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Kocher K, Bhattacharya S, Niforatos-Andescavage N, Almalvez M, Henderson D, Vilain E, Limperopoulos C, Délot EC. Genome-wide neonatal epigenetic changes associated with maternal exposure to the COVID-19 pandemic. BMC Med Genomics 2023; 16:268. [PMID: 37899449 PMCID: PMC10614377 DOI: 10.1186/s12920-023-01707-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 10/17/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND During gestation, stressors to the fetus, including viral exposure or maternal psychological distress, can fundamentally alter the neonatal epigenome, and may be associated with long-term impaired developmental outcomes. The impact of in utero exposure to the COVID-19 pandemic on the newborn epigenome has yet to be described. METHODS This study aimed to determine whether there are unique epigenetic signatures in newborns who experienced otherwise healthy pregnancies that occurred during the COVID-19 pandemic (Project RESCUE). The pre-pandemic control and pandemic cohorts (Project RESCUE) included in this study are part of a prospective observational and longitudinal cohort study that evaluates the impact of elevated prenatal maternal stress during the COVID-19 pandemic on early childhood neurodevelopment. Using buccal swabs collected at birth, differential DNA methylation analysis was performed using the Infinium MethylationEPIC arrays and linear regression analysis. Pathway analysis and gene ontology enrichment were performed on resultant gene lists. RESULTS Widespread differential methylation was found between neonates exposed in utero to the pandemic and pre-pandemic neonates. In contrast, there were no apparent epigenetic differences associated with maternal COVID-19 infection during pregnancy. Differential methylation was observed among genomic sites that underpin important neurological pathways that have been previously reported in the literature to be differentially methylated because of prenatal stress, such as NR3C1. CONCLUSIONS The present study reveals potential associations between exposure to the COVID-19 pandemic during pregnancy and subsequent changes in the newborn epigenome. While this finding warrants further investigation, it is a point that should be considered in any study assessing newborn DNA methylation studies obtained during this period, even in otherwise healthy pregnancies.
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Affiliation(s)
- Kristen Kocher
- Center for Genetic Medicine Research, Children's National Research & Innovation Campus, Washington, DC, USA
- Department of Genomics & Precision Medicine, George Washington University, Washington, DC, USA
| | - Surajit Bhattacharya
- Center for Genetic Medicine Research, Children's National Research & Innovation Campus, Washington, DC, USA
| | | | - Miguel Almalvez
- Institute for Clinical and Translational Science, University of California, Irvine, CA, USA
| | - Diedtra Henderson
- Developing Brain Institute, Children's National Hospital, Washington, DC, USA
| | - Eric Vilain
- Institute for Clinical and Translational Science, University of California, Irvine, CA, USA.
| | | | - Emmanuèle C Délot
- Center for Genetic Medicine Research, Children's National Research & Innovation Campus, Washington, DC, USA.
- Department of Genomics & Precision Medicine, George Washington University, Washington, DC, USA.
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Bornhorst M, Eze A, Bhattacharya S, Putnam E, Almira-Suarez MI, Rossi C, Kambhampati M, Almalvez M, Barseghyan M, Del Risco N, Dotson D, Turner J, Myseros JS, Vilain E, Packer RJ, Nazarian J, Rood B, Barseghyan H. Optical genome mapping identifies a novel pediatric embryonal tumor with a ZNF532::NUTM1 fusion. J Pathol 2023. [PMID: 37203791 DOI: 10.1002/path.6085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 03/06/2023] [Accepted: 03/31/2023] [Indexed: 05/20/2023]
Abstract
The molecular characteristics of pediatric brain tumors have not only allowed for tumor subgrouping but have led to the introduction of novel treatment options for patients with specific tumor alterations. Therefore, an accurate histologic and molecular diagnosis is critical for optimized management of all pediatric patients with brain tumors, including central nervous system embryonal tumors. We present a case where optical genome mapping identified a ZNF532::NUTM1 fusion in a patient with a unique tumor best characterized histologically as a central nervous system embryonal tumor with rhabdoid features. Additional analyses including immunohistochemistry for NUT protein, methylation array, whole genome, and RNA-sequencing was done to confirm the presence of the fusion in the tumor. This is the first description of a pediatric patient with a ZNF532::NUTM1 fusion, yet the histology of this tumor is similar to that of adult cancers with ZNF::NUTM1 fusions reported in the literature. Although rare, the distinct pathology and underlying molecular characteristics of the ZNF532::NUTM1 tumor separates this from other embryonal tumors. Therefore, screening for this or similar NUTM1 rearrangements should be considered for all patients with unclassified central nervous system tumors with rhabdoid features to ensure accurate diagnosis. Ultimately, with additional cases, we may be able to better inform therapeutic management for these patients. © 2023 The Pathological Society of Great Britain and Ireland.
