Structural variants (SVs) rearrange large segments of DNA1 and can have profound consequences in evolution and human disease2,3. As national biobanks, disease-association studies, and clinical genetic testing have grown increasingly reliant on genome sequencing, population references such as the Genome Aggregation Database (gnomAD)4 have become integral in the interpretation of single-nucleotide variants (SNVs)5. However, there are no reference maps of SVs from high-coverage genome sequencing comparable to those for SNVs. Here we present a reference of sequence-resolved SVs constructed from 14,891 genomes across diverse global populations (54% non-European) in gnomAD. We discovered a rich and complex landscape of 433,371 SVs, from which we estimate that SVs are responsible for 25–29% of all rare protein-truncating events per genome. We found strong correlations between natural selection against damaging SNVs and rare SVs that disrupt or duplicate protein-coding sequence, which suggests that genes that are highly intolerant to loss-of-function are also sensitive to increased dosage6. We also uncovered modest selection against noncoding SVs in cis-regulatory elements, although selection against protein-truncating SVs was stronger than all noncoding effects. Finally, we identified very large (over one megabase), rare SVs in 3.9% of samples, and estimate that 0.13% of individuals may carry an SV that meets the existing criteria for clinically important incidental findings7. This SV resource is freely distributed via the gnomAD browser8 and will have broad utility in population genetics, disease-association studies, and diagnostic screening.

The RecQ DNA helicase WRN is a synthetic lethal target for cancers with microsatellite instability (MSI), a form of genetic hypermutability arising from impaired mismatch repair 1-4 . WRN depletion induces widespread DNA double strand breaks (DSBs) in MSI cells, leading to cell cycle arrest and/or apoptosis. However, the mechanism by which WRN protects MSI cancers from DSBs remains unclear. Here, we demonstrate that TAdinucleotide repeats are highly unstable in MSI cells and exhibit surprisingly large-scale expansions, distinct from previously described insertion/deletion mutations of a few nucleotides 5 . We show that expanded TA repeats form non-B DNA secondary structures that stall replication forks, activate the ATR checkpoint kinase, and necessitate unwinding by the WRN helicase. In the absence of WRN, the expanded TA-dinucleotide repeats are susceptible to MUS81 nuclease cleavage, leading to massive chromosome shattering. Thus, our study uncovers a distinct biomarker within MSI tumors that underlies the synthetic lethal dependence on WRN, thereby supporting the development of WRN-based therapeutics.

A Correction to this paper has been published: https://doi.org/10.1038/s41586-020-03176-6.

Paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome are diseases of excess activation of the alternative pathway of complement that are treated with eculizumab, a humanized monoclonal antibody against the terminal complement component C5. Eculizumab must be administered intravenously, and moreover some patients with paroxysmal nocturnal hemoglobinuria on eculizumab have symptomatic extravascular hemolysis, indicating an unmet need for additional therapeutic approaches. We report the activity of two novel small-molecule inhibitors of the alternative pathway component Factor D using in vitro correlates of both paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. Both compounds bind human Factor D with high affinity and effectively inhibit its proteolytic activity against purified Factor B in complex with C3b. When tested using the traditional Ham test with cells from paroxysmal nocturnal hemoglobinuria patients, the Factor D inhibitors significantly reduced complement-mediated hemolysis at concentrations as low as 0.01 μM. Additionally the compound ACH-4471 significantly decreased C3 fragment deposition on paroxysmal nocturnal hemoglobinuria erythrocytes, indicating a reduced potential relative to eculizumab for extravascular hemolysis. Using the recently described modified Ham test with serum from patients with atypical hemolytic uremic syndrome, the compounds reduced the alternative pathway-mediated killing of PIGA-null reagent cells, thus establishing their potential utility for this disease of alternative pathway of complement dysregulation and validating the modified Ham test as a system for pre-clinical drug development for atypical hemolytic uremic syndrome. Finally, ACH-4471 blocked alternative pathway activity when administered orally to cynomolgus monkeys. In conclusion, the small-molecule Factor D inhibitors show potential as oral therapeutics for human diseases driven by the alternative pathway of complement, including paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome.

In this paper, we study the effects of parity violation on non-Gaussianities of primordial gravitational waves in the framework of the Hořava-Lifshitz theory of gravity, in which high-order spatial derivative operators, including the ones violating parity, generically appear. By calculating the three-point function, we find that the leading-order contributions to the non-Gaussianities come from the usual second-order derivative terms, which produce the same bispectrum as that found in general relativity. The contributions from highorder spatial nth derivative terms are always suppressed by a factor ðH=M Ã Þ nÀ2 ðn ! 3Þ, where H denotes the inflationary energy and M Ã the suppression mass scale of the high-order spatial derivative operators of the theory. Therefore, the next leading-order contributions come from the three-dimensional gravitational ChernSimons term. With some reasonable arguments, it is shown that this three-dimensional operator is the only one that violates the parity and in the meantime has nonvanishing contributions to non-Gaussianities.