Abstract
Accumulating DNA damage plays a crucial role in aging, particularly in post-mitotic tissues by disrupting transcription and causing transcriptional stress—a state marked by reduced transcriptional productivity. Transcriptional stress disproportionately affects long genes, due to the random distribution of DNA lesions across the genome. An estimate for the total number of transcription-blocking lesions (TBLs) required to induce transcriptional stress and contribute to aging is lacking. Here, we estimated the number of TBLs accumulating with age, by integrating experimental data with a mathematical model based solely on fundamental biological principles. Using 5-ethynyluridine (EU) incorporation, we assessed transcriptional activity in dermal fibroblasts and liver tissue from Ercc1−/−, Ercc1d/-, and Xpg−/− mice—models with DNA repair deficiencies that exhibit a wide range of premature aging features between 5 and 26 weeks of age. We then compared the experimental data to our model, which captured the overall trend of transcriptional decline, supporting a correlation between accumulating DNA damage and reduced transcription during aging. Wildtype mice were found to accumulate approximately 62 TBLs per day, whereas DNA repair-deficient mice exhibited a markedly higher burden, accumulating 1,600–5,000 TBLs daily. These insights offer a quantitative understanding of transcriptional stress, which is crucial for elucidating the aging process.
1 Introduction
Aging is generally associated with a progressive decline in physical and cognitive abilities, and a key role in this process is played by DNA damage (; ). DNA lesions are generally very difficult to detect and reliably quantify because of their heterogeneous nature and low abundance. However, it is estimated that mammalian cells may encounter on average approximately 100,000 DNA lesions daily from endogenous and exogenous sources, with roughly 104 being AP sites—abasic sites where a DNA base has been lost due to spontaneous hydrolysis. (). Ultraviolet (UV) radiation from sunlight alone can already lead to the formation of up to 100,000 lesions per day in keratinocytes (), underlining the substantial burden of DNA damage on the genome. While cells possess a sophisticated network of DNA repair pathways to counteract various types of damage, these mechanisms are not 100% efficient. Consequently, DNA damage accumulates in tissues over time, contributing to the aging process (; ; ; ).
As DNA damage accumulates in the genome with age (; ; ), it physically blocks elongating RNA, thereby interfering with gene expression (). Moreover, a lesion-stalled RNA polymerase in the liver of a 2-year old wildtype mouse is estimated to arrest on average three additional RNA polymerases, forming a queue (). In cells with a high number of transcription-blocking lesions (TBLs), this results in reduced transcriptional productivity, a state known as transcriptional stress. Through this mechanism, DNA damage can impact nearly every hallmark of the aging phenotype, such as genomic instability, loss of proteostasis, deregulated nutrient sensing and inflammation (), suggesting it could serve as a unifying driver of the aging process (; ).
Since DNA damage occurs roughly uniformly across the genome, long genes statistically face damage more frequently than short genes. This skews transcriptional output toward shorter genes, impacting gene expression profiles (). Such shifts in transcriptional activity disrupt the regulation of numerous pathways associated with various aging hallmarks (). Our lab identified transcriptional stress in multiple species and tissues: in at least 14 different tissues in mice, 11 in rats, and 6 in humans, ranging from heart to retina, and provided direct evidence that it is caused by DNA damage ().
Other studies have also reported gene-length dependent transcriptional stress (; ; ; ; ). For instance, Stoeger et al. further identified increased transcriptional stress with age in various transcriptomic datasets from mice and humans, and found that the phenomenon is responsive to anti-aging interventions (). Additionally, Ibañez-Solé et al. observed transcriptional stress in single-cell RNA sequencing datasets across multiple tissues and cell types during mouse and human aging (). Enrichment analyses indicate that long genes are indeed associated with longevity and aging-related pathways (; ). Finally, Soheili-Nezhad et al. found that long genes are less expressed in brains of Alzheimer’s patients, potentially contributing to the disease’s pathogenesis (). This transcriptional stress was more pronounced in brain regions commonly affected in Alzheimer’s disease, and less in regions more resilient to Alzheimer’s disease (). These findings collectively indicate that transcriptional stress likely plays an important role in the aging process, though causality has not yet been established.
The connection between transcriptional stress and aging is well-illustrated by progeroid mouse models, such as Ercc1d/- and Xpg−/− mice (; ). These mouse models have genetic deficiencies in either Ercc1 or Xpg, factors that are crucial for repairing DNA lesions that impede transcription via transcription-coupled nucleotide excision repair (TC-NER) (). They exhibit progressively reduced transcription levels in tissues like the liver and kidney (), alongside numerous characteristics associated with premature aging, such as declining liver, kidney and cardiovascular function, weight loss, sarcopenia, and features of neurodegeneration including tremors, hearing and vision loss, imbalance and overall frailty (; ; ).
As estimated in our previous analysis, approximately 40% of elongating RNA polymerases appear stalled in liver of a 2-year old wildtype mouse (). This degree of transcriptional stress is most likely caused by various types of endogenous DNA lesions which are capable of blocking transcription, including cyclopurines, DNA adducts of aldehydes, interstrand crosslinks, DNA-protein crosslinks () and advanced glycation end products (AGEs) (; ). However, the quantity of DNA lesions responsible for inducing transcriptional stress and contributing to aging has only been approximated for some lesion types.
In this study, our objective was to estimate the number of TBLs that form during aging by integrating experimental data with a mathematical model. Initially, we quantified the level of DNA damage that leads to a certain reduction in transcription and assessed the accuracy of this method. We investigated global transcription levels using EU incorporation in human fibroblasts following UV light treatment, which induces transcription-blocking DNA damage, and compared the results to the predictions of our mathematical model. In addition to cultured cells, we analyzed global transcription levels in mice. We used liver tissue slices obtained from wildtype, Ercc1−/−, Ercc1d/-, and Xpg−/− mice across various ages to assess the accumulation of DNA damage associated with aging in vivo and compared this data with our mathematical model. We found notable similarities between the experimental data and the model, as well as some remarkable differences. Our study provides a quantitative framework for estimating TBLs during aging, offering insights into how transcriptional stress accumulates over time.