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Affiliation(s)
- Miriam Bornhorst
- Division of Hematology/Oncology, Children's National Hospital, Washington, DC, USA
- Brain Tumor Institute, Children's National Hospital, Washington, DC, USA
- Center for Genetics Medicine Research, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
- Center for Neuroscience and Behavioral Medicine, Children's National Hospital, Washington, DC, USA
| | - Augustine Eze
- Brain Tumor Institute, Children's National Hospital, Washington, DC, USA
- Center for Genetics Medicine Research, Children's National Hospital, Washington, DC, USA
| | - Surajit Bhattacharya
- Center for Genetics Medicine Research, Children's National Hospital, Washington, DC, USA
| | - Ethan Putnam
- Brain Tumor Institute, Children's National Hospital, Washington, DC, USA
- Center for Genetics Medicine Research, Children's National Hospital, Washington, DC, USA
| | | | - Christopher Rossi
- Divison of Pathology, Children's National Hospital, Washington, DC, USA
| | - Madhuri Kambhampati
- Center for Genetics Medicine Research, Children's National Hospital, Washington, DC, USA
| | - Miguel Almalvez
- Center for Genetics Medicine Research, Children's National Hospital, Washington, DC, USA
| | - Mariam Barseghyan
- Department of Obstetrics and Gynecology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Nicole Del Risco
- School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | | | - Joyce Turner
- Division of Genetics and Metabolism, Children's National Hospital, Washington, DC, USA
| | - John S Myseros
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Eric Vilain
- Center for Genetics Medicine Research, Children's National Hospital, Washington, DC, USA
- Center for Genomics and Precision Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Roger J Packer
- Brain Tumor Institute, Children's National Hospital, Washington, DC, USA
- Center for Neuroscience and Behavioral Medicine, Children's National Hospital, Washington, DC, USA
| | - Javad Nazarian
- Brain Tumor Institute, Children's National Hospital, Washington, DC, USA
- Center for Genetics Medicine Research, Children's National Hospital, Washington, DC, USA
- Center for Genomics and Precision Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Brian Rood
- Division of Hematology/Oncology, Children's National Hospital, Washington, DC, USA
- Brain Tumor Institute, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
- Center for Cancer and Immunology Research, Children's National Hospital, Washington, DC, USA
| | - Hayk Barseghyan
- Center for Genetics Medicine Research, Children's National Hospital, Washington, DC, USA
- Center for Genomics and Precision Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
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Sharim H, Grunwald A, Gabrieli T, Michaeli Y, Margalit S, Torchinsky D, Arielly R, Nifker G, Juhasz M, Gularek F, Almalvez M, Dufault B, Chandra SS, Liu A, Bhattacharya S, Chen YW, Vilain E, Wagner KR, Pevsner J, Reifenberger J, Lam ET, Hastie AR, Cao H, Barseghyan H, Weinhold E, Ebenstein Y. Long-read single-molecule maps of the functional methylome. Genome Res 2019; 29:646-656. [PMID: 30846530 PMCID: PMC6442387 DOI: 10.1101/gr.240739.118] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 02/25/2019] [Indexed: 01/23/2023]
Abstract
We report on the development of a methylation analysis workflow for optical detection of fluorescent methylation profiles along chromosomal DNA molecules. In combination with Bionano Genomics genome mapping technology, these profiles provide a hybrid genetic/epigenetic genome-wide map composed of DNA molecules spanning hundreds of kilobase pairs. The method provides kilobase pair–scale genomic methylation patterns comparable to whole-genome bisulfite sequencing (WGBS) along genes and regulatory elements. These long single-molecule reads allow for methylation variation calling and analysis of large structural aberrations such as pathogenic macrosatellite arrays not accessible to single-cell second-generation sequencing. The method is applied here to study facioscapulohumeral muscular dystrophy (FSHD), simultaneously recording the haplotype, copy number, and methylation status of the disease-associated, highly repetitive locus on Chromosome 4q.
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Affiliation(s)
- Hila Sharim
- School of Chemistry, Center for Nanoscience and Nanotechnology, Center for Light-Matter Interaction, Raymond and Beverly Sackler Faculty of Exact Sciences, Tel Aviv University, Ramat Aviv 6997801, Israel
| | - Assaf Grunwald
- School of Chemistry, Center for Nanoscience and Nanotechnology, Center for Light-Matter Interaction, Raymond and Beverly Sackler Faculty of Exact Sciences, Tel Aviv University, Ramat Aviv 6997801, Israel
| | - Tslil Gabrieli
- School of Chemistry, Center for Nanoscience and Nanotechnology, Center for Light-Matter Interaction, Raymond and Beverly Sackler Faculty of Exact Sciences, Tel Aviv University, Ramat Aviv 6997801, Israel
| | - Yael Michaeli
- School of Chemistry, Center for Nanoscience and Nanotechnology, Center for Light-Matter Interaction, Raymond and Beverly Sackler Faculty of Exact Sciences, Tel Aviv University, Ramat Aviv 6997801, Israel
| | - Sapir Margalit
- School of Chemistry, Center for Nanoscience and Nanotechnology, Center for Light-Matter Interaction, Raymond and Beverly Sackler Faculty of Exact Sciences, Tel Aviv University, Ramat Aviv 6997801, Israel
| | - Dmitry Torchinsky
- School of Chemistry, Center for Nanoscience and Nanotechnology, Center for Light-Matter Interaction, Raymond and Beverly Sackler Faculty of Exact Sciences, Tel Aviv University, Ramat Aviv 6997801, Israel
| | - Rani Arielly
- School of Chemistry, Center for Nanoscience and Nanotechnology, Center for Light-Matter Interaction, Raymond and Beverly Sackler Faculty of Exact Sciences, Tel Aviv University, Ramat Aviv 6997801, Israel
| | - Gil Nifker
- School of Chemistry, Center for Nanoscience and Nanotechnology, Center for Light-Matter Interaction, Raymond and Beverly Sackler Faculty of Exact Sciences, Tel Aviv University, Ramat Aviv 6997801, Israel
| | - Matyas Juhasz
- Institute of Organic Chemistry RWTH Aachen University, D-52056 Aachen, Germany
| | - Felix Gularek
- Institute of Organic Chemistry RWTH Aachen University, D-52056 Aachen, Germany
| | - Miguel Almalvez
- Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC 20010, USA
| | - Brandon Dufault
- Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC 20010, USA
| | - Sreetama Sen Chandra
- Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC 20010, USA
| | - Alexander Liu
- Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC 20010, USA
| | - Surajit Bhattacharya
- Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC 20010, USA
| | - Yi-Wen Chen
- Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC 20010, USA
| | - Eric Vilain
- Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC 20010, USA
| | - Kathryn R Wagner
- Kennedy Krieger Institute and Departments of Neurology and Neuroscience, The Johns Hopkins School of Medicine, Baltimore, Maryland 21205, USA
| | - Jonathan Pevsner
- Kennedy Krieger Institute and Departments of Neurology and Neuroscience, The Johns Hopkins School of Medicine, Baltimore, Maryland 21205, USA
| | | | - Ernest T Lam
- Bionano Genomics, Incorporated, San Diego, California 92121, USA
| | - Alex R Hastie
- Bionano Genomics, Incorporated, San Diego, California 92121, USA
| | - Han Cao
- Bionano Genomics, Incorporated, San Diego, California 92121, USA
| | - Hayk Barseghyan
- Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC 20010, USA
| | - Elmar Weinhold
- Institute of Organic Chemistry RWTH Aachen University, D-52056 Aachen, Germany
| | - Yuval Ebenstein
- School of Chemistry, Center for Nanoscience and Nanotechnology, Center for Light-Matter Interaction, Raymond and Beverly Sackler Faculty of Exact Sciences, Tel Aviv University, Ramat Aviv 6997801, Israel
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Barseghyan H, Symon A, Zadikyan M, Almalvez M, Segura EE, Eskin A, Bramble MS, Arboleda VA, Baxter R, Nelson SF, Délot EC, Harley V, Vilain E. Identification of novel candidate genes for 46,XY disorders of sex development (DSD) using a C57BL/6J-Y POS mouse model. Biol Sex Differ 2018; 9:8. [PMID: 29378665 PMCID: PMC5789682 DOI: 10.1186/s13293-018-0167-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 01/19/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Disorders of sex development (DSD) have an estimated frequency of 0.5% of live births encompassing a variety of urogenital anomalies ranging from mild hypospadias to a discrepancy between sex chromosomes and external genitalia. In order to identify the underlying genetic etiology, we had performed exome sequencing in a subset of DSD cases with 46,XY karyotype and were able to identify the causative genetic variant in 35% of cases. While the genetic etiology was not ascertained in more than half of the cases, a large number of variants of unknown clinical significance (VUS) were identified in those exomes. METHODS To investigate the relevance of these VUS in regards to the patient's phenotype, we utilized a mouse model in which the presence of a Y chromosome from the poschiavinus strain (Y POS ) on a C57BL/6J (B6) background results in XY undervirilization and sex reversal, a phenotype characteristic to a large subset of human 46,XY DSD cases. We assessed gene expression differences between B6-Y B6 and undervirilized B6-Y POS gonads at E11.5 and identified 515 differentially expressed genes (308 underexpressed and 207 overexpressed in B6-Y POS males). RESULTS We identified 15 novel candidate genes potentially involved in 46,XY DSD pathogenesis by filtering the list of human VUS-carrying genes provided by exome sequencing with the list of differentially expressed genes from B6-Y POS mouse model. Additionally, we identified that 7 of the 15 candidate genes were significantly underexpressed in the XY gonads of mice with suppressed Sox9 expression in Sertoli cells suggesting that some of the candidate genes may be downstream of a well-known sex determining gene, Sox9. CONCLUSION The use of a DSD-specific animal model improves variant interpretation by correlating human sequence variants with transcriptome variation.
