3
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Palencia-Campos A, Aoto PC, Machal EMF, Rivera-Barahona A, Soto-Bielicka P, Bertinetti D, Baker B, Vu L, Piceci-Sparascio F, Torrente I, Boudin E, Peeters S, Van Hul W, Huber C, Bonneau D, Hildebrand MS, Coleman M, Bahlo M, Bennett MF, Schneider AL, Scheffer IE, Kibæk M, Kristiansen BS, Issa MY, Mehrez MI, Ismail S, Tenorio J, Li G, Skålhegg BS, Otaify GA, Temtamy S, Aglan M, Jønch AE, De Luca A, Mortier G, Cormier-Daire V, Ziegler A, Wallis M, Lapunzina P, Herberg FW, Taylor SS, Ruiz-Perez VL. Germline and Mosaic Variants in PRKACA and PRKACB Cause a Multiple Congenital Malformation Syndrome. Am J Hum Genet 2020; 107:977-988. [PMID: 33058759 DOI: 10.1016/j.ajhg.2020.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 04/28/2020] [Accepted: 09/09/2020] [Indexed: 12/19/2022] Open
Abstract
PRKACA and PRKACB code for two catalytic subunits (Cα and Cβ) of cAMP-dependent protein kinase (PKA), a pleiotropic holoenzyme that regulates numerous fundamental biological processes such as metabolism, development, memory, and immune response. We report seven unrelated individuals presenting with a multiple congenital malformation syndrome in whom we identified heterozygous germline or mosaic missense variants in PRKACA or PRKACB. Three affected individuals were found with the same PRKACA variant, and the other four had different PRKACB mutations. In most cases, the mutations arose de novo, and two individuals had offspring with the same condition. Nearly all affected individuals and their affected offspring shared an atrioventricular septal defect or a common atrium along with postaxial polydactyly. Additional features included skeletal abnormalities and ectodermal defects of variable severity in five individuals, cognitive deficit in two individuals, and various unusual tumors in one individual. We investigated the structural and functional consequences of the variants identified in PRKACA and PRKACB through the use of several computational and experimental approaches, and we found that they lead to PKA holoenzymes which are more sensitive to activation by cAMP than are the wild-type proteins. Furthermore, expression of PRKACA or PRKACB variants detected in the affected individuals inhibited hedgehog signaling in NIH 3T3 fibroblasts, thereby providing an underlying mechanism for the developmental defects observed in these cases. Our findings highlight the importance of both Cα and Cβ subunits of PKA during human development.
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Affiliation(s)
- Adrian Palencia-Campos
- Instituto de Investigaciones Biomédicas "Alberto Sols," Consejo Superior de Investigaciones Científicas (CSIC)-Universidad Autónoma de Madrid (UAM), Madrid, 28029, Spain; CIBER de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), Madrid, 28029, Spain
| | - Phillip C Aoto
- Department of Pharmacology, University of California, San Diego, 9400 Gilman Drive, La Jolla, CA 92093-0654, USA
| | - Erik M F Machal
- Institute for Biology, Department of Biochemistry, University of Kassel, Kassel, 34132, Germany
| | - Ana Rivera-Barahona
- Instituto de Investigaciones Biomédicas "Alberto Sols," Consejo Superior de Investigaciones Científicas (CSIC)-Universidad Autónoma de Madrid (UAM), Madrid, 28029, Spain; CIBER de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), Madrid, 28029, Spain
| | - Patricia Soto-Bielicka
- Instituto de Investigaciones Biomédicas "Alberto Sols," Consejo Superior de Investigaciones Científicas (CSIC)-Universidad Autónoma de Madrid (UAM), Madrid, 28029, Spain
| | - Daniela Bertinetti
- Institute for Biology, Department of Biochemistry, University of Kassel, Kassel, 34132, Germany
| | - Blaine Baker
- Department of Pharmacology, University of California, San Diego, 9400 Gilman Drive, La Jolla, CA 92093-0654, USA
| | - Lily Vu
- Department of Pharmacology, University of California, San Diego, 9400 Gilman Drive, La Jolla, CA 92093-0654, USA
| | - Francesca Piceci-Sparascio
- Medical Genetics Unit, Casa Sollievo della Sofferenza Foundation, IRCCS, San Giovanni Rotondo, 71013, Italy
| | - Isabella Torrente
- Medical Genetics Unit, Casa Sollievo della Sofferenza Foundation, IRCCS, San Giovanni Rotondo, 71013, Italy
| | - Eveline Boudin
- Department of Medical Genetics, University of Antwerp, Edegem, 2650, Belgium
| | - Silke Peeters
- Department of Medical Genetics, University of Antwerp, Edegem, 2650, Belgium
| | - Wim Van Hul
- Department of Medical Genetics, University of Antwerp, Edegem, 2650, Belgium
| | - Celine Huber
- Clinical Genetics and Reference Center for Skeletal Dysplasia, AP-HP, Necker-Enfants Malades Hospital, Paris, 75015, France; Université De Paris, INSERM UMR1163, Institut Imagine, Paris, 75015, France
| | - Dominique Bonneau
- Biochemistry and Genetics Department, Angers Hospital, Angers Cedex 9, 49933, France; UMR CNRS 6015-INSERM U1083, MitoVasc Institute, Angers University, Angers Cedex 9, 49933, France
| | - Michael S Hildebrand
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Heidelberg, 3084, Victoria, Australia; Murdoch Children's Research Institute, Parkville, 3052, Victoria, Australia
| | - Matthew Coleman
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Heidelberg, 3084, Victoria, Australia; Murdoch Children's Research Institute, Parkville, 3052, Victoria, Australia
| | - Melanie Bahlo
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, 3052, Victoria, Australia; Department of Medical Biology, University of Melbