activation
• Tumor Predisposition
• Deep research literature mapping

Citation Inventory (for evidence mapping)

• DOI:10.1161/circep.123.012022
• DOI:10.3390/genes15081015

Pathophysiology description Costello syndrome (CS) is a Rasopathy caused by heterozygous, germline gain-of-function variants in HRAS that dysregulate Ras protein signal transduction and downstream effector pathways. Core signaling derangements include persistent activation of the RAS/MAPK cascade and aberrant PI3K signaling observed in patient-derived cells, which together perturb proliferation, differentiation, growth, and survival programs across multiple tissues (developmental, cardiac, ectodermal, and oncogenic contexts) (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33, faienza2024cardiacphenotypeand pages 2-4).

At the cellular level in the heart, HRAS-mutant atrial-like cardiomyocytes (hiPSC-derived) exhibit an increased fraction of pacemaker-like cells, elevated funny current (If), and a hybrid atrial/nodal transcriptional program with upregulation of ISL1, TBX3, and TBX18, along with disrupted intracellular calcium handling. These electrophysiologic and transcriptional changes mechanistically link hyperactive HRAS to multifocal atrial tachycardia (MAT) and arrhythmogenesis in CS. Pharmacologic modulation in vitro shows that ivabradine (HCN/If inhibitor) and flecainide (Nav1.5 blocker) reduce beating rates, while verapamil (L-type Ca2+ channel blocker) attenuates irregularity, providing proof-of-mechanism and candidate antiarrhythmic strategies (publication URL: https://doi.org/10.1161/circep.123.012022; Apr 2024) (rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5).

Tumor predisposition is characteristic, with a lifetime risk on the order of 10–15% for embryonal rhabdomyosarcoma, neuroblastoma, and transitional cell carcinoma of the bladder, consistent with the role of HRAS pathway hyperactivation in oncogenic transformation. Cardiovascular disease is prominent and includes congenital heart defects (CHD), hypertrophic cardiomyopathy (HCM), and distinctive supraventricular arrhythmias such as MAT, which may occur independently of HCM. MEK inhibition is discussed as a targeted therapeutic approach in severe RASopathy-associated cardiac disease, reflecting the centrality of MAPK hyperactivation in pathogenesis (gripp2023hrasrelatedcostellosyndrome pages 6-8, gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33).

Direct supporting quotes - “CS-associated gain-of-function HRASG12 mutations in induced pluripotent stem cells-derived [atrial-like cardiomyocytes] trigger transcriptional changes associated with enhanced automaticity and arrhythmic activity consistent with multifocal atrial tachycardia.” (URL: https://doi.org/10.1161/circep.123.012022; Apr 2024) (rodriguez2024hrasmutantcardiomyocyte pages 1-3) - In HRAS-mutant atrial-like cardiomyocytes, “the hyperpolarization activated cyclic nucleotide gated potassium channel inhibitor ivabradine and the Nav1.5 blocker flecainide significantly decreased beating rates… verapamil attenuated their irregularity,” linking If and Ca2+ handling to the arrhythmic phenotype (URL: https://doi.org/10.1161/circep.123.012022; Apr 2024) (rodriguez2024hrasmutantcardiomyocyte pages 3-5). - Prolonged PI3K signaling has been reported in HRAS patient fibroblasts, supporting a role for PI3K/AKT axis dysregulation in CS pathogenesis (gripp2023hrasrelatedcostellosyndrome pages 31-33).

1. Core Pathophysiology
2. Primary mechanisms: Germline HRAS activation drives constitutive Ras signal transduction, with downstream RAS/MAPK hyperactivation and evidence for aberrant PI3K signaling, thereby altering lineage programs, growth, and survival. Cardiac-specific effects include ectopic pacemaker-nodal programming in atrial cardiomyocytes and calcium-handling abnormalities that produce MAT. Oncogenic signaling predisposes to embryonal tumors and bladder carcinoma (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33, rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5).
3. Dysregulated molecular pathways: RAS/MAPK cascade (Ras–Raf–MEK–ERK), PI3K/AKT signaling; cardiomyocyte pacemaker pathway (HCN/If) and Ca2+ homeostasis are second-order effectors in arrhythmia pathogenesis (gripp2023hrasrelatedcostellosyndrome pages 31-33, faienza2024cardiacphenotypeand pages 2-4, rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5).

4. Affected cellular processes: Proliferation and differentiation (developmental anomalies), hypertrophic growth and excitation–contraction coupling (HCM, arrhythmias), and oncogenic transformation (tumor predisposition). In atrial cells, increased pacemaker-like lineage fraction, If augmentation, and Ca2+ dysregulation are central (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33, rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5).

5. Key Molecular Players

6. Genes/Proteins (HGNC): HRAS (HGNC:5173) is causal; RASopathy-relevant nodes that contextualize pathway biology include RAF1, BRAF, KRAS, NRAS, MAP2K1/2, and MAPK1, although non-HRAS genes are not causal in classical CS (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33, faienza2024cardiacphenotypeand pages 2-4).
7. Chemical Entities (CHEBI) and targeted agents: MEK inhibitor trametinib is discussed for severe RASopathy cardiac disease (targeting MAPK hyperactivation). In arrhythmic ACM models: ivabradine (HCN/If inhibitor), flecainide (Na+ channel blocker), verapamil (L-type Ca2+ channel blocker) modulated HRAS-driven phenotypes (gripp2023hrasrelatedcostellosyndrome pages 1-4, faienza2024cardiacphenotypeand pages 2-4, rodriguez2024hrasmutantcardiomyocyte pages 3-5).
8. Cell Types (CL): Atrial cardiomyocytes with a shift toward pacemaker-nodal programming; increased pacemaker-like cell proportion is a key mechanistic finding in the arrhythmia model (rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5).

9. Anatomical Locations (UBERON): Heart/atrium (CHD, HCM, MAT), skin (papillomata and ectodermal features), urinary bladder (transitional cell carcinoma), cerebellum (postnatal overgrowth/Chiari) (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33, faienza2024cardiacphenotypeand pages 2-4).

10. Biological Processes (GO terms)

11. Ras protein signal transduction (GO:0007265) and RAS/MAPK cascade (GO:0000165) are centrally dysregulated by HRAS activation (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33, faienza2024cardiacphenotypeand pages 2-4).
12. PI3K signaling (GO:0014065) shows prolonged activity in patient fibroblasts, implicating AKT/mTOR axis involvement in growth and oncogenesis (gripp2023hrasrelatedcostellosyndrome pages 31-33).

13. Cardiac electrical and calcium-handling processes: regulation of heart rate via pacemaker If current and intracellular calcium ion homeostasis (e.g., GO:0070588), underlying MAT in CS models (rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5).

14. Cellular Components

15. Plasma membrane signaling complexes (RAS at inner leaflet membranes; receptor-proximal signaling), cytosol and nucleus for ERK/AKT effectors; in cardiomyocytes, sarcolemma ion channels (HCN, Nav1.5, Cav1.2) and sarcoplasmic reticulum Ca2+ handling machinery represent key locales of dysfunction (rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5, faienza2024cardiacphenotypeand pages 2-4).

16. Disease Progression

17. Initial trigger: De novo heterozygous HRAS gain-of-function variant.
18. Early developmental effects: Abnormal Ras/MAPK and PI3K signaling perturb organogenesis and growth, producing characteristic craniofacial features, feeding difficulty/failure to thrive, short stature, hypotonia, and neurodevelopmental issues; cerebellar overgrowth and Chiari/hydrocephalus may develop postnatally (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33).
19. Cardiac phase: High prevalence of CHD and HCM; atrial electrical remodeling with pacemaker-nodal reprogramming and Ca2+ dysregulation yields MAT/ectopic atrial tachycardia in infancy/early childhood (gripp2023hrasrelatedcostellosyndrome pages 6-8, gripp2023hrasrelatedcostellosyndrome pages 1-4, rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5).

20. Oncogenesis: Elevated lifetime risk for embryonal tumors (RMS, NB) and bladder carcinoma emerges from sustained HRAS effector pathway activation (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33).

21. Phenotypic Manifestations and Statistics

22. Cardiovascular involvement is frequent. Reported series document cardiovascular abnormalities in the large majority of patients; CHD around 44%; hypertrophic cardiomyopathy approximately 60–61%; supraventricular arrhythmias in roughly half, including MAT that often presents in infancy and can occur independent of HCM (gripp2023hrasrelatedcostellosyndrome pages 6-8, gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33). Recent RASopathy-focused cardiology review reports HCM prevalence “~65% in Costello syndrome” and atrial arrhythmias “up to 56%,” underscoring the burden of cardiac disease (URL: https://doi.org/10.3390/genes15081015; Aug 2024) (faienza2024cardiacphenotypeand pages 7-8).
23. Tumor predisposition: Lifetime tumor risk on the order of 10–15% with a spectrum including rhabdomyosarcoma, neuroblastoma, and transitional cell carcinoma of the bladder (gripp2023hrasrelatedcostellosyndrome pages 6-8, gripp2023hrasrelatedcostellosyndrome pages 1-4).

Current applications and real-world implementations - Precision electrophysiology: The HRAS-mutant atrial-like cardiomyocyte model establishes a mechanistic basis for MAT and nominates HCN inhibition (ivabradine), Nav1.5 blockade (flecainide), and L-type Ca2+ channel blockade (verapamil) as rational antiarrhythmic interventions to test clinically in CS-associated tachyarrhythmias (URL: https://doi.org/10.1161/circep.123.012022; Apr 2024) (rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5). - Targeted pathway inhibition: MEK inhibition (e.g., trametinib) is discussed/considered for severe RASopathy-associated cardiac disease, aligning treatment with RAS/MAPK pathway hyperactivation in CS (gripp2023hrasrelatedcostellosyndrome pages 1-4, faienza2024cardiacphenotypeand pages 2-4). - Surveillance protocols: Given tumor predisposition, longitudinal screening (e.g., abdominal/pelvic ultrasound in early childhood; bladder surveillance later) is standard practice in CS management frameworks (gripp2023hrasrelatedcostellosyndrome pages 1-4).

Expert opinions and analysis - Contemporary expert summaries emphasize CS as a prototypic Rasopathy with multisystem involvement driven by HRAS gain-of-function, with prominent cardiac and oncologic risks. Arrhythmia mechanisms are increasingly understood through hiPSC models showing pacemaker-nodal reprogramming and Ca2+ dysregulation. These insights prioritize HCN, Na+ channel, and L-type Ca2+ channel modulators in addition to MAPK-directed therapy for organ-specific complications (rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5, gripp2023hrasrelatedcostellosyndrome pages 1-4, faienza2024cardiacphenotypeand pages 2-4).

Evidence items with PMIDs/URLs/dates - Rodríguez NA et al. HRAS-mutant cardiomyocyte model of multifocal atrial tachycardia. Circulation: Arrhythmia & Electrophysiology. Apr 2024. URL: https://doi.org/10.1161/circep.123.012022 (rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5). - Gripp KW, Weaver KN. HRAS-related Costello syndrome (GeneReviews-like chapter). 2023. Key statistics and clinical correlations, tumor risk and management principles (gripp2023hrasrelatedcostellosyndrome pages 6-8, gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33). - Faienza MF et al. Cardiac phenotype and gene mutations in RASopathies. Genes. Aug 2024;15:1015. URL: https://doi.org/10.3390/genes15081015 (faienza2024cardiacphenotypeand pages 2-4, faienza2024cardiacphenotypeand pages 7-8).

Gene/protein annotations with ontology terms - HRAS (HGNC:5173): causal gene; pathway: RAS/MAPK (GO:0000165); process: Ras protein signal transduction (GO:0007265); additional effector: PI3K signaling (GO:0014065). Tissues: heart/atrium (UBERON:0000948/0002080), skin (UBERON:0002097), urinary bladder (UBERON:0001255), cerebellum (UBERON:0002037). Phenotypes: HCM (HPO:0001639), multifocal atrial tachycardia (HPO term). Chemicals: trametinib (CHEBI:90698), ivabradine (CHEBI:83587), flecainide (CHEBI:5126), verapamil (CHEBI:9945) (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33, faienza2024cardiacphenotypeand pages 2-4, rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5).

Phenotype associations (HPO terms) - Hypertrophic cardiomyopathy (HPO:0001639): high prevalence and major morbidity (gripp2023hrasrelatedcostellosyndrome pages 6-8, gripp2023hrasrelatedcostellosyndrome pages 1-4, faienza2024cardiacphenotypeand pages 7-8). - Multifocal atrial tachycardia (HPO term): frequent, often early-onset supraventricular arrhythmia linked mechanistically to pacemaker-nodal reprogramming and Ca2+ dysregulation (rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5, gripp2023hrasrelatedcostellosyndrome pages 1-4). - Tumor predisposition phenotypes: rhabdomyosarcoma, neuroblastoma, transitional cell carcinoma of the bladder (HPO tumor terms) (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33).

Cell type involvement (CL terms) - Atrial cardiomyocytes with increased pacemaker-like cell fraction; mechanistic basis for arrhythmia in CS (CL term for atrial cardiomyocyte) (rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5).

Anatomical locations (UBERON terms) - Heart/atrium (cardiac structural and electrophysiological disease); skin (ectodermal features); urinary bladder (solid tumor predisposition); cerebellum (postnatal overgrowth/Chiari) (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33, faienza2024cardiacphenotypeand pages 2-4).

Chemical entities (CHEBI terms) - Trametinib (CHEBI:90698), ivabradine (CHEBI:83587), flecainide (CHEBI:5126), verapamil (CHEBI:9945) (gripp2023hrasrelatedcostellosyndrome pages 1-4, faienza2024cardiacphenotypeand pages 2-4, rodriguez2024hrasmutantcardiomyocyte pages 3-5).

Recent developments and latest research (2023–2024) - 2024 hiPSC-derived atrial cardiomyocyte modeling established a direct mechanistic link from HRAS gain-of-function to MAT via nodal-like reprogramming and If/Ca2+ dysregulation, and nominated ivabradine, flecainide, and verapamil as rational modulators (Apr 2024; URL: https://doi.org/10.1161/circep.123.012022) (rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5). - Contemporary reviews consolidate high cardiac burden and provide updated prevalence ranges for HCM and arrhythmias in RASopathies, including CS, underscoring the need for targeted pathway therapies and careful risk stratification (Aug 2024; URL: https://doi.org/10.3390/genes15081015) (faienza2024cardiacphenotypeand pages 2-4, faienza2024cardiacphenotypeand pages 7-8). - Expert clinical overviews reaffirm the tumor spectrum and surveillance rationale, as well as the potential role of MAPK pathway inhibition in severe cardiac phenotypes (2023) (gripp2023hrasrelatedcostellosyndrome pages 6-8, gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33).

Structured artifact | Category | Entity (standard name) | Ontology ID | Mechanistic/phenotypic role in Costello syndrome | Evidence | |---|---|---|---|---| | Gene | HRAS (HRas proto-oncogene) | HGNC:5173 | Germline gain-of-function HRAS variants cause Costello syndrome; drive developmental defects, tumor predisposition, hypertrophic cardiomyopathy and supraventricular arrhythmias via RAS pathway dysregulation and prolonged PI3K signaling. | (gripp2023hrasrelatedcostellosyndrome pages 6-8, gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33) | | Pathway | RAS/MAPK cascade | GO:0000165 | Constitutively activated in CS; mediates abnormal cell proliferation/differentiation contributing to cardiac hypertrophy and developmental phenotypes. | (gripp2023hrasrelatedcostellosyndrome pages 1-4, faienza2024cardiacphenotypeand pages 2-4, gripp2023hrasrelatedcostellosyndrome pages 31-33) | | Process | Ras protein signal transduction | GO:0007265 | Upstream signaling node altered by HRAS variants; perturbs downstream MAPK and PI3K/AKT effectors affecting multiple tissues. | (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33) | | Pathway | PI3K signaling | GO:0014065 | Prolonged/aberrant PI3K/AKT activity reported in patient cells; implicated in oncogenesis and cardiac/myocyte hypertrophic responses. | (gripp2023hrasrelatedcostellosyndrome pages 31-33, faienza2024cardiacphenotypeand pages 2-4) | | Cell program | Atrial cardiomyocyte / pacemaker-like program (cell fate shift) | CL:0002321 (atrial cardiomyocyte) | HRAS-mutant atrial-like cardiomyocytes adopt hybrid atrial/nodal transcriptional program (↑ISL1, TBX3, TBX18) increasing pacemaker-like cells and automaticity. | (rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5) | | Process | Calcium handling in cardiomyocytes | GO:0006816 / GO:0070588 | Disrupted intracellular Ca2+ homeostasis in HRAS-mutant ACMs contributes to arrhythmic activity and abnormal excitation–contraction coupling. | (rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5) | | Anatomy | Heart / atrium | UBERON:0000948 / UBERON:0002080 | Primary organ system affected: congenital heart defects, hypertrophic cardiomyopathy, and atrial arrhythmias (multifocal atrial tachycardia) are common clinical manifestations. | (gripp2023hrasrelatedcostellosyndrome pages 6-8, gripp2023hrasrelatedcostellosyndrome pages 1-4, faienza2024cardiacphenotypeand pages 2-4) | | Anatomy | Skin | UBERON:0002097 | Ectodermal/cutaneous involvement: papillomata, keratoderma and other skin findings commonly observed in CS. | (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33) | | Anatomy | Urinary bladder | UBERON:0001255 | Predisposition to transitional cell carcinoma of the bladder reported as part of tumor spectrum in CS. | (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33) | | Anatomy | Cerebellum | UBERON:0002037 | Postnatal cerebellar overgrowth and Chiari I/hydrocephalus reported; neurodevelopmental involvement linked to HRAS signaling effects. | (gripp2023hrasrelatedcostellosyndrome pages 1-4) | | Phenotype | Hypertrophic cardiomyopathy | HPO:0001639 | High prevalence (~60% in some series); major determinant of morbidity/mortality in CS patients. | (gripp2023hrasrelatedcostellosyndrome pages 6-8, faienza2024cardiacphenotypeand pages 2-4, gripp2023hrasrelatedcostellosyndrome pages 31-33) | | Phenotype | Multifocal atrial tachycardia (MAT) | HPO:— (multifocal atrial tachycardia) | Frequent, treatment-resistant supraventricular arrhythmia of infancy/early childhood in CS; mechanistic link to increased pacemaker-like cells and ↑If current. | (rodriguez2024hrasmutantcardiomyocyte pages 1-3, gripp2023hrasrelatedcostellosyndrome pages 1-4, rodriguez2024hrasmutantcardiomyocyte pages 3-5) | | Phenotype cluster | Rhabdomyosarcoma; Neuroblastoma; Transitional cell carcinoma | HPO:— (see individual tumor terms) | Tumor predisposition (lifetime risk ~10–15% reported) with early-onset pediatric tumors (RMS, NB) and bladder carcinoma risk. | (gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33, gripp2023hrasrelatedcostellosyndrome pages 13-14) | | Drug | Trametinib (MEK inhibitor) | CHEBI:90698 | Used compassionately/considered for severe RASopathy-associated cardiac disease (MEK inhibition targets hyperactive MAPK signaling). | (gripp2023hrasrelatedcostellosyndrome pages 1-4, faienza2024cardiacphenotypeand pages 2-4, rodriguez2024hrasmutantcardiomyocyte pages 3-5) | | Drug | Ivabradine (HCN/If inhibitor) | CHEBI:83587 | Reduces elevated beating rates in HRAS-mutant atrial-like cardiomyocytes by inhibiting funny current; shown to decrease automaticity in cellular model. | (rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5) | | Drug | Flecainide (Na+ channel blocker) | CHEBI:5126 | Nav1.5 blockade reduced beating rate in HRAS-mutant ACMs in vitro; evaluated as antiarrhythmic in models/patients. | (rodriguez2024hrasmutantcardiomyocyte pages 3-5) | | Drug | Verapamil (L-type Ca2+ channel blocker) | CHEBI:9945 | Attenuated irregularity of beating in HRAS-mutant ACMs by modulating Ca2+ flux; supports role of Ca2+ handling in arrhythmogenesis. | (rodriguez2024hrasmutantcardiomyocyte pages 3-5) |

Table: Compact table summarizing core genes, pathways, cell/tissue involvements, phenotypes and drugs relevant to Costello syndrome, with evidence pointers to the gathered sources (pqac IDs). This aids rapid integration into a disease knowledge base with ontology references.

References (with links where available) - Rodríguez NA, Patel N, Dariolli R, et al. HRAS-mutant cardiomyocyte model of multifocal atrial tachycardia. Circulation: Arrhythmia & Electrophysiology. Apr 2024. https://doi.org/10.1161/circep.123.012022 (rodriguez2024hrasmutantcardiomyocyte pages 1-3, rodriguez2024hrasmutantcardiomyocyte pages 3-5). - Gripp KW, Weaver KN. HRAS-related Costello syndrome. 2023. Summary of epidemiology, phenotype, tumor risk, and management (gripp2023hrasrelatedcostellosyndrome pages 6-8, gripp2023hrasrelatedcostellosyndrome pages 1-4, gripp2023hrasrelatedcostellosyndrome pages 31-33). - Faienza MF, Meliota G, Mentino D, et al. Cardiac phenotype and gene mutations in RASopathies. Genes. Aug 2024;15:1015. https://doi.org/10.3390/genes15081015 (faienza2024cardiacphenotypeand pages 2-4, faienza2024cardiacphenotypeand pages 7-8).

References

1. (gripp2023hrasrelatedcostellosyndrome pages 1-4): KW Gripp and KN Weaver. Hras-related costello syndrome. Unknown journal, 2023.

2. (gripp2023hrasrelatedcostellosyndrome pages 31-33): KW Gripp and KN Weaver. Hras-related costello syndrome. Unknown journal, 2023.

3. (faienza2024cardiacphenotypeand pages 2-4): Maria Felicia Faienza, Giovanni Meliota, Donatella Mentino, Romina Ficarella, Mattia Gentile, Ugo Vairo, and Gabriele D’amato. Cardiac phenotype and gene mutations in rasopathies. Genes, 15:1015, Aug 2024. URL: https://doi.org/10.3390/genes15081015, doi:10.3390/genes15081015. This article has 11 citations and is from a poor quality or predatory journal.

4. (rodriguez2024hrasmutantcardiomyocyte pages 1-3): Nelson A. Rodríguez, Nihir Patel, Rafael Dariolli, Simon Ng, Angelika G. Aleman, Jingqi Q.X. Gong, Hung-Mo Lin, Matthew Rodríguez, Rebecca Josowitz, Katia Sol-Church, Karen W. Gripp, Xianming Lin, Soomin C. Song, Glenn I. Fishman, Eric A. Sobie, and Bruce D. Gelb. hras -mutant cardiomyocyte model of multifocal atrial tachycardia. Circulation: Arrhythmia and Electrophysiology, Apr 2024. URL: https://doi.org/10.1161/circep.123.012022, doi:10.1161/circep.123.012022. This article has 2 citations and is from a peer-reviewed journal.

5. (rodriguez2024hrasmutantcardiomyocyte pages 3-5): Nelson A. Rodríguez, Nihir Patel, Rafael Dariolli, Simon Ng, Angelika G. Aleman, Jingqi Q.X. Gong, Hung-Mo Lin, Matthew Rodríguez, Rebecca Josowitz, Katia Sol-Church, Karen W. Gripp, Xianming Lin, Soomin C. Song, Glenn I. Fishman, Eric A. Sobie, and Bruce D. Gelb. hras -mutant cardiomyocyte model of multifocal atrial tachycardia. Circulation: Arrhythmia and Electrophysiology, Apr 2024. URL: https://doi.org/10.1161/circep.123.012022, doi:10.1161/circep.123.012022. This article has 2 citations and is from a peer-reviewed journal.

6. (gripp2023hrasrelatedcostellosyndrome pages 6-8): KW Gripp and KN Weaver. Hras-related costello syndrome. Unknown journal, 2023.

7. (faienza2024cardiacphenotypeand pages 7-8): Maria Felicia Faienza, Giovanni Meliota, Donatella Mentino, Romina Ficarella, Mattia Gentile, Ugo Vairo, and Gabriele D’amato. Cardiac phenotype and gene mutations in rasopathies. Genes, 15:1015, Aug 2024. URL: https://doi.org/10.3390/genes15081015, doi:10.3390/genes15081015. This article has 11 citations and is from a poor quality or predatory journal.

8. (gripp2023hrasrelatedcostellosyndrome pages 13-14): KW Gripp and KN Weaver. Hras-related costello syndrome. Unknown journal, 2023.