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Lacombe D, Bloch-Zupan A, Bredrup C, Cooper EB, Houge SD, García-Miñaúr S, Kayserili H, Larizza L, Lopez Gonzalez V, Menke LA, Milani D, Saettini F, Stevens CA, Tooke L, Van der Zee JA, Van Genderen MM, Van-Gils J, Waite J, Adrien JL, Bartsch O, Bitoun P, Bouts AHM, Cueto-González AM, Dominguez-Garrido E, Duijkers FA, Fergelot P, Halstead E, Huisman SA, Meossi C, Mullins J, Nikkel SM, Oliver C, Prada E, Rei A, Riddle I, Rodriguez-Fonseca C, Rodríguez Pena R, Russell J, Saba A, Santos-Simarro F, Simpson BN, Smith DF, Stevens MF, Szakszon K, Taupiac E, Totaro N, Valenzuena Palafoll I, Van Der Kaay DCM, Van Wijk MP, Vyshka K, Wiley S, Hennekam RC. Diagnosis and management in Rubinstein-Taybi syndrome: first international consensus statement. J Med Genet 2024; 61:503-519. [PMID: 38471765 DOI: 10.1136/jmg-2023-109438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 02/15/2024] [Indexed: 03/14/2024]
Abstract
Rubinstein-Taybi syndrome (RTS) is an archetypical genetic syndrome that is characterised by intellectual disability, well-defined facial features, distal limb anomalies and atypical growth, among numerous other signs and symptoms. It is caused by variants in either of two genes (CREBBP, EP300) which encode for the proteins CBP and p300, which both have a function in transcription regulation and histone acetylation. As a group of international experts and national support groups dedicated to the syndrome, we realised that marked heterogeneity currently exists in clinical and molecular diagnostic approaches and care practices in various parts of the world. Here, we outline a series of recommendations that document the consensus of a group of international experts on clinical diagnostic criteria for types of RTS (RTS1: CREBBP; RTS2: EP300), molecular investigations, long-term management of various particular physical and behavioural issues and care planning. The recommendations as presented here will need to be evaluated for improvements to allow for continued optimisation of diagnostics and care.
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Affiliation(s)
- Didier Lacombe
- Department of Medical Genetics, University Hospital of Bordeaux, and INSERM U1211, University of Bordeaux, 33076 Bordeaux, France
| | - Agnès Bloch-Zupan
- Faculté de Chirurgie Dentaire, Université de Strasbourg, and Centre de référence des maladies rares orales et dentaires, Hôpitaux Universitaires de Strasbourg, Strasbourg, and Institut de Génétique et de Biologie Moléculaire et Cellulaire, INSERM U1258, Illkirch, France
| | - Cecilie Bredrup
- Department of Clinical Medicine, University of Bergen, 5020 Bergen, Norway
| | - Edward B Cooper
- Department of Anesthesiology, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sofia Douzgou Houge
- Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway and Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Sixto García-Miñaúr
- Instituto de Genética Médica y Molecular (INGEMM), Hospital Universitario La Paz, Madrid, Spain
| | - Hülya Kayserili
- Department of Medical Genetics, Koc University School of Medicine (KUSOM), 34010 Istanbul, Turkey
| | - Lidia Larizza
- Laboratorio di Ricerca in Citogenetica medica e Genetica Molecolare, Centro di Ricerche e Tecnologie Biomediche IRCCS-Istituto Auxologico Italiano, Milano, Italy
| | - Vanesa Lopez Gonzalez
- Department of Pediatrics, Medical Genetics Section, Virgen de la Arrixaca University Hospital, IMIB, CIBERER, Murcia, Spain
| | - Leonie A Menke
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Donatella Milani
- Fondazione IRCCS, Ca'Granda Ospedale Maggiore, 20122 Milan, Italy
| | - Francesco Saettini
- Fondazione Matilde Tettamanti Menotti De Marchi Onlus, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Monza, Italy
| | - Cathy A Stevens
- Department of Pediatrics, University of Tennessee College of Medicine, Chattanooga, Tennessee, USA
| | - Lloyd Tooke
- Department of Pediatrics, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Jill A Van der Zee
- Department of Pediatric Urology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Maria M Van Genderen
- Bartiméus Diagnostic Center for complex visual disorders, Zeist and Department of Ophthalmology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Julien Van-Gils
- Department of Medical Genetics, University Hospital of Bordeaux, and INSERM U1211, University of Bordeaux, 33076 Bordeaux, France
| | - Jane Waite
- School of Psychology, College of Health and Life Sciences, Aston University, Birmingham, UK
| | - Jean-Louis Adrien
- Université de Paris, Laboratoire de Psychopathologie et Processus de Santé, Boulogne Billancourt, France
| | - Oliver Bartsch
- MVZ - Humangenetik, University Medical Center, Johannes Gutenberg University Mainz, 55131 Mainz, Germany
| | - Pierre Bitoun
- Département de Genetique, SIDVA 91, Juvisy-sur-Orge, France
| | - Antonia H M Bouts
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anna M Cueto-González
- Department of Clinical and Molecular Genetics, University Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | | | - Floor A Duijkers
- Department of Human Genetics, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Patricia Fergelot
- Department of Medical Genetics, University Hospital of Bordeaux, and INSERM U1211, University of Bordeaux, 33076 Bordeaux, France
| | - Elizabeth Halstead
- Psychology and Human Development Department, University College London, London, UK
| | - Sylvia A Huisman
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Zodiak, Prinsenstichting, Purmerend, Netherlands
| | - Camilla Meossi
- Fondazione IRCCS, Ca'Granda Ospedale Maggiore, 20122 Milan, Italy
| | - Jo Mullins
- Rubinstein-Taybi Syndrome Support Group, Registered Charity, Rickmansworth, UK
| | - Sarah M Nikkel
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Chris Oliver
- School of Psychology, University of Birmingham, Edgbaston, UK
| | - Elisabetta Prada
- Fondazione IRCCS, Ca'Granda Ospedale Maggiore, 20122 Milan, Italy
| | - Alessandra Rei
- Associazione Rubinstein-Taybi Syndrome-Una Vita Speciale, Organizzazione di Volontariato (ODV), Gornate Olona, Varese, Italy
| | - Ilka Riddle
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | | | | | - Janet Russell
- Associazione Rubinstein-Taybi Syndrome-Una Vita Speciale, Organizzazione di Volontariato (ODV), Gornate Olona, Varese, Italy
| | | | - Fernando Santos-Simarro
- Unit of Molecular Diagnostics and Clinical Genetics, Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
| | - Brittany N Simpson
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - David F Smith
- Department of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, and Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Markus F Stevens
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Katalin Szakszon
- Institution of Pediatrics, University of Debrecen Clinical Centre, Debrecen, Hungary
| | - Emmanuelle Taupiac
- Department of Medical Genetics, University Hospital of Bordeaux, and INSERM U1211, University of Bordeaux, 33076 Bordeaux, France
| | - Nadia Totaro
- Associazione Rubinstein-Taybi Syndrome-Una Vita Speciale, Organizzazione di Volontariato (ODV), Gornate Olona, Varese, Italy
| | - Irene Valenzuena Palafoll
- Department of Clinical and Molecular Genetics, University Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Daniëlle C M Van Der Kaay
- Division of Paediatric Endocrinology, Department of Paediatrics, Erasmus University Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Michiel P Van Wijk
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, University Amsterdam, Amsterdam, Netherlands
| | - Klea Vyshka
- European Reference Network on Rare Congenital Malformations and Rare Intellectual Disability (ERN-ITHACA), Robert Debré University Hospital, Paris, France
| | - Susan Wiley
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Raoul C Hennekam
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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van Voorden AJ, Keijser R, Veenboer GJM, Lopes Cardozo SA, Diek D, Vlaardingerbroek JA, van Dijk M, Ris-Stalpers C, van Pelt AMM, Afink GB. EP300 facilitates human trophoblast stem cell differentiation. Proc Natl Acad Sci U S A 2023; 120:e2217405120. [PMID: 37406095 PMCID: PMC10334808 DOI: 10.1073/pnas.2217405120] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/05/2023] [Indexed: 07/07/2023] Open
Abstract
Early placenta development involves cytotrophoblast differentiation into extravillous trophoblast (EVT) and syncytiotrophoblast (STB). Defective trophoblast development and function may result in severe pregnancy complications, including fetal growth restriction and pre-eclampsia. The incidence of these complications is increased in pregnancies of fetuses affected by Rubinstein-Taybi syndrome, a developmental disorder predominantly caused by heterozygous mutations in CREB-binding protein (CREBBP) or E1A-binding protein p300 (EP300). Although the acetyltransferases CREBBP and EP300 are paralogs with many overlapping functions, the increased incidence of pregnancy complications is specific for EP300 mutations. We hypothesized that these complications have their origin in early placentation and that EP300 is involved in that process. Therefore, we investigated the role of EP300 and CREBBP in trophoblast differentiation, using human trophoblast stem cells (TSCs) and trophoblast organoids. We found that pharmacological CREBBP/EP300 inhibition blocks differentiation of TSCs into both EVT and STB lineages, and results in an expansion of TSC-like cells under differentiation-inducing conditions. Specific targeting by RNA interference or CRISPR/Cas9-mediated mutagenesis demonstrated that knockdown of EP300 but not CREBBP, inhibits trophoblast differentiation, consistent with the complications seen in Rubinstein-Taybi syndrome pregnancies. By transcriptome sequencing, we identified transforming growth factor alpha (TGFA, encoding TGF-α) as being strongly upregulated upon EP300 knockdown. Moreover, supplementing differentiation medium with TGF-α, which is a ligand for the epidermal growth factor receptor (EGFR), likewise affected trophoblast differentiation and resulted in increased TSC-like cell proliferation. These findings suggest that EP300 facilitates trophoblast differentiation by interfering with at least EGFR signaling, pointing towards a crucial role for EP300 in early human placentation.
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Affiliation(s)
- A. Jantine van Voorden
- Reproductive Biology Laboratory, Amsterdam Reproduction & Development, Amsterdam University Medical Centers, University of Amsterdam1105 AZ, Amsterdam, the Netherlands
| | - Remco Keijser
- Reproductive Biology Laboratory, Amsterdam Reproduction & Development, Amsterdam University Medical Centers, University of Amsterdam1105 AZ, Amsterdam, the Netherlands
| | - Geertruda J. M. Veenboer
- Reproductive Biology Laboratory, Amsterdam Reproduction & Development, Amsterdam University Medical Centers, University of Amsterdam1105 AZ, Amsterdam, the Netherlands
| | - Solange A. Lopes Cardozo
- Reproductive Biology Laboratory, Amsterdam Reproduction & Development, Amsterdam University Medical Centers, University of Amsterdam1105 AZ, Amsterdam, the Netherlands
| | - Dina Diek
- Reproductive Biology Laboratory, Amsterdam Reproduction & Development, Amsterdam University Medical Centers, University of Amsterdam1105 AZ, Amsterdam, the Netherlands
| | - Jennifer A. Vlaardingerbroek
- Reproductive Biology Laboratory, Amsterdam Reproduction & Development, Amsterdam University Medical Centers, University of Amsterdam1105 AZ, Amsterdam, the Netherlands
| | - Marie van Dijk
- Reproductive Biology Laboratory, Amsterdam Reproduction & Development, Amsterdam University Medical Centers, University of Amsterdam1105 AZ, Amsterdam, the Netherlands
| | - Carrie Ris-Stalpers
- Reproductive Biology Laboratory, Amsterdam Reproduction & Development, Amsterdam University Medical Centers, University of Amsterdam1105 AZ, Amsterdam, the Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam University Medical Centers, University of Amsterdam1105 AZ, Amsterdam, the Netherlands
| | - Ans M. M. van Pelt
- Reproductive Biology Laboratory, Amsterdam Reproduction & Development, Amsterdam University Medical Centers, University of Amsterdam1105 AZ, Amsterdam, the Netherlands
| | - Gijs B. Afink
- Reproductive Biology Laboratory, Amsterdam Reproduction & Development, Amsterdam University Medical Centers, University of Amsterdam1105 AZ, Amsterdam, the Netherlands
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Qu’d D, Schmitt LM, Leston A, Harris JR, Slavotinek A, Riddle I, Brightman DS, Simpson BN. Behavioral and neuropsychiatric challenges across the lifespan in individuals with Rubinstein-Taybi syndrome. Front Genet 2023; 14:1116919. [PMID: 37415602 PMCID: PMC10321757 DOI: 10.3389/fgene.2023.1116919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 06/06/2023] [Indexed: 07/08/2023] Open
Abstract
Introduction: Rubinstein-Taybi syndrome (RSTS) is a rare congenital disorder characterized by developmental and intellectual disability, broadening of thumbs and halluces, and characteristic facial features. Pathogenic variants in CREBBP lead to RSTS type 1 (RSTS1) and in EP300 lead to RSTS type 2 (RSTS2). Individuals with RSTS can demonstrate a variety of behavioral and neuropsychiatric challenges, including anxiety, hyperactivity/inattention, self-injury, repetitive behaviors, and aggression. Behavioral challenges are consistently reported as one of the primary factors impacting quality of life. Despite the high prevalence and morbidity of behavioral and neuropsychiatric features of RSTS, a paucity of data exists regarding its natural history. Methods: To better understand the neurocognitive and behavioral challenges faced by individuals with RSTS, 71 caregivers of individuals with RSTS, ranging in age from one to 61 years, completed four questionnaires measuring obsessive compulsive disorder (OCD)-like symptoms, anxiety, challenging behaviors, and adaptive behavior and living skills. Results: Results revealed a high prevalence of neuropsychiatric and behavioral challenges across ages. We found specific challenging behaviors were worse in school age individuals. Scaled adaptive behavior and living skill scores differed across ages with an increased gap between typically developing peers becoming more apparent at older ages. Between types, individuals with RSTS2 had better adaptive behavior and living skills and less stereotypic behaviors but higher social phobia than individuals with RSTS1. Further, female individuals with RSTS1 appear to have increased hyperactivity. However, both groups had impairments in adaptive functioning compared to typically developing peers. Discussion: Our findings support and expand previous reports of a high prevalence of neuropsychiatric and behavioral challenges in individuals with RSTS. However, we are the first to report differences between types of RSTS. Further, age-related differences were seen with higher challenging behaviors within school-age individuals, which may improve over time, and lower adaptive behavioral skills compared to normative scales. Anticipation of these potential differential challenges across age is vital for proactive management for individuals with RSTS. Our study underscores the importance of enacting neuropsychiatric and behavioral screening earlier in childhood so appropriate management can be implemented. However, further longitudinal studies in larger cohorts are needed to understand better how behavioral and neuropsychiatric characteristics of RSTS evolve over the lifespan and differentially affect subpopulation groups.
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Affiliation(s)
- Dima Qu’d
- Division of Human Genetics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Lauren M. Schmitt
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Amber Leston
- University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Jacqueline R. Harris
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Neurogenetics, Hugo W. Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD, United States
| | - Anne Slavotinek
- Division of Human Genetics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Ilka Riddle
- University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Diana S. Brightman
- Division of Human Genetics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Brittany N. Simpson
- Division of Human Genetics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Belanger Deloge R, Zhao X, Luna PN, Shaw CA, Rosenfeld JA, Scott DA. High molecular diagnostic yields and novel phenotypic expansions involving syndromic anorectal malformations. Eur J Hum Genet 2023; 31:296-303. [PMID: 36474027 PMCID: PMC9995493 DOI: 10.1038/s41431-022-01255-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 11/04/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
Abstract
Evidence suggests that genetic factors contribute to the development of anorectal malformations (ARMs). However, the etiology of the majority of ARMs cases remains unclear. Exome sequencing (ES) may be underutilized in the diagnostic workup of ARMs due to uncertainty regarding its diagnostic yield. In a clinical database of ~17,000 individuals referred for ES, we identified 130 individuals with syndromic ARMs. A definitive or probable diagnosis was made in 45 of these individuals for a diagnostic yield of 34.6% (45/130). The molecular diagnostic yield of individuals who initially met criteria for VACTERL association was lower than those who did not (26.8% vs 44.1%; p = 0.0437), suggesting that non-genetic factors may play an important role in this subset of syndromic ARM cases. Within this cohort, we identified two individuals who carried de novo pathogenic frameshift variants in ADNP, two individuals who were homozygous for pathogenic variants in BBS1, and single individuals who carried pathogenic or likely pathogenic variants in CREBBP, EP300, FANCC, KDM6A, SETD2, and SMARCA4. The association of these genes with ARMs was supported by previously published cases, and their similarity to known ARM genes as demonstrated using a machine learning algorithm. These data suggest that ES should be considered for all individuals with syndromic ARMs in whom a molecular diagnosis has not been made, and that ARMs represent a low penetrance phenotype associated with Helsmoortel-van der Aa syndrome, Bardet-Biedl syndrome 1, Rubinstein-Taybi syndromes 1 and 2, Fanconi anemia group C, Kabuki syndrome 2, SETD2-related disorders, and Coffin-Siris syndrome 4.
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Affiliation(s)
- Raymond Belanger Deloge
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Xiaonan Zhao
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, 77030, USA
- Baylor Genetics, Houston, TX, USA
| | - Pamela N Luna
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Chad A Shaw
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Jill A Rosenfeld
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Daryl A Scott
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, 77030, USA.
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX, 77030, USA.
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Bai Z, Li G, Kong X. Case report: a Chinese girl like atypical Rubinstein-Taybi syndrome caused by a novel heterozygous mutation of the EP300 gene. BMC Med Genomics 2023; 16:24. [PMID: 36797748 PMCID: PMC9933371 DOI: 10.1186/s12920-022-01424-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 12/19/2022] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Rubinstein-Taybi syndrome (RSTS) is an extremely rare autosomal dominant inheritable disorder caused by CREBBP and EP300 mutations, while atypical RSTS harbouring variant from the same genes but not obvious resembling RSTS. There are only a few cases of Menke-Hennekam syndrome (MKHK) with variant of exon 30 or 31 of CREBBP or EP300 gene have been reported that not resembling RSTS recent years. Atypical RSTS cannot be accurately classified as MKHK, nor is it easy to identify the obvious classic characteristics of RSTS. The clinical manifestations and genetic variation of atypical RSTS are not fully understood. CASE PRESENTATION We present a Chinese core family with a girl had recurrent respiratory tract infection and developmental delay. The patient with language and motor mild development retardation, she has slight abnormal facial features, mild hirsutism and post-axial hexadactylia of left foot. Her cisterna magna is enlarged to connect with the fourth ventricle, and the ventricular system is enlarged. She has a malacia beside the posterior horn of the left lateral ventricle. The patient has primary low immunoglobulin G and A, but her level of immunoglobulin M content in blood is normal. The patient harbors a novel heterozygous frameshift variant of c.2499dupG in exon 14 of EP300 gene, that it is proved to de novo origin. The mutation is judged to be a pathogenic mutation, and it has high-grade pathogenic evidence. CONCLUSION The clinical and genetic evaluation of this case corroborates that clinical features caused by c.2499dupG in exon 14 of EP300 are less marked than RSTS2 patient although it is difficult to establish an accurate genotype-phenotype correlation. Our additional case also helps to deepen the clinical and genetic spectrum in this disorder. The case provides a novel mutation of EP300 and enriches the phenotypes related with the gene. We have contributed new variation and disease information for guardians and doctors to broaden the knowledge about EP300-RSTS genotype and phenotype, this may contribute to ameliorate the health management of patients and improve the genetic counseling to the families.
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Affiliation(s)
- Zhouxian Bai
- grid.412633.10000 0004 1799 0733The Genetics and Prenatal Diagnosis Center, The Department of Obstetrics and Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 Henan China
| | - Gaopan Li
- grid.412633.10000 0004 1799 0733The Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 Henan China
| | - Xiangdong Kong
- The Genetics and Prenatal Diagnosis Center, The Department of Obstetrics and Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China.
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Zenker M, Mohnike K, Palm K. Syndromic forms of congenital hyperinsulinism. Front Endocrinol (Lausanne) 2023; 14:1013874. [PMID: 37065762 PMCID: PMC10098214 DOI: 10.3389/fendo.2023.1013874] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 03/07/2023] [Indexed: 04/18/2023] Open
Abstract
Congenital hyperinsulinism (CHI), also called hyperinsulinemic hypoglycemia (HH), is a very heterogeneous condition and represents the most common cause of severe and persistent hypoglycemia in infancy and childhood. The majority of cases in which a genetic cause can be identified have monogenic defects affecting pancreatic β-cells and their glucose-sensing system that regulates insulin secretion. However, CHI/HH has also been observed in a variety of syndromic disorders. The major categories of syndromes that have been found to be associated with CHI include overgrowth syndromes (e.g. Beckwith-Wiedemann and Sotos syndromes), chromosomal and monogenic developmental syndromes with postnatal growth failure (e.g. Turner, Kabuki, and Costello syndromes), congenital disorders of glycosylation, and syndromic channelopathies (e.g. Timothy syndrome). This article reviews syndromic conditions that have been asserted by the literature to be associated with CHI. We assess the evidence of the association, as well as the prevalence of CHI, its possible pathophysiology and its natural course in the respective conditions. In many of the CHI-associated syndromic conditions, the mechanism of dysregulation of glucose-sensing and insulin secretion is not completely understood and not directly related to known CHI genes. Moreover, in most of those syndromes the association seems to be inconsistent and the metabolic disturbance is transient. However, since neonatal hypoglycemia is an early sign of possible compromise in the newborn, which requires immediate diagnostic efforts and intervention, this symptom may be the first to bring a patient to medical attention. As a consequence, HH in a newborn or infant with associated congenital anomalies or additional medical issues remains a differential diagnostic challenge and may require a broad genetic workup.
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Affiliation(s)
- Martin Zenker
- Institute of Human Genetics, University Hospital, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- *Correspondence: Martin Zenker,
| | - Klaus Mohnike
- Department of Pediatrics, University Hospital, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Katja Palm
- Department of Pediatrics, University Hospital, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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Levetan C, Van Gils J, Saba A, Rodríguez-Fonseca C, Fieggen K, Tooke L. Rubinstein-Taybi Syndrome: Presentation in the First Month of Life. J Pediatr 2022; 249:106-110. [PMID: 35803299 DOI: 10.1016/j.jpeds.2022.06.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/08/2022] [Accepted: 06/30/2022] [Indexed: 10/17/2022]
Abstract
This web-based survey of 311 respondents from 25 countries provides additional information about the early presentation of Rubinstein-Taybi syndrome. Most (86%) infants present during the neonatal period, with 69% of these within 24 hours of life. Prolonged hospital stay is common (61%).
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Affiliation(s)
- Candice Levetan
- Department of Paediatrics, University of Cape Town, Cape Town, South Africa
| | - Julien Van Gils
- Medical Genetics Department, Bordeaux University, Bordeaux, France
| | | | | | - Karen Fieggen
- Division of Human Genetics, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lloyd Tooke
- Division of Neonatology, Department of Paediatrics, University of Cape Town, Cape Town, South Africa.