2 Results
2.1 Model assumptions
We developed a mathematical model to better understand the characteristics of DNA damage accumulation and transcriptional stress over time, allowing us to estimate the approximate number of TBLs accumulating with aging (Figure 1). The mathematical model, elaborated in detail in (), is based on four biological assumptions. First, assuming a diploid state, transcription is evenly distributed between the two alleles of a gene present on the pair of homologous chromosomes. Second, DNA damage is equally likely to occur in either of the two DNA strands, so when DNA damage occurs, there is a 50% chance that transcription will be maintained. Third, our model exclusively considers unrepaired (i.e., persistent) DNA damage, ignoring DNA lesions that are repaired. Although repair is not considered in the model, the framework remains applicable to organisms with functional repair mechanisms, as DNA repair acts to reduce, but not entirely prevent, the accumulation of TBLs. In this case, DNA damage is simply modeled to accumulate at a slower rate. Finally, persistent DNA damage is uniformly distributed across the genome and accumulates at a constant, defined input rate, as supported by quantifications of different DNA lesion types in different mouse tissues () and human PBMCs (). Although specific hotspots have been identified (; ), possibly due to factors like chromatin structure, this assumption of uniform distribution is also the basis of another mathematical model on aging cells (). This approach allows us to account for the cumulative accumulation of unrepaired DNA damage in each cell over an organism’s lifespan.
FIGURE 1
As input, the model requires a list of genes expressed in the specific organ and cell type of the target species. For each gene ∈ {1, … , 2N}, it also requires its length to calculate the probability of acquiring TBLs . Since we assume DNA damage is uniformly distributed across the genome, the probability is proportional to the gene’s length and the total genome length L. Since there are two alleles of each gene, with each allele consisting of two DNA strands, L is multiplied by 4. Therefore, the probability is given by (
Additionally, the model requires the weighted expression level for each expressed gene, measured by nascent RNA sequencing, with (Figure 1).
2.2 Transcription in human fibroblasts after UV damage
It is essential to understand the variability of in vitro data before applying our model to in vivo data, as the intrinsic error will be amplified in in vivo data. Therefore, we first calibrated the model, described in more detail in (
Cells were synchronized in G0/G1 by growing to full confluency and then culturing for an additional 2 weeks before UV treatment. This extended culturing period ensured that only a minor, negligible fraction of cells continued proliferating, which helped avoid cell death during S-phase caused by the induced damage and prevented DNA repair pathways active solely in S-phase from repairing the damage. The percentage of replicating cells, quantified using EdU (5-ethynyl-2-deoxyuridine) incorporation, never exceeded 7% in any sample and was below 2% in most samples (Supplementary Figure S2A).
We induced transcriptional stress in cells using UV-C irradiation, because it induces TBLs in a quick and constant manner, and the amount of TBLs induced per 1 J/m2 UV-C exposure is known (
We observed a UV dose-dependent decrease in EU-intensity levels by approximately 15% after exposure to 1 J/m2 and by about 65% after 6 J/m2 (Figures 2A,B). Our focus was exclusively on quantifying the EU signal within the nucleoplasm, i.e., the nucleus without nucleoli, to avoid bias from high, damage-resistant rRNA transcription. In the context of aging, low doses (below 2 or 3 TBLs per 100 kb) are of physiological relevance, as such levels are typically encountered under natural conditions, such as chronic low-level UV exposure combined with endogenous DNA damage (
FIGURE 2

Transcription in human fibroblasts after UV-induced DNA damage. (A) Representative confocal images of XP25RO (XPA-deficient) cells treated with different UV doses (0–6 J/m2), stained with transcription marker EU (green) and DNA marker Hoechst (blue) 24 h post-treatment. Scale bar = 30 μm. (B) Quantification of EU intensity in XP25RO cells 24 h after UV exposure (0–6 J/m2), based on four independent experiments. Error bars represent the SEM. Unpaired two-tailed Student’s t-test: *p ≤ 0.05; **p ≤ 0.01; ***p ≤ 0.001; ****p ≤ 0.0001. (C) Non-linear (third-order polynomial) and linear regression analysis of EU intensity data from four independent experiments in XP25RO cells. EU intensity was converted to transcription loss (100% – EU intensity), and UV dose was converted to amount of TBLs per 100 kb. Error bars represent the SEM. (D) Mathematical model on transcriptional stress in human cells, depicting transcription loss versus DNA damage per 100 kb, together with experimental data and non-linear fit from (C) in red. Transcription loss was modelled for different doses of DNA damage in between 0 and 4 DNA lesions per 100 kb to generate the black curve. Black error bars represent the 95% confidence interval of the model calibrated on nascent RNA sequencing data from four independent cell populations. Red error bars depict the SEM of four independent experiments. (E) Transcription loss as a function of the number of TBLs per 100 kb, as predicted by the mathematical model for both mouse liver and human fibroblasts. In both input data sets, genes below 5 kb were filtered out. Error bars indicate the standard deviation.
To compare these results with our mathematical model predictions, we calculated the percentage of transcription loss per TBL for different doses of DNA damage. We found that the results of the EU stainings and the model match relatively well, with an average absolute error of the model from the data of 7.1%, or 0.95 times the SEM of the experimental data (Figure 2D). Although the model’s predictions differ in accuracy depending on the dose of TBLs (Table 1), it approximates transcription loss reasonably well compared to the experimental data. In summary, our findings illustrate that transcriptional stress induced by a known amount of DNA damage can be modeled with an average absolute error rate of 7.1%, or 0.95 times the experimental SEM within the dose range tested using this method. This is crucial to understand before applying our model to in vivo data, as the intrinsic error will be amplified due to biological and technical variation.
TABLE 1
| UV dose (J/m2) | 1 | 2 | 3 | 4 | 5 | 6 |
|---|---|---|---|---|---|---|
| #TBLs per 100 kb | 0.55 | 1.10 | 1.65 | 2.20 | 2.75 | 3.30 |
| #TBLs in total | 17,600 | 35,200 | 52,800 | 70,400 | 88,000 | 105,600 |
| Absolute error of the model (%) | 1.18 | 6.12 | 0.94 | 7.05 | 12.0 | 15.0 |
| Experimental SEM (%) | 5.61 | 6.11 | 9.39 | 9.06 | 7.86 | 7.12 |
| Absolute error in #SEMs | 0.21 | 1.00 | 0.10 | 0.78 | 1.53 | 2.10 |
| Relative error of the model (%) | 7.90 | 29.6 | 2.76 | 14.7 | 20.7 | 23.0 |
| Relative error in #SEMs | 1.41 | 4.85 | 0.29 | 1.63 | 2.64 | 3.23 |
Absolute and relative error rates (in % and in #SEMs) of the mathematical model for human fibroblasts as compared to the experimental data based on EU-incorporation levels.