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Affiliation(s)
- Hayk Barseghyan
- Center for Genetic Medicine Research, Children’s Research Institute, Children’s National Health System, Washington, DC, 20010 USA
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Aleisha Symon
- Department of Brain and Gender, Hudson Institute of Medical Research, Clayton, VIC 3168 Australia
| | - Mariam Zadikyan
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Miguel Almalvez
- Center for Genetic Medicine Research, Children’s Research Institute, Children’s National Health System, Washington, DC, 20010 USA
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Eva E. Segura
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Ascia Eskin
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Matthew S. Bramble
- Center for Genetic Medicine Research, Children’s Research Institute, Children’s National Health System, Washington, DC, 20010 USA
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Valerie A. Arboleda
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Ruth Baxter
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Stanley F. Nelson
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Emmanuèle C. Délot
- Center for Genetic Medicine Research, Children’s Research Institute, Children’s National Health System, Washington, DC, 20010 USA
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
| | - Vincent Harley
- Department of Brain and Gender, Hudson Institute of Medical Research, Clayton, VIC 3168 Australia
| | - Eric Vilain
- Center for Genetic Medicine Research, Children’s Research Institute, Children’s National Health System, Washington, DC, 20010 USA
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095 USA
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5
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Barseghyan H, Tang W, Wang RT, Almalvez M, Segura E, Bramble MS, Lipson A, Douine ED, Lee H, Délot EC, Nelson SF, Vilain E. Next-generation mapping: a novel approach for detection of pathogenic structural variants with a potential utility in clinical diagnosis. Genome Med 2017; 9:90. [PMID: 29070057 PMCID: PMC5655859 DOI: 10.1186/s13073-017-0479-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 10/10/2017] [Indexed: 11/13/2022] Open
Abstract
Background Massively parallel DNA sequencing, such as exome sequencing, has become a routine clinical procedure to identify pathogenic variants responsible for a patient’s phenotype. Exome sequencing has the capability of reliably identifying inherited and de novo single-nucleotide variants, small insertions, and deletions. However, due to the use of 100–300-bp fragment reads, this platform is not well powered to sensitively identify moderate to large structural variants (SV), such as insertions, deletions, inversions, and translocations. Methods To overcome these limitations, we used next-generation mapping (NGM) to image high molecular weight double-stranded DNA molecules (megabase size) with fluorescent tags in nanochannel arrays for de novo genome assembly. We investigated the capacity of this NGM platform to identify pathogenic SV in a series of patients diagnosed with Duchenne muscular dystrophy (DMD), due to large deletions, insertion, and inversion involving the DMD gene. Results We identified deletion, duplication, and inversion breakpoints within DMD. The sizes of deletions were in the range of 45–250 Kbp, whereas the one identified insertion was approximately 13 Kbp in size. This method refined the location of the break points within introns for cases with deletions compared to current polymerase chain reaction (PCR)-based clinical techniques. Heterozygous SV were detected in the known carrier mothers of the DMD patients, demonstrating the ability of the method to ascertain carrier status for large SV. The method was also able to identify a 5.1-Mbp inversion involving the DMD gene, previously identified by RNA sequencing. Conclusions We showed the ability of NGM technology to detect pathogenic structural variants otherwise missed by PCR-based techniques or chromosomal microarrays. NGM is poised to become a new tool in the clinical genetic diagnostic strategy and research due to its ability to sensitively identify large genomic variations. Electronic supplementary material The online version of this article (doi:10.1186/s13073-017-0479-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hayk Barseghyan
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA.,Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC, 20010, USA
| | - Wilson Tang
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA
| | - Richard T Wang
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA
| | - Miguel Almalvez
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA.,Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC, 20010, USA
| | - Eva Segura
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA
| | - Matthew S Bramble
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA.,Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC, 20010, USA
| | - Allen Lipson
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA
| | - Emilie D Douine
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA
| | - Hane Lee
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA
| | - Emmanuèle C Délot
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA.,Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA.,Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC, 20010, USA
| | - Stanley F Nelson
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA.,Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA
| | - Eric Vilain
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA. .,Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA. .,Center for Genetic Medicine Research, Children's National Health System, Children's Research Institute, Washington, DC, 20010, USA.
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