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Di Fede E, Grazioli P, Lettieri A, Parodi C, Castiglioni S, Taci E, Colombo EA, Ancona S, Priori A, Gervasini C, Massa V. Epigenetic disorders: Lessons from the animals–animal models in chromatinopathies. Front Cell Dev Biol 2022; 10:979512. [PMID: 36225316 PMCID: PMC9548571 DOI: 10.3389/fcell.2022.979512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Chromatinopathies are defined as genetic disorders caused by mutations in genes coding for protein involved in the chromatin state balance. So far 82 human conditions have been described belonging to this group of congenital disorders, sharing some molecular features and clinical signs. For almost all of these conditions, no specific treatment is available. For better understanding the molecular cascade caused by chromatin imbalance and for envisaging possible therapeutic strategies it is fundamental to combine clinical and basic research studies. To this end, animal modelling systems represent an invaluable tool to study chromatinopathies. In this review, we focused on available data in the literature of animal models mimicking the human genetic conditions. Importantly, affected organs and abnormalities are shared in the different animal models and most of these abnormalities are reported as clinical manifestation, underlying the parallelism between clinics and translational research.
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Affiliation(s)
- Elisabetta Di Fede
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Paolo Grazioli
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Antonella Lettieri
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Chiara Parodi
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Silvia Castiglioni
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Esi Taci
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Elisa Adele Colombo
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Silvia Ancona
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Alberto Priori
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
- “Aldo Ravelli” Center for Neurotechnology and Experimental Brain Therapeutics, Università Degli Studi di Milano, Milan, Italy
| | - Cristina Gervasini
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
- “Aldo Ravelli” Center for Neurotechnology and Experimental Brain Therapeutics, Università Degli Studi di Milano, Milan, Italy
| | - Valentina Massa
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
- “Aldo Ravelli” Center for Neurotechnology and Experimental Brain Therapeutics, Università Degli Studi di Milano, Milan, Italy
- *Correspondence: Valentina Massa,
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9
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Antonyan L, Ernst C. Putative Roles of SETBP1 Dosage on the SET Oncogene to Affect Brain Development. Front Neurosci 2022; 16:813430. [PMID: 35685777 PMCID: PMC9173722 DOI: 10.3389/fnins.2022.813430] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 04/19/2022] [Indexed: 12/24/2022] Open
Abstract
Mutations in SET BINDING PROTEIN 1 (SETBP1) cause two different clinically distinguishable diseases called Schinzel–Giedion syndrome (SGS) or SETBP1 deficiency syndrome (SDD). Both disorders are disorders of protein dosage, where SGS is caused by decreased rate of protein breakdown due to mutations in a proteosome targeting domain, and SDD is caused by heterozygous loss-of-function mutations leading to haploinsufficiency. While phenotypes of affected individuals support a role for SETBP1 in brain development, little is known about the mechanisms that might underlie this. The binding partner which gave SETBP1 its name is SET and there is extensive literature on this important oncogene in non-neural tissues. Here we describe different molecular complexes in which SET is involved as well as the role of these complexes in brain development. Based on this information, we postulate how SETBP1 protein dosage might influence these SET-containing molecular pathways and affect brain development. We examine the roles of SET and SETBP1 in acetylation inhibition, phosphatase activity, DNA repair, and cell cycle control. This work provides testable hypotheses for how altered SETBP1 protein dosage affects brain development.
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10
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Enomoto Y, Yokoi T, Tsurusaki Y, Murakami H, Tominaga M, Minatogawa M, Abe-Hatano C, Kuroda Y, Ohashi I, Ida K, Shiiya S, Kumaki T, Naruto T, Mitsui J, Harada N, Kido Y, Kurosawa K. Divergent variant patterns among 19 patients with Rubinstein-Taybi syndrome uncovered by comprehensive genetic analysis including whole genome sequencing. Clin Genet 2021; 101:335-345. [PMID: 34958122 DOI: 10.1111/cge.14103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/21/2021] [Accepted: 12/24/2021] [Indexed: 12/01/2022]
Abstract
Rubinstein-Taybi syndrome (RSTS) is characterized by dysmorphic facial features, broad thumbs, and intellectual disability. CREBBP or EP300 are causative genes. To elucidate the underlying genetic and genomic architecture related to the RSTS phenotype, we performed comprehensive genetic analysis targeting CREBBP and/or EP300 in 22 clinically diagnosed patients. During the 11-year study period, we used several analysis methods including high resolution melting, array-based comparative genomic hybridization, panel-based exome sequencing, whole exome sequencing, and whole genome sequencing (WGS). We identified the causative variants in 19 patients (86.3%), but they were variable and complex, so we must combine multiple analysis methods. Notably, we found genetic alterations in the non-coding regions of two patients (10.5%, 2/19): scattered deletions including a partial 5'-untranslated region of CREBBP in one patient (all coding exons were intact), and a deep 229-bp intronic deletion in another patient, resulting in a splicing error. Furthermore, we identified rare clinical findings: two patients with an EP300 variant showed abnormal development of the neural tube, and one patient with a CREBBP variant had anorectal atresia with a cloaca. Our findings expand the allelic heterogeneity of RSTS, underscore the utility of comprehensive genetic analysis, and suggest that WGS may be a practical diagnostic strategy.
