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Mary L, Fradin M, Pasquier L, Quelin C, Loget P, Le Lous M, Le Bouar G, Nivot-Adamiak S, Lokchine A, Dubourg C, Jauffret V, Nouyou B, Henry C, Launay E, Odent S, Jaillard S, Belaud-Rotureau MA. Role of chromosomal imbalances in the pathogenesis of DSD: A retrospective analysis of 115 prenatal samples. Eur J Med Genet 2023; 66:104748. [PMID: 36948288 DOI: 10.1016/j.ejmg.2023.104748] [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: 09/16/2022] [Revised: 03/10/2023] [Accepted: 03/18/2023] [Indexed: 03/24/2023]
Abstract
Differences of sex development (DSDs) are a group of congenital conditions characterized by a discrepancy between chromosomal, gonadal, and genital sex development of an individual, with significant impact on medical, psychological and reproductive life. The genetic heterogeneity of DSDs complicates the diagnosis and almost half of the patients remains undiagnosed. In this context, chromosomal imbalances in syndromic DSD patients may help to identify new genes implicated in DSDs. In this study, we aimed at describing the burden of chromosomal imbalances including submicroscopic ones (copy number variants or CNVs) in a cohort of prenatal syndromic DSD patients, and review their role in DSDs. Our patients carried at least one pathogenic or likely pathogenic chromosomal imbalance/CNV or low-level mosaicism for aneuploidy. Almost half of the cases resulted from an unbalanced chromosomal rearrangement. Chromosome 9p/q, 4p/q, 3q and 11q anomalies were more frequently observed. Review of the literature confirmed the causative role of CNVs in DSDs, either in disruption of known DSD-causing genes (SOX9, NR0B1, NR5A1, AR, ATRX, …) or as a tool to suspect new genes in DSDs (HOXD cluster, ADCY2, EMX2, CAMK1D, …). Recurrent CNVs of regulatory elements without coding sequence content (i.e. duplications/deletions upstream of SOX3 or SOX9) confirm detection of CNVs as a mean to explore our non-coding genome. Thus, CNV detection remains a powerful tool to explore undiagnosed DSDs, either through routine techniques or through emerging technologies such as long-read whole genome sequencing or optical genome mapping.
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Affiliation(s)
- L Mary
- CHU Rennes, Service de Cytogénétique et Biologie Cellulaire, F-35033, Rennes, France; Univ Rennes, CHU Rennes, Inserm, EHESP, Irset, UMR_S, 1085, F-35000, Rennes, France.
| | - M Fradin
- Service de Génétique Clinique, Centre de Référence Anomalies Du Développement, CLAD Ouest, CHU Rennes, Rennes, France
| | - L Pasquier
- Service de Génétique Clinique, Centre de Référence Anomalies Du Développement, CLAD Ouest, CHU Rennes, Rennes, France; Université de Rennes, IGDR (Institut de Génétique et Développement), CNRS UMR 6290, INSERM ERL 1305, Rennes, France
| | - C Quelin
- Service de Génétique Clinique, Centre de Référence Anomalies Du Développement, CLAD Ouest, CHU Rennes, Rennes, France
| | - P Loget
- Service D'Anatomie Pathologique, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - M Le Lous
- Unité de Médecine Fœtale, Service de Gynécologie-Obstétrique, CHU Rennes, Rennes, France
| | - G Le Bouar
- Unité de Médecine Fœtale, Service de Gynécologie-Obstétrique, CHU Rennes, Rennes, France
| | - S Nivot-Adamiak
- Service D'endocrinologie Pédiatrique, CHU Rennes, Rennes, France
| | - A Lokchine
- CHU Rennes, Service de Cytogénétique et Biologie Cellulaire, F-35033, Rennes, France
| | - C Dubourg
- Université de Rennes, IGDR (Institut de Génétique et Développement), CNRS UMR 6290, INSERM ERL 1305, Rennes, France; Service de Génétique Moléculaire et Génomique, CHU de Rennes, Rennes, 35033, France
| | - V Jauffret
- CHU Rennes, Service de Cytogénétique et Biologie Cellulaire, F-35033, Rennes, France
| | - B Nouyou
- CHU Rennes, Service de Cytogénétique et Biologie Cellulaire, F-35033, Rennes, France
| | - C Henry
- CHU Rennes, Service de Cytogénétique et Biologie Cellulaire, F-35033, Rennes, France
| | - E Launay
- CHU Rennes, Service de Cytogénétique et Biologie Cellulaire, F-35033, Rennes, France
| | - S Odent
- Service de Génétique Clinique, Centre de Référence Anomalies Du Développement, CLAD Ouest, CHU Rennes, Rennes, France; Université de Rennes, IGDR (Institut de Génétique et Développement), CNRS UMR 6290, INSERM ERL 1305, Rennes, France
| | - S Jaillard
- CHU Rennes, Service de Cytogénétique et Biologie Cellulaire, F-35033, Rennes, France; Univ Rennes, CHU Rennes, Inserm, EHESP, Irset, UMR_S, 1085, F-35000, Rennes, France
| | - M A Belaud-Rotureau
- CHU Rennes, Service de Cytogénétique et Biologie Cellulaire, F-35033, Rennes, France; Univ Rennes, CHU Rennes, Inserm, EHESP, Irset, UMR_S, 1085, F-35000, Rennes, France
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2
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Lucas-Herald AK, Rodie ME, Ahmed SF. Update on the management of a newborn with a suspected difference of sex development. Arch Dis Child 2022; 107:866-871. [PMID: 34772663 DOI: 10.1136/archdischild-2020-320872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 10/26/2021] [Indexed: 11/04/2022]
Abstract
Differences or disorders of sex development are a group of heterogeneous conditions, which most commonly present in the newborn period, with the appearance of atypical genitalia on newborn examination. Over recent years, the improvement in our knowledge of these conditions has been accompanied by advances in diagnostic technology and therapeutic options, as well as societal shifts in attitudes and expectations. These factors have placed an even greater emphasis than before on the need for early expert input through a multidisciplinary service that can support the patient and the family; perform and interpret the investigations required to reach a diagnosis; and formulate a management plan that lays down the foundation for optimal long-term outcome. While providing a regional service, the expert team should also be committed to research and quality improvement through participation in national and international networks.
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Affiliation(s)
| | - Martina E Rodie
- Office for Rare Conditions, University of Glasgow, Glasgow, UK
- Department of Neonatology, Queen Elizabeth University Hospital Campus, Glasgow, UK
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
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Ahmed SF, Alimusina M, Batista RL, Domenice S, Lisboa Gomes N, McGowan R, Patjamontri S, Mendonca BB. The Use of Genetics for Reaching a Diagnosis in XY DSD. Sex Dev 2022; 16:207-224. [DOI: 10.1159/000524881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/03/2022] [Indexed: 11/19/2022] Open
Abstract
Reaching a firm diagnosis is vital for the long-term management of a patient with a difference or disorder of sex development (DSD). This is especially the case in XY DSD where the diagnostic yield is particularly low. Molecular genetic technology is playing an increasingly important role in the diagnostic process, and it is highly likely that it will be used more often at an earlier stage in the diagnostic process. In many cases of DSD, the clinical utility of molecular genetics is unequivocally clear, but in many other cases there is a need for careful exploration of the benefit of genetic diagnosis through long-term monitoring of these cases. Furthermore, the incorporation of molecular genetics into the diagnostic process requires a careful appreciation of the strengths and weaknesses of the evolving technology, and the interpretation of the results requires a clear understanding of the wide range of conditions that are associated with DSD.
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Sewell R, Buchanan CL, Davis S, Christakis DA, Dempsey A, Furniss A, Kazak AE, Kerlek AJ, Magnusen B, Pajor NM, Pyle L, Pyle LC, Razzaghi H, Schwartz BI, Vogiatzi MG, Nokoff NJ. Behavioral Health Diagnoses in Youth with Differences of Sex Development or Congenital Adrenal Hyperplasia Compared with Controls: A PEDSnet Study. J Pediatr 2021; 239:175-181.e2. [PMID: 34461062 PMCID: PMC8604751 DOI: 10.1016/j.jpeds.2021.08.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/10/2021] [Accepted: 08/23/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the odds of a behavioral health diagnosis among youth with differences of sex development (DSD) or congenital adrenal hyperplasia (CAH) compared with matched controls in the PEDSnet database. STUDY DESIGN All youth with a diagnosis of DSD (n = 1216) or CAH (n = 1647) and at least 1 outpatient encounter were extracted from the PEDSnet database and propensity-score matched on 8 variables (1:4) with controls (n = 4864 and 6588, respectively) using multivariable logistic regression. The likelihood of having behavioral health diagnoses was examined using generalized estimating equations. RESULTS Youth with DSD had higher odds of a behavioral health diagnosis (OR, 1.7; 95% CI, 1.4-2.1; P < .0001) and neurodevelopmental diagnosis (OR, 1.7; 95% CI, 1.4, 2.0; P < .0001) compared with matched controls. Youth with CAH did not have an increased odds of a behavioral health diagnosis (OR, 1.0; 95% CI, 0.9, 1.1; P = .9) compared with matched controls but did have higher odds of developmental delay (OR, 1.8; 95% CI, 1.4, 2.4; P < .0001). CONCLUSIONS Youth with DSD diagnosis have higher odds of a behavioral health or neurodevelopmental diagnosis compared with matched controls. Youth with CAH have higher odds of developmental delay, highlighting the need for screening in both groups.
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Affiliation(s)
- Rachel Sewell
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Cindy L Buchanan
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Shanlee Davis
- Division of Endocrinology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Dimitri A Christakis
- Seattle Children's Research Institute, Center for Child Health, Behavior & Development, Seattle, WA
| | | | - Anna Furniss
- University of Colorado Anschutz Medical Campus, Adult & Child Consortium for Health Outcomes Research & Delivery, Aurora, CO
| | - Anne E Kazak
- Nemours Children's Health, Department of Pediatrics, Center for Healthcare Delivery Science and Thomas Jefferson University, Wilmington, DE
| | - Anna J Kerlek
- Department of Psychiatry and Behavioral Health, Nationwide Children's Hospital, Columbus, OH
| | - Brianna Magnusen
- Nationwide Children's Hospital, Institute for Informatics, Columbus, OH
| | - Nathan M Pajor
- Cincinnati Children's Hospital Medical Center, Division of Pulmonary Medicine and University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, OH
| | - Laura Pyle
- Division of Endocrinology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Louise C Pyle
- Division of Human Genetics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hanieh Razzaghi
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Beth I Schwartz
- Nemours Children's Health, Department of Pediatrics and Thomas Jefferson University, Department of Obstetrics and Gynecology, Wilmington, DE
| | - Maria G Vogiatzi
- Division of Endocrinology and Diabetes, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Natalie J Nokoff
- Division of Endocrinology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO.
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Jacobson JD, Willig LK, Gatti J, Strickland J, Egan A, Saunders C, Farrow E, Heckert LL. High Molecular Diagnosis Rate in Undermasculinized Males with Differences in Sex Development Using a Stepwise Approach. Endocrinology 2020; 161:5721303. [PMID: 32010941 DOI: 10.1210/endocr/bqz015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 10/31/2019] [Indexed: 12/11/2022]
Abstract
Differences of sex development (DSDs) are a constellation of conditions that result in genital ambiguity or complete sex reversal. Although determining the underlying genetic variants can affect clinical management, fewer than half of undermasculinized males ever receive molecular diagnoses. Next-generation sequencing (NGS) technology has improved diagnostic capabilities in several other diseases, and a few small studies suggest that it may improve molecular diagnostic capabilities in DSDs. However, the overall diagnostic rate that can be achieved with NGS for larger groups of patients with DSDs remains unknown. In this study, we aimed to implement a tiered approach to genetic testing in undermasculinized males seen in an interdisciplinary DSD clinic to increase the molecular diagnosis rate in this group. We determined the diagnosis rate in patients undergoing all clinically available testing. Patients underwent a stepwise approach to testing beginning with a karyotype and progressing through individual gene testing, microarray, panel testing, and then to whole-exome sequencing (WES) if no molecular cause was found. Deletion/duplication studies were also done if deletions were suspected. Sixty undermasculinized male participants were seen in an interdisciplinary DSD clinic from 2008 to 2016. Overall, 37/60 (62%) of patients with Y chromosomes and 46% of those who were 46XY received molecular diagnoses. Of the 46,XY patients who underwent all available genetic testing, 18/28 (64%) achieved molecular diagnoses. This study suggests that the addition of WES testing can result in a higher rate of molecular diagnoses compared to genetic panel testing.
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Affiliation(s)
- Jill D Jacobson
- Division of Endocrinology and Diabetes, Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Laurel K Willig
- Division of Nephrology, Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- Center for Pediatric Genomic Medicine Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - John Gatti
- Division of Urology, Department of Surgery, Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Julie Strickland
- Division of Pediatric and Adolescent Gynecology, Department of Surgery, Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Anna Egan
- Developmental and Behavioral Sciences, Department of Pediatrics, Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Carol Saunders
- Center for Pediatric Genomic Medicine Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Emily Farrow
- Center for Pediatric Genomic Medicine Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Leslie L Heckert
- Department of Molecular and Integrative Physiology, University of Kansas School of Medicine, Kansas City, Kansas
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Ohlsson Gotby V, Söder O, Frisén L, Serlachius E, Bölte S, Almqvist C, Larsson H, Lichtenstein P, Tammimies K. Hypogonadotrophic hypogonadism, delayed puberty and risk for neurodevelopmental disorders. J Neuroendocrinol 2019; 31:e12803. [PMID: 31630461 DOI: 10.1111/jne.12803] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 08/31/2019] [Accepted: 10/18/2019] [Indexed: 12/29/2022]
Abstract
Hypogonadotrophic hypogonadism (HH) is a rare disorder that manifests absent puberty and infertility. Genetic syndromes with hypogonadism, such as Klinefelter syndrome, are associated with an increased risk of neurodevelopmental disorders (NDDs). However, it is not clear whether patients with HH or transient delayed puberty in general, have an increased risk of NDDs. We performed a register-based study on a national cohort of 264 patients with HH and 7447 patients diagnosed with delayed puberty that was matched with 2640 and 74 470 controls, respectively. The outcome was defined as having any of the following NDD diagnoses: (i) autism spectrum disorder (ASD); (ii) attention deficit hyperactivity disorder (ADHD); or (iii) intellectual disability (ID). Additional sensitivity analyses were performed to control for different parental and birth variables, as well as diagnosed malformation syndromes and chromosomal anomalies (ie, Down's and Turner syndromes). Patients with HH had increased risk for being diagnosed with ASD (odds ratio [OR] = 5.7; 95% confidence interval [CI] = 2.6-12.6), ADHD (OR = 3.0; 95% CI = 1.8-5.1) and ID (OR = 18.0; 95% CI = 8.9-36.3) compared to controls. Patients with delayed puberty also had a significantly increased risk of being diagnosed with an NDD. These associations remained significant after adjustments. This is the first study to demonstrate a significant association between HH, delayed puberty and NDDs in a population-based cohort. Clinicians should be aware of the overlap between these disorders. Further studies should explore the mechanisms behind these associations.
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Affiliation(s)
- Vide Ohlsson Gotby
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Olle Söder
- Division of Pediatric Endocrinology, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Louise Frisén
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutete, Stockholm, Sweden
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Eva Serlachius
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutete, Stockholm, Sweden
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Sven Bölte
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
- Division of Neuropsychiatry, Department of Women's and Children's Health, Center of Neurodevelopmental Disorders at Karolinska Institutet (KIND), Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Kristiina Tammimies
- Division of Neuropsychiatry, Department of Women's and Children's Health, Center of Neurodevelopmental Disorders at Karolinska Institutet (KIND), Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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Nixon R, Cerqueira V, Kyriakou A, Lucas-Herald A, McNeilly J, McMillan M, Purvis AI, Tobias ES, McGowan R, Ahmed SF. Prevalence of endocrine and genetic abnormalities in boys evaluated systematically for a disorder of sex development. Hum Reprod 2018; 32:2130-2137. [PMID: 28938747 PMCID: PMC5850224 DOI: 10.1093/humrep/dex280] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Indexed: 12/31/2022] Open
Abstract
STUDY QUESTION What is the likelihood of identifying genetic or endocrine abnormalities in a group of boys with 46, XY who present to a specialist clinic with a suspected disorder of sex development (DSD)? SUMMARY ANSWER An endocrine abnormality of the gonadal axis may be present in a quarter of cases and copy number variants (CNVs) or single gene variants may be present in about half of the cases. WHAT IS KNOWN ALREADY Evaluation of 46, XY DSD requires a combination of endocrine and genetic tests but the prevalence of these abnormalities in a sufficiently large group of boys presenting to one specialist multidisciplinary service is unclear. STUDY, DESIGN, SIZE, DURATION This study was a retrospective review of investigations performed on 122 boys. PARTICIPANTS/MATERIALS, SETTING, METHODS All boys who attended the Glasgow DSD clinic, between 2010 and 2015 were included in the study. The median external masculinization score (EMS) of this group was 9 (range 1-11). Details of phenotype, endocrine and genetic investigations were obtained from case records. MAIN RESULTS AND THE ROLE OF CHANCE An endocrine abnormality of gonadal function was present in 28 (23%) with a median EMS of 8.3 (1-10.5) whilst the median EMS of boys with normal endocrine investigations was 9 (1.5-11) (P = 0.03). Endocrine abnormalities included a disorder of gonadal development in 19 (16%), LH deficiency in 5 (4%) and a disorder of androgen synthesis in 4 (3%) boys. Of 43 cases who had array-comparative genomic hybridization (array-CGH), CNVs were reported in 13 (30%) with a median EMS of 8.5 (1.5-11). Candidate gene analysis using a limited seven-gene panel in 64 boys identified variants in 9 (14%) with a median EMS of 8 (1-9). Of the 21 boys with a genetic abnormality, 11 (52%) had normal endocrine investigations. LIMITATIONS, REASONS FOR CAUTION A selection bias for performing array-CGH in cases with multiple congenital malformations may have led to a high yield of CNVs. It is also possible that the yield of single gene variants may have been higher than reported if the investigators had used a more extended gene panel. WIDER IMPLICATIONS OF THE FINDINGS The lack of a clear association between the extent of under-masculinization and presence of endocrine and genetic abnormalities suggests a role for parallel endocrine and genetic investigations in cases of suspected XY DSD. STUDY FUNDING/COMPETING INTEREST(S) RN was supported by the James Paterson Bursary and the Glasgow Children's Hospital Charity Summer Scholarship. SFA, RM and EST are supported by a Scottish Executive Health Department grant 74250/1 for the Scottish Genomes Partnership. EST is also supported by MRC/EPSRC Molecular Pathology Node and Wellcome Trust ISSF funding. There are no conflicts of interest. TRIAL REGISTRATION NUMBER None.
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Affiliation(s)
- R Nixon
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Office Block, 1345 Govan Road, Glasgow G51 4TF, UK
| | - V Cerqueira
- West of Scotland Clinical Genetics Service, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
| | - A Kyriakou
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Office Block, 1345 Govan Road, Glasgow G51 4TF, UK
| | - A Lucas-Herald
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Office Block, 1345 Govan Road, Glasgow G51 4TF, UK
| | - J McNeilly
- Biochemistry Department, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
| | - M McMillan
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Office Block, 1345 Govan Road, Glasgow G51 4TF, UK
| | - A I Purvis
- West of Scotland Clinical Genetics Service, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
| | - E S Tobias
- West of Scotland Clinical Genetics Service, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK.,Academic Medical Genetics and Pathology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
| | - R McGowan
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Office Block, 1345 Govan Road, Glasgow G51 4TF, UK.,West of Scotland Clinical Genetics Service, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
| | - S F Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Office Block, 1345 Govan Road, Glasgow G51 4TF, UK
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