2.3 Transcription in aging mouse hepatocytes
Next, we calibrated the model, set out in more detail in (
An examination of nuclear size in liver slices revealed larger nuclei in aged wildtype mice and mice with DNA repair deficiencies, with a progressive increase observed with advancing age (Supplementary Figures S5A, B). This finding suggests that cells become polyploid, which is a well-known feature of liver aging in wildtype, and in DNA-damage deficient mice (
We examined EU levels in hepatocytes from wildtype mice, and from mice with deficiencies in DNA repair, specifically Ercc1−/− (
FIGURE 3

EU incorporation as measure for transcription in mouse liver. (A–D) Representative confocal images of mouse liver sections stained for EU and Hoechst. Scale bar = 25 μm. (A) Wildtype (WT, 7 and 104 weeks), (B)Xpg−/− (7 and 14 weeks), (C)Ercc1d/- (10 and 18 weeks), (D)Ercc1−/− (4 and 8 weeks). (E–K) Average normalized EU intensities in hepatocytes. Data points represent the median of each field of view (FOV); error bars indicate standard deviation (SD) across FOVs. (E) 4-week-old WT (N = 1) and Ercc1−/− (N = 2), (F) 6-week-old WT (N = 1) and Ercc1−/− (N = 3), (G) 8-week-old WT (N = 1) and Ercc1−/− (N = 3), (H) 7-week-old WT (N = 2) and Xpg−/− (N = 3), (I) 10-week-old WT (N = 2), Xpg−/− (N = 3), and Ercc1d/- (N = 3), (J) 14-week-old WT (N = 4), Xpg−/− (N = 3), and Ercc1d/- (N = 3), (K) 18-week-old WT (N = 1) and Ercc1d/- (N = 3). (L) EU intensities in young (6, 7, 8 weeks, N = 7) and old (104 weeks, N = 4) WT mice, including data from our previous publication (
We estimated the rate at which TBLs accumulate in each mouse model (Table 2) by performing a goodness-of- fit analysis on the first EU incorporation data point (Figure 4A). The second and third data point were used to validate the predictive performance of the calibrated model and calculate the error rate. For wildtype mice, we fitted the model to the last data point, and then conversely predicted the first data point to estimate the error rate, since there were only two data points, and the first (at 7 weeks) was assumed to have 0% transcription loss. Using the estimated rates, we calculated transcription loss for each different mouse model (Figures 4B,C). We used the closed-form formula, described above (Figure 1), for the expected value of : , as derived in Proposition 2 of (
TABLE 2
| Genotype | Number of unrepaired TBLs per day ±SD | Absolute error model (%) | Relative error model (%) | 50%-survival age (weeks) | ||||
|---|---|---|---|---|---|---|---|---|
| 2nd point | 3rd point | Average | 2nd point | 3rd point | Average | |||
| Xpg−/− | 1,621 ± 150 | 21.6 | 3.9 | 12.7 | 29.9 | 6.0 | 17.5 | 18.2 |
| Ercc1d/- | 2,315 ± 163 | 9.7 | 1.7 | 5.7 | 16.0 | 2.2 | 9.1 | 21.8 |
| Ercc1−/− | 4,978 ± 372 | 19.8 | 13.1 | 16.4 | 40.6 | 21.1 | 30.1 | 8.0 |
| Wildtype | 62 ± 7.0 | NA | NA | 3.6 | NA | NA | NA | 120 |
Occurrence rate of unrepaired TBLs in each mouse model, including standard deviation (SD), absolute and relative error compared to experimental data (of the second and third data point and the average) in %, and 50% survival age in weeks.
FIGURE 4

Mathematical model on DNA damage and transcription loss. (A) Average percentage of transcription loss in hepatocytes, as measured by EU staining of liver sections for each mouse model (wildtype, Xpg−/−, Ercc1d/- and Ercc1−/−) at different, relevant ages. Error bars represent SEM across mice (N = 3 for Xpg−/−, Ercc1−/− and Ercc1d/- mice, N = 4 for wildtype mice). (B) Percentage of transcription loss in hepatocytes, as predicted by the mathematical model for each mouse model (wildtype, Xpg−/−, Ercc1d/- and Ercc1−/−), across different, relevant ages. Error bars represent SD based on nascent RNA sequencing data of three independent mice. (C) As in (B), but for a narrower age range. (D) Comparison of average transcription loss between predictions from our mathematical model and experimental data from liver sections. Error bars represent the standard deviation (SD) for the model and the standard error of the mean (SEM) for the experimental data. (E) As in (D) but for a narrower age range.
Among the mouse models investigated, the Ercc1−/− mutant exhibited the most severe age-dependent decline in EU incorporation, showing approximately 50% transcription loss at 4 weeks (Figure 3E), which is consistent with previous research (
The difference between the Xpg−/− and Ercc1d/- mouse models, however, was relatively small. Although their lifespans are comparable, with Xpg−/− mice exhibiting a slightly shorter lifespan, the model predicted a higher daily number of TBLs in Ercc1d/- livers than in Xpg−/− livers, contrary to what their lifespans suggest. Supporting the model’s predictions, we found more severe liver pathology in Ercc1d/- mice than in Xpg−/− mice (Figure 5A). In particular, we detected more polyploidy in Ercc1d/- livers compared to Xpg−/− or wildtype livers (Figure 5B; Supplementary Figure S5A). Thus, although Xpg−/− mice have a shorter lifespan, they may accumulate TBLs in hepatocytes at a lower rate than Ercc1d/- mice. This discrepancy may reflect survivorship bias, meaning that the observed lifespan reflects only the organs most affected (e.g., brain), while other organs like the liver may accumulate differing levels of TBLs without causing early death. Notably, neither model dies from liver pathology, as seen in Ercc1−/− mice (
FIGURE 5

Liver pathology. (A) Representative images of H&E staining of liver: WT 18 weeks old (upper left panel), Ercc1d/- 18 weeks old (upper right panel), Xpg−/− 14 weeks old (lower left panel) and Ercc1−/− 8 weeks old (lower right panel), all female. Magnification: ×40. Scale bar: 50 µm. (B) Area of hepatocyte nuclei in wildtype, Xpg−/−, Ercc1d/- and Ercc1−/− mice, as measured using H&E staining. Unpaired two-tailed Student’s t-test: *p ≤ 0.05; **p ≤ 0.01; ***p ≤ 0.001; ****p ≤ 0.0001.