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Affiliation(s)
- Yumi Enomoto
- Clinical Research Institute, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Takayuki Yokoi
- Division of Medical Genetics, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Yoshinori Tsurusaki
- Clinical Research Institute, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Hiroaki Murakami
- Division of Medical Genetics, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Makiko Tominaga
- Division of Medical Genetics, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Mari Minatogawa
- Division of Medical Genetics, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Chihiro Abe-Hatano
- Division of Medical Genetics, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Yukiko Kuroda
- Division of Medical Genetics, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Ikuko Ohashi
- Division of Medical Genetics, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Kazumi Ida
- Division of Medical Genetics, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Shizuka Shiiya
- Division of Medical Genetics, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tatsuro Kumaki
- Division of Medical Genetics, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Takuya Naruto
- Clinical Research Institute, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Jun Mitsui
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Noriaki Harada
- Department of Clinical Laboratory, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Yasuhiro Kido
- Department of Pediatrics, Saitama Medical Center, Dokkyo Medical University, Koshigaya, Japan
| | - Kenji Kurosawa
- Clinical Research Institute, Kanagawa Children's Medical Center, Yokohama, Japan.,Division of Medical Genetics, Kanagawa Children's Medical Center, Yokohama, Japan
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11
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Martins F, Roussen AC, Rezende N, Hiraoka C, Zamunaro M, Gallottini M. Oral and cephalometric study in Brazilian Rubinstein-Taybi syndrome patients. SPECIAL CARE IN DENTISTRY 2021; 42:143-148. [PMID: 34590347 DOI: 10.1111/scd.12645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/12/2021] [Accepted: 08/17/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to describe a detailed investigation of craniofacial and dental characteristics in a group of Brazilian Rubinstein-Taybi syndrome (RSTS) patients. METHODS AND RESULTS Thirteen RSTS patients treated in a special care dental clinic after 10 years were studied. Panoramic radiographs were obtained from all patients, and cephalometric analysis was performed in eight patients. Five male and eight white female patients with a median age of 11.7 years were analyzed. All the RSTS patients were mouth breathers and presented malocclusion, transverse hypoplastic maxilla, nine subjects (9/13; 69.2%) had posterior crossbite, and eight (61.53%) exhibited talon cusps. Most patients presented class II skeletal pattern and were brachycephalic. Regarding systemic disorders, one patient (7.69%) reported seizure episodes during childhood, and four patients (30.76%) presented heart valve disorders. All patients presented reduced attention span, low intolerance to dental interventions, impulsiveness, and irritability. CONCLUSIONS Since RSTS exhibits oral and skeletal changes, early dental treatment is essential for these patients. Dentists must be aware of medical problems related to heart disease and persist in conditioning techniques to obtain cooperation and avoid dental care under general anesthesia.
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Affiliation(s)
- Fabiana Martins
- Special Care Dentistry Center, School of Dentistry, University of São Paulo, São Paulo, Brazil.,School of Dentistry, University of Santo Amaro, São Paulo, Brazil
| | - Ana Clelia Roussen
- Special Care Dentistry Center, School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - Nathalie Rezende
- Special Care Dentistry Center, School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - Cybelle Hiraoka
- Special Care Dentistry Center, School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - Marcelo Zamunaro
- Special Care Dentistry Center, School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - Marina Gallottini
- Special Care Dentistry Center, School of Dentistry, University of São Paulo, São Paulo, Brazil
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12
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Choi N, Kim HY, Lim BC, Chae JH, Kim SY, Ko JM. Genetic and clinical heterogeneity in Korean patients with Rubinstein-Taybi syndrome. Mol Genet Genomic Med 2021; 9:e1791. [PMID: 34427995 PMCID: PMC8580098 DOI: 10.1002/mgg3.1791] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/22/2021] [Accepted: 08/13/2021] [Indexed: 12/21/2022] Open
Abstract
Background Rubinstein–Taybi syndrome (RSTS) is a rare congenital malformation syndrome with clinical characteristics such as hypertrichosis, high arched eyebrows, large beaked nose, and broad thumbs and halluces. RSTS patients showed intellectual disability and health problems such as short stature, ophthalmologic abnormalities, congenital heart defects, genitourinary defects, and variable types of tumors. Although mutations in CREBBP and EP300 genes are associated with RSTS features, genetic causation is still unknown in 30% of patients. Methods We present clinical and molecular genetic characteristics of 25 unrelated Korean patients clinically diagnosed with RSTS. Sanger sequencing analysis and multiplex ligation‐dependent probe amplification for CREBBP in 25 patients and exome sequencing of CREBBP‐negative cases were performed in nine patients successively. Results Causative variants were identified in 20 (80%) patients: 16 (64%) in CREBBP and 4 (16%) in EP300. All the identified variants predict protein truncation (11 frameshift, 2 nonsense, 1 splicing‐site, and 6 large intragenic deletions); there are no repeatedly identified sequence variants. Four of the CREBBP and all four EP300 variants are novel. Intellectual disability was noted in 24/25 patients (96%); no difference was found between CREBBP and EP300 groups. One patient with a CREBBP variant (4%) had malignant tumor. Conclusions To date, this is the largest cohort of patients with RSTS including EP300‐related patients in Korea. Future large‐scale studies to find genetic mutation of molecularly unsolved patients and long‐term prospective studies are required to validate our results.
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Affiliation(s)
- Naye Choi
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hwa Young Kim
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Chan Lim
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.,Rare Disease Center, Seoul National University Hospital, Seoul, Korea
| | - Jong-Hee Chae
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.,Rare Disease Center, Seoul National University Hospital, Seoul, Korea
| | - Soo Yeon Kim
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.,Rare Disease Center, Seoul National University Hospital, Seoul, Korea
| | - Jung Min Ko
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.,Rare Disease Center, Seoul National University Hospital, Seoul, Korea
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13
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Van Gils J, Magdinier F, Fergelot P, Lacombe D. Rubinstein-Taybi Syndrome: A Model of Epigenetic Disorder. Genes (Basel) 2021; 12:968. [PMID: 34202860 PMCID: PMC8303114 DOI: 10.3390/genes12070968] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 05/31/2021] [Accepted: 06/16/2021] [Indexed: 12/24/2022] Open
Abstract
The Rubinstein-Taybi syndrome (RSTS) is a rare congenital developmental disorder characterized by a typical facial dysmorphism, distal limb abnormalities, intellectual disability, and many additional phenotypical features. It occurs at between 1/100,000 and 1/125,000 births. Two genes are currently known to cause RSTS, CREBBP and EP300, mutated in around 55% and 8% of clinically diagnosed cases, respectively. To date, 500 pathogenic variants have been reported for the CREBBP gene and 118 for EP300. These two genes encode paralogs acting as lysine acetyltransferase involved in transcriptional regulation and chromatin remodeling with a key role in neuronal plasticity and cognition. Because of the clinical heterogeneity of this syndrome ranging from the typical clinical diagnosis to features overlapping with other Mendelian disorders of the epigenetic machinery, phenotype/genotype correlations remain difficult to establish. In this context, the deciphering of the patho-physiological process underlying these diseases and the definition of a specific episignature will likely improve the diagnostic efficiency but also open novel therapeutic perspectives. This review summarizes the current clinical and molecular knowledge and highlights the epigenetic regulation of RSTS as a model of chromatinopathy.
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Affiliation(s)
- Julien Van Gils
- Reference Center AD SOOR, AnDDI-RARE, INSERM U 1211, Medical Genetics Department, Bordeaux University, Centre Hospitalier Universitaire de Bordeaux, 33076 Bordeaux, France; (P.F.); (D.L.)
| | - Frederique Magdinier
- Marseille Medical Genetics, INSERM U 1251, MMG, Aix Marseille University, 13385 Marseille, France;
| | - Patricia Fergelot
- Reference Center AD SOOR, AnDDI-RARE, INSERM U 1211, Medical Genetics Department, Bordeaux University, Centre Hospitalier Universitaire de Bordeaux, 33076 Bordeaux, France; (P.F.); (D.L.)
| | - Didier Lacombe
- Reference Center AD SOOR, AnDDI-RARE, INSERM U 1211, Medical Genetics Department, Bordeaux University, Centre Hospitalier Universitaire de Bordeaux, 33076 Bordeaux, France; (P.F.); (D.L.)
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14
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Wild KT, Nomakuchi TT, Sheppard SE, Leavens KF, De León DD, Zackai EH. Hyperinsulinism in an individual with an EP300 variant of Rubinstein-Taybi syndrome. Am J Med Genet A 2021; 185:1251-1255. [PMID: 33442921 PMCID: PMC8621558 DOI: 10.1002/ajmg.a.62085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/01/2021] [Accepted: 01/03/2021] [Indexed: 01/21/2023]
Abstract
Rubinstein-Taybi syndrome (RSTS) is an autosomal dominant genetic syndrome characterized by distinct facial features, broad thumbs, growth restriction, microcephaly, intellectual disability, and developmental delay. Pathogenic variants in both CREBBP and EP300 have been associated with RSTS. Here we present a case of a female with hyperinsulinism and features consistent with RSTS, found to have a pathogenic variant in EP300. While there have been a few rare case reports of hyperinsulinism in RSTS, we suggest that hyperinsulinism might be a more prominent feature in EP300 variant RSTS than previously recognized.
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Affiliation(s)
- K. Taylor Wild
- Division of Human Genetics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tomoki T. Nomakuchi
- Division of Human Genetics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah E. Sheppard
- Division of Human Genetics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Center for Applied Genomics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Karla F. Leavens
- Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Diva D. De León
- Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elaine H. Zackai
- Division of Human Genetics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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