To further explore the impact of DNA repair deficiency, we assumed that Ercc1−/− mice are unable to repair any type of transcription-blocking DNA damage, while Xpg−/− mice retain the ability to repair crosslinks. Ercc1 plays an essential role not only in NER, but also in crosslink repair through the Fanconi Anemia (FA) pathway (
Ercc1d/- mice are predicted to retain approximately 54% of TBL repair capacity (Table 2). These mice have one truncated Ercc1 allele and one null allele, resulting in an RNA transcript level of the truncated allele that accounts for approximately 7.5% of total Ercc1 expression in wildtype mice (
3 Discussion
In this study, we attempted to quantify the accumulation of transcription-blocking DNA damage during aging by integrating global transcription level measurements with a mathematical model based on fundamental biological assumptions (
Our findings are largely consistent with those reported in previous studies. Previous research, using mass spectrometry, discovered approximately 132,500 cyclopurine lesions in the Ercc1d/- liver genome at 18 weeks, or 5.0 cyclopurines per 100 kb of the diploid mouse genome (
In addition to cyclopurines, interstrand crosslinks are potentially of significant interest in the context of transcriptional stress. Endogenous interstrand crosslinks are formed by for example, aldehydes, nitric oxide or oxidized abasic lesions (
DNA-associated advanced glycation end products (DNA-AGEs), alongside cyclopurines and interstrand crosslinks, could play an important role in the context of transcriptional stress. DNA-AGEs form through non-enzymatic reactions between reducing sugars or reactive carbonyl species (e.g., methylglyoxal) and DNA bases, resulting in irreversible modifications. These reactions are mostly driven by metabolic processes such as glycolysis, oxidative stress, and lipid peroxidation, and are strongly correlated to life style and dietary choices (
Working with a simplified mathematical model inevitably introduces uncertainty, as illustrated by the model’s error rate for human fibroblasts following UV-induced damage (Table 1). Moreover, the in vitro experimental data from human fibroblasts appear to follow a more linear trend than the model predicts, with the model plateauing at a lower number of TBLs. We speculate that these differences between experimental data and model may be caused by several factors. Importantly, both the experimental data and the model exclude ribosomal genes: ribosomal RNA is filtered out in the experimental data by excluding nucleolar staining, and ribosomal genes are also removed during the mapping of nascent RNA sequencing input data.
One factor that could contribute to the discrepancy is that the model assumes transcription ceases entirely upon the acquisition of a lesion anywhere in the transcribed strand of a gene. In contrast, in cells, RNA polymerases continue transcription up to the lesion. Furthermore, in the model, damage accumulates gradually, whereas UV-induced damage in fibroblasts occurs within seconds. Although fibroblasts are given 24 h to adapt to the damage, certain factors such as the abrupt imbalance in RNA polymerase II turnover, may have persistent effects. In addition, DNA damage is exposure-dependent (e.g., UV in sunlight), and with aging, most cellular processes—including protective systems such as antioxidant defenses and DNA repair mechanisms—decline in function. This functional decline likely increases the rate at which DNA damage accumulates with age. However, for simplicity, our model assumes a constant rate of DNA damage accumulation.
A further limitation is that the model does not account for DNA replication, which can displace stalled RNA polymerases and thereby restore lesion accessibility for the repair machinery. Similarly, polyploidization could mitigate transcriptional blockages by providing additional, undamaged copies of the genome for transcription. The model also omits the potential bypass of TBLs via transcriptional bypass, a process in which RNA polymerases transiently bypass DNA damage to allow continued transcription (
Finally, while human dermal fibroblasts and mouse hepatocytes serve as a solid starting point for investigation, it is essential to acknowledge that our focus on this specific cell type does not fully represent the dynamics of transcriptional stress and aging across an entire organism. Therefore, caution is required when extrapolating these results to the broader spectrum of organismal aging. Expanding the study to include additional mouse tissues, such as mouse dermal fibroblasts, could offer valuable insights. Another limitation of our mouse study was the restricted number of time points and the small sample size per time point, which introduced considerable variability between individual mice. A further limitation of our study is the strong dependence of the model’s predictions on the nascent RNA-seq datasets used as input. Variations in experimental protocols, sequencing depth, RNA quality, and data processing can substantially influence the number and identity of detected genes, thereby affecting transcription loss estimates. This dependence may impact the generalizability of our findings across different tissues and experimental conditions. Consequently, the findings reported here should be taken with caution due to numerous unknowns and inherent limitations. Nevertheless, as a first attempt to quantify transcriptional stress in these models, this study provides novel and important insights for the field.
In summary, our mathematical model advances the understanding of DNA damage accumulation and its implications for transcriptional stress and aging. By predicting outcomes such as the daily persistence of approximately 15 unrepaired TBLs in the liver of wildtype mice, the model offers valuable insights into the accumulation of DNA damage over time, contributing to a deeper understanding of the aging process. Interestingly, in combination with previous studies (
4 Materials and methods
4.1 Mice
Mouse housing and experiments were conducted in strict accordance with the Animal Welfare Act of the Dutch government, following the Guide for the Care and Use of Laboratory Animals and adhering to guidelines approved by the Dutch Ethical Committee in full compliance with European legislation. The institutional ethical committee for animal care and usage granted approval for the animal protocol.
DNA repair-deficient premature aging mouse models, generated in-house, and their wildtype littermates in F1 C57BL6J/FVB (1:1) hybrid background were euthanized using cervical dislocation at 10, 14, and 18 weeks for Ercc1d/− mutants (
All animals were bred and kept on AIN93G synthetic pellets (Research Diet Services; gross energy content 4.9 kcal g−1 dry mass, digestible energy 3.97 kcal g−1). They were housed in a controlled environment (20–22 °C, 12 h light:12 h dark cycle) and individually accommodated in ventilated cages under specific pathogen-free conditions at the Animal Resource Center (Erasmus University Medical Center). Statistical methods were employed to determine sample sizes, resulting in a group size of 3 animals, only males. Data collection and analysis were not performed blind to the experiment conditions, and randomization of animals to experimental groups was not applicable.
4.2 Nascent RNA labeling in vivo
Mice were intraperitoneally injected with 5-EU (AXXORA) at a dosage of 0.088 mg per gram of body weight. Five hours post-injection, mice were euthanized, and tissue samples were collected, formalin-fixed and embedded in paraffin.
4.3 Cell culture
XP25RO cells (XPA knock-out primary patient skin fibroblasts) were cultured at 37 °C in DMEM with 10% FBS and 1% PS at 5% CO2 and 20% O2, passaged weekly at a 1:7 ratio. C5RO cells (wildtype primary skin fibroblasts) were cultured in F10 with 15% FBS and 1% PS, under the same conditions. The XP25RO and C5RO cell lines present in this study were a kind gift from Arjan Theil. Cells were seeded in 35 mm dishes with glass slides, grown to confluence, and maintained for 2 weeks with medium refreshed bi-weekly. Subsequently, cells were exposed to UV-C radiation at doses of 0, 1, 2, 3, 4, 5 or 6 J/m2 using a 254-nm germicidal lamp (Philips). After a 24-h period, cells were fixed using 2% PFA for 15 min, after incubation with EU (5-ethynyluridine, 0.325 mM, 1 h) or EdU (5-ethynyl-2-deoxyuridine, 10 μM, 2 h) to label newly synthesized RNA or DNA, respectively.
4.4 EU or EdU labeling on human cells
Following fixation, cells were permeabilized with 0.1% Triton X-100 in PBS for 10 min at room temperature. A click-it cocktail was prepared per 24-mm coverslip using 79 μL 50 mM Tris (pH 7.0), 1 μL Atto 488 azide (Lumiprobe, 11,830), 10 μL 40 mM CuSO4·5H2O, and 10 μL 100 mM ascorbic acid. After PBS washes, 100 μL of the cocktail was added, and cells were incubated for 1 h at room temperature in the dark. Cells were then washed (3× PBS-T, 1× PBS), stained with Hoechst 33,342 (ThermoFisher, 62,249; 20 μM, 20 min), and mounted in Aqua Poly mount (Polysciences, 18,606–20). Slides were dried overnight in the dark and imaged using a Zeiss LSM700 confocal microscope with a 20× dry lens.
Images were analyzed using an ImageJ macro that segmented nuclei based on Hoechst staining with Otsu thresholding. Nuclei between 24.4 and 250 μm2 and circularity >0.6 were selected to focus on diploid hepatocytes. Nucleoli were segmented within nuclei using a ‘Moments’ threshold after background subtraction. The macro then measured mean nucleoplasmic signal in the original EU channel by subtracting nucleoli from nuclei. Nuclear area was also quantified. A Python script calculated mean EU intensity in nucleoplasm, and data from four independent experiments, normalized to 0 J/m2 controls, were graphed in GraphPad Prism. EdU-positive cells were defined by a manually set intensity threshold per experiment.
Our study concentrated on quantifying the EU signal within the nucleoplasm of cells, excluding the nucleoli (Supplementary Figure S2B). This approach was chosen because rRNA transcription in the nucleoli typically remains high, likely due to the fact that rRNA genes are relatively short, present in >100 copies and intensively transcribed, which renders them less prone to DNA damage (
4.5 Nascent RNA sequencing on human fibroblasts
For nascent RNA sequencing, TERT-immortalized C3RO cells (wildtype skin fibroblasts) were grown in DMEM with 10% FBS and 1% PS at 5% CO2 and 20% O2 until fully confluent, for steady-state labeling. Cells were mock-treated with DMSO for 48 h, followed by a 15-min pulse with 1 mM EU at 37 °C. Four independent biological replicates were performed. Total EU-labeled RNA was then extracted using the Qiagen miRNeasy kit (217,004), according the manufacturer’s protocol.
Nascent RNA was isolated using the Click-iT Nascent RNA Capture Kit (ThermoFisher, C10365) according to the manufacturer’s guidelines, with the largest recommended input amounts. EU RNA-bound beads were suspended in fragment-, prime-, and elute buffer from the KAPA RNA HyperPrep Kit (Roche, KK8540), heated to 94 °C for 6 min, then prepared into libraries with 15 PCR cycles and purified. Library quality was assessed using the High Sensitivity D1000 assay on a TapeStation system (Agilent). Libraries were sequenced using a NovaSeq 6000 system (Agilent), with equal RNA input per sample.
The EU-sequencing reads were preprocessed using FastQC v.0.11.9, FastQScreen v.0.14.0, and Trimmomatic v.0.35 (
4.6 EU labeling
Male mouse liver tissues were sectioned into 3 μm slices using a microtome (HM335E, Microm). After deparaffinization and rehydration, slices were washed with PBS and permeabilized with 0.1% Triton X-100 in PBS for 10 min at room temperature. A click-it cocktail was prepared by mixing 79% 50 mM Tris buffer (pH 7.0), 1% Atto 488 azide (Lumiprobe, 11,830), 10% 40 mM CuSO4·5H2O, and 10% 100 mM ascorbic acid. Following permeabilization, slices were washed, incubated with 150 µL click-it cocktail for 30 min in the dark at room temperature, washed again with PBS, then stained with Hoechst 33,342 (Invitrogen, C10337) for 15 min and washed. Slices were mounted using Aqua Poly mount (Polysciences, 18,606–20) and dried overnight in the dark. Imaging was performed with a Zeiss LSM700 confocal microscope using a 20x dry lens.
Images were analyzed using an ImageJ macro that segmented nuclei based on Hoechst staining with Otsu thresholding. Nuclei sized between 24.4 μm2 and 70 μm2 with circularity >0.7 were selected to focus on diploid hepatocytes. Nucleoli were segmented using a ‘Moments’ threshold after background subtraction. The macro measured the mean nucleoplasmic signal by subtracting nucleoli from nuclei on the EU channel (Supplementary Figure S2B), and nuclear area was quantified. A Python script calculated the median mean EU intensity per field of view. Graphs were generated with GraphPad Prism. Data from Ercc1d/-, Ercc1−/−, and Xpg−/− livers were normalized per imaging session using a wildtype 7-week reference sample, and further normalized within age groups by dividing by corresponding wildtype values.
4.7 HE staining
Female mouse liver tissues were sectioned into 3 μm slices (HM335E, Microm). After deparaffinization and rehydration, slices were stained with Gill’s No. 3 hematoxylin (Merck, GHS332) for 5 min, rinsed in running tap water for 1 min, and briefly in 70% ethanol. Tissues were then counterstained with Eosin-Y (Sigma, 230,251) for 30 s, followed by dehydration through graded ethanol series (70%, 95%, 100% twice) and xylene (twice). Slides were mounted with Pertex (00811-EX) and scanned on a Nanozoomer (Hamamatsu). Hepatocyte nuclear area was analyzed using NDP View 2 software.
4.8 Nascent RNA sequencing (mouse liver)
Nascent RNA sequencing of young mouse liver was performed as described elsewhere (
EU-seq reads were preprocessed using FastQC v.0.11.9 and Trimmomatic v.0.35 (
4.9 Determining the timepoint of acute transcriptional response resolution (24h)
A previous study utilizing bromouridine-tagged nascent RNA sequencing (Bru-Seq) (
We quantified the intragenic distribution of reads using a metric called tilt, defined as the difference in the slopes of linear regressions fitted to RPKM values along the gene body before and after UV-induced DNA damage. A negative tilt indicates reduced transcription toward the 3′end, reflecting impaired transcription elongation due to transcription-blocking lesions (TBLs). Shortly after UV exposure, reads accumulate at the 5′end of genes, as TBLs hinder RNA polymerase progression. In wildtype and GG-NER-deficient cells, this distribution normalizes within 24 h through TC-NER. In contrast, TC-NER-deficient CSB−/- cells fail to restore normal distribution, as stalled RNA polymerases are not removed and block access to other repair pathways. Although overall transcription levels seem to recover, transcript completion remains impaired. As 5′transcription levels increase and spread toward the 3′end, the persistent stalling leads to incomplete transcripts, explaining why tilt recovery lags behind average transcription recovery.
4.10 Fitting the model
The daily rate of DNA damage was determined in silico by minimizing the error between the model from (
Relative error was calculated by comparing the model’s predicted average transcription loss to experimental data at the second and third time points, since the first time point was used for fitting. For wildtype mice, only the first time point’s error was considered, as the second was used for fitting. The formulas for relative and absolute error (%) per time point are as follows:where is the expected transcription loss predicted by the model (upon accumulated TBLs which, due to constant accumulation rate, has a direct correspondence to time measured in days), and is the average transcription loss measured experimentally.
Statements
Data availability statement
The original contributions presented in the study are publicly available. Human fibroblast nascent RNA sequencing data (C3RO cells, n = 4) have been deposited under BioProject accession number PRJNA1017406 (NCBI SRA accessions: SRR26060338, SRR26060336, SRR26060309, SRR26060320). Mouse liver EU-seq data (n = 3) are available under NCBI SRA accession number PRJNA603447 (SRX7638577, SRX7638578, SRX7638579).
Ethics statement
Ethical approval was not required for the studies on humans in accordance with the local legislation and institutional requirements because only commercially available established cell lines were used. The animal study was approved by Erasmus MC Animal Welfare Body (AWB). The study was conducted in accordance with the local legislation and institutional requirements.
Author contributions
Jv: Conceptualization, Data curation, Formal Analysis, Investigation, Methodology, Visualization, Writing – original draft, Writing – review and editing, Project administration. MR: Conceptualization, Formal Analysis, Software, Writing – review and editing. RB: Writing – review and editing, Investigation, Methodology. Yv: Investigation, Methodology, Writing – review and editing. JD: Investigation, Writing – review and editing. SD: Writing – review and editing, Formal Analysis, Software. JC: Data curation, Writing – review and editing. JH: Funding acquisition, Resources, Supervision, Writing – review and editing. JP: Conceptualization, Funding acquisition, Resources, Supervision, Writing – review and editing.
Funding
The author(s) declare that financial support was received for the research and/or publication of this article. Financial support is acknowledged from the National Institute of Health (NIH)/National Institute of Ageing (NIA) (P01 AG017242; DNA repair, mutations and cell aging), European Research Council Advanced Grant Dam2Age, Dutch research organization ZonMW Memorabel project ID 733050810, ONCODE (Dutch Cancer Society), as well as European Joint Research Project on Rare Diseases, RD20-113, acronym TC-NER. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Acknowledgments
We would like to thank Roland Kanaar for his helpful suggestions and critical assessment of the manuscript.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declare that Generative AI was used in the creation of this manuscript. During the preparation of this work the authors used ChatGPT to optimize language. After using this tool, the authors reviewed and edited the content as needed and takes full responsibility for the content of the published article.
Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fmolb.2025.1659589/full#supplementary-material
References
1
AmenteS.ScalaG.MajelloB.AzmounS.TempestH. G.PremiS.et al (2021). Genome-wide mapping of genomic DNA damage: methods and implications. Cell Mol. Life Sci.78 (21-22), 6745–6762. 10.1007/s00018-021-03923-6
2
Andrade-LimaL. C.VelosoA.PaulsenM. T.MenckC. F.LjungmanM. (2015). DNA repair and recovery of RNA synthesis following exposure to ultraviolet light are delayed in long genes. Nucleic Acids Res.43 (5), 2744–2756. 10.1093/nar/gkv148
3
BarnhoornS.UittenboogaardL. M.JaarsmaD.VermeijW. P.TresiniM.WeymaereM.et al (2014). Cell-autonomous progeroid changes in conditional mouse models for repair endonuclease XPG deficiency. PLoS Genet.10 (10), e1004686. 10.1371/journal.pgen.1004686
4
BohrV. A.SmithC. A.OkumotoD. S.HanawaltP. C. (1985). DNA repair in an active gene: removal of pyrimidine dimers from the DHFR gene of CHO cells is much more efficient than in the genome overall. Cell40 (2), 359–369. 10.1016/0092-8674(85)90150-3
5
BolgerA. M.LohseM.UsadelB. (2014). Trimmomatic: a flexible trimmer for illumina sequence data. Bioinformatics30 (15), 2114–2120. 10.1093/bioinformatics/btu170
6
ChaudhuriJ.BainsY.GuhaS.KahnA.HallD.BoseN.et al (2018). The role of advanced glycation end products in aging and metabolic diseases: Bridging association and causality. Cell Metab.28 (3), 337–352. 10.1016/j.cmet.2018.08.014
7
ClausonC.SchärerO. D.NiedernhoferL. (2013). Advances in understanding the complex mechanisms of DNA interstrand cross-link repair. Cold Spring Harb. Perspect. Biol.5 (10), a012732. 10.1101/cshperspect.a012732
8
De SilvaI. U.McHughP. J.ClingenP. H.HartleyJ. A. (2002). Defects in interstrand cross-link uncoupling do not account for the extreme sensitivity of ERCC1 and XPF cells to cisplatin. Nucleic Acids Res.30 (17), 3848–3856. 10.1093/nar/gkf479
9
DolléM. E.KuiperR. V.RoodbergenM.RobinsonJ.de VlugtS.WijnhovenS. W.et al (2011). Broad segmental progeroid changes in short-lived Ercc1(-/Δ7) mice. Pathobiol. Aging Age Relat. Dis.1, 7219. 10.3402/pba.v1i0.7219
10
EickbushT. H.EickbushD. G. (2007). Finely orchestrated movements: evolution of the ribosomal RNA genes. Genetics175 (2), 477–485. 10.1534/genetics.107.071399
11
FribouletL.Postel-VinayS.SourisseauT.AdamJ.StoclinA.PonsonnaillesF.et al (2013). ERCC1 function in nuclear excision and interstrand crosslink repair pathways is mediated exclusively by the ERCC1-202 isoform. Cell Cycle12 (20), 3298–3306. 10.4161/cc.26309
12
GreggS. Q.RobinsonA. R.NiedernhoferL. J. (2011). Physiological consequences of defects in ERCC1-XPF DNA repair endonuclease. DNA Repair (Amst).10 (7), 781–791. 10.1016/j.dnarep.2011.04.026
13
GyenisA.ChangJ.DemmersJ.BruensS. T.BarnhoornS.BrandtR. M. C.et al (2023). Genome-wide RNA polymerase stalling shapes the transcriptome during aging. Nat. Genet.55 (2), 268–279. 10.1038/s41588-022-01279-6
14
HoeijmakersJ. H. J. (2009). DNA damage, aging, and cancer. N. Engl. J. Med.361 (15), 1475–1485. 10.1056/NEJMra0804615
15
HoushK.JhaJ. S.HaldarT.AminS. B. M.IslamT.WallaceA.et al (2021). Formation and repair of unavoidable, endogenous interstrand cross-links in cellular DNA. DNA Repair (Amst)98, 103029. 10.1016/j.dnarep.2020.103029
16
Ibañez-SoléO.BarrioI.IzetaA. (2023). Age or lifestyle-induced accumulation of genotoxicity is associated with a length-dependent decrease in gene expression. iScience26 (4), 106368. 10.1016/j.isci.2023.106368
17
JaramilloR.ShuckS.ChanY.LiuX.BatesS.LimP.et al (2017). DNA advanced glycation end products (DNA-AGEs) are elevated in urine and tissue in an animal model of type 2 diabetes. Chem. Res. Toxicol.30, 689–698. 10.1021/acs.chemrestox.6b00414
18
KalinowskiD. P.IllenyeS.Van HoutenB. (1992). Analysis of DNA damage and repair in murine leukemia L1210 cells using a quantitative polymerase chain reaction assay. Nucleic Acids Res.20 (13), 3485–3494. 10.1093/nar/20.13.3485
19
LansH.MarteijnJ. A.VermeulenW. (2012). ATP-Dependent chromatin remodeling in the DNA-Damage response. Epigenetics Chromatin5, 4. 10.1186/1756-8935-5-4
20
LeeJ. W.RatnakumarK.HungK.-F.RokunoheD.KawasumiM. (2020). Deciphering UV-induced DNA damage responses to prevent and treat skin cancer. Photochem. Photobiol.96 (3), 478–499. 10.1111/php.13245
21
LombardD. B.ChuaK. F.MostoslavskyR.FrancoS.GostissaM.AltF. W. (2005). DNA repair, genome stability, and aging. Cell120 (4), 497–512. 10.1016/j.cell.2005.01.028
22
López-OtínC.BlascoM. A.PartridgeL.SerranoM.KroemerG. (2023). Hallmarks of aging: an expanding universe. Cell.186 (2), 243–278. 10.1016/j.cell.2022.11.001
23
ManandharM.LoweryM. G.BoulwareK. S.LinK. H.LuY.WoodR. D. (2017). Transcriptional consequences of XPA disruption in human cell lines. DNA Repair (Amst)57, 76–90. 10.1016/j.dnarep.2017.06.028
24
MoriT.NakaneH.IwamotoT.KrokidisM. G.ChatgilialogluC.TanakaK.et al (2019). High levels of oxidatively generated DNA damage 8,5′-cyclo-2′-deoxyadenosine accumulate in the brain tissues of Xeroderma pigmentosum group A gene-knockout mice. DNA Repair80, 52–58. 10.1016/j.dnarep.2019.04.004
25
NassarL. R.BarberG. P.Benet-PagèsA.CasperJ.ClawsonH.DiekhansM.et al (2023). The UCSC genome browser database: 2023 update. Nucleic Acids Res.51 (D1), D1188–D1195. 10.1093/nar/gkac1072
26
NiedernhoferL. J.GarinisG. A.RaamsA.LalaiA. S.RobinsonA. R.AppeldoornE.et al (2006). A new progeroid syndrome reveals that genotoxic stress suppresses the somatotroph axis. Nature444 (7122), 1038–1043. 10.1038/nature05456
27
OsterodM.HollenbachS.HengstlerJ. G.BarnesD. E.LindahlT.EpeB. (2001). Age-related and tissue-specific accumulation of oxidative DNA base damage in 7,8-dihydro-8-oxoguanine-DNA glycosylase (Ogg1) deficient mice. Carcinogenesis22 (9), 1459–1463. 10.1093/carcin/22.9.1459
28
RasetaM.GrintJ.DealyS.ChangJ.HoeijmakersJ.PothofJ. (2024). Mathematical model of transcription loss due to accumulated DNA damage. bioRxiv. 10.1101/2024.07.15.603615
29
RobinsonA. R.YousefzadehM. J.RozgajaT. A.WangJ.LiX.TilstraJ. S.et al (2018). Spontaneous DNA damage to the nuclear genome promotes senescence, redox imbalance and aging. Redox Biol.17, 259–273. 10.1016/j.redox.2018.04.007
30
SchumacherB.PothofJ.VijgJ.HoeijmakersJ. H. J. (2021). The central role of DNA damage in the ageing process. Nature592 (7856), 695–703. 10.1038/s41586-021-03307-7
31
Soheili-NezhadS.van der LindenR. J.Olde RikkertM.SprootenE.PoelmansG. (2021). Long genes are more frequently affected by somatic mutations and show reduced expression in alzheimer's disease: implications for disease etiology. Alzheimers Dement.17 (3), 489–499. 10.1002/alz.12211
32
Soheili-NezhadS.Ibáñez-SoléO.IzetaA.HoeijmakersJ. H. J.StoegerT. (2024). Time is ticking faster for long genes in aging. Trends Genet.40 (4), 299–312. 10.1016/j.tig.2024.01.009
33
SongR.AcarM. (2019). Stochastic modeling of aging cells reveals how damage accumulation, repair, and cell-division asymmetry affect clonal senescence and population fitness. BMC Bioinforma.20 (1), 391. 10.1186/s12859-019-2921-3
34
StoegerT.GrantR. A.McQuattie-PimentelA. C.AnekallaK. R.LiuS. S.Tejedor-NavarroH.et al (2022). Aging is associated with a systemic length-associated transcriptome imbalance. Nat. Aging2 (12), 1191–1206. 10.1038/s43587-022-00317-6
35
TamaeD.LimP.WuenschellG. E.TerminiJ. (2011). Mutagenesis and repair induced by the DNA advanced glycation end product N2-1-(Carboxyethyl)-2′-deoxyguanosine in human cells. Biochemistry50 (12), 2321–2329. 10.1021/bi101933p
36
TiwariV.WilsonD. M. (2019). DNA damage and associated DNA repair defects in disease and premature aging. Am. J. Hum. Genet.105 (2), 237–257. 10.1016/j.ajhg.2019.06.005
37
TrapnellC.PachterL.SalzbergS. L. (2009). TopHat: discovering splice junctions with RNA-seq. Bioinformatics25 (9), 1105–1111. 10.1093/bioinformatics/btp120
38
van den HeuvelD.KimM.WondergemA. P.van der MeerP. J.WitkampM.LambregtseF.et al (2023). A disease-associated XPA allele interferes with TFIIH binding and primarily affects transcription-coupled nucleotide excision repair. Proc. Natl. Acad. Sci. U. S. A.120 (11), e2208860120. 10.1073/pnas.2208860120
39
van SluisM.YuQ.van der WoudeM.Gonzalo-HansenC.DealyS. C.JanssensR. C.et al (2024). Transcription-coupled DNA-Protein crosslink repair by CSB and CRL4(CSA)-mediated degradation. Nat. Cell Biol.26 (5), 770–783. 10.1038/s41556-024-01394-y
40
VermeijW. P.DolléM. E.ReilingE.JaarsmaD.Payan-GomezC.BombardieriC. R.et al (2016). Restricted diet delays accelerated ageing and genomic stress in DNA-repair-deficient mice. Nature537 (7620), 427–431. 10.1038/nature19329
41
VlachogiannisN. I.NtourosP. A.PappaM.KravvaritiE.KostakiE. G.FragoulisG. E.et al (2023). Chronological age and DNA damage accumulation in blood mononuclear cells: a linear association in healthy humans after 50 years of age. Int. J. Mol. Sci.24 (8), 7148. 10.3390/ijms24087148
42
WalmacqC.WangL.ChongJ.ScibelliK.LubkowskaL.GnattA.et al (2015). Mechanism of RNA polymerase II bypass of oxidative cyclopurine DNA lesions. Proc. Natl. Acad. Sci.112 (5), E410–E419. 10.1073/pnas.1415186112
43
WangM.-J.ChenF.LauJ. T. Y.HuY.-P. (2017). Hepatocyte polyploidization and its association with pathophysiological processes. Cell Death & Dis.8 (5), e2805–e. 10.1038/cddis.2017.167
44
WeedaG.DonkerI.de WitJ.MorreauH.JanssensR.VissersC. J.et al (1997). Disruption of mouse ERCC1 results in a novel repair syndrome with growth failure, nuclear abnormalities and senescence. Curr. Biol.7 (6), 427–439. 10.1016/s0960-9822(06)00190-4
45
WuW.HillS. E.NathanW. J.PaianoJ.CallenE.WangD.et al (2021). Neuronal enhancers are hotspots for DNA single-strand break repair. Nature593 (7859), 440–444. 10.1038/s41586-021-03468-5
46
YousefzadehM.HenpitaC.VyasR.Soto-PalmaC.RobbinsP.NiedernhoferL. (2021). DNA Damage—how and why we age?eLife10, e62852. 10.7554/eLife.62852
Summary
Keywords
aging, transcriptional stress, DNA damage, mathematical modeling, nucleotide excision repair
Citation
van de Grint J, Raseta M, Brandt R, van Loon Y, Demmers J, Dealy S, Chang J, Hoeijmakers J and Pothof J (2025) Transcriptional stress in aging: integrating experimental data and modeling to quantify DNA damage accumulation. Front. Mol. Biosci. 12:1659589. doi: 10.3389/fmolb.2025.1659589
Received
09 July 2025
Accepted
19 August 2025
Published
08 September 2025
Volume
12 - 2025
Edited by
Belén Gomez-Gonzalez, Spanish National Research Council (CSIC), Spain
Reviewed by
Chetan C Rawal, University of Southern California, United States
Cristina González-Aguilera, Spanish National Research Council (CSIC), Spain
Updates

Check for updates
Copyright
© 2025 van de Grint, Raseta, Brandt, van Loon, Demmers, Dealy, Chang, Hoeijmakers and Pothof.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Joris Pothof, j.pothof@erasmusmc.nl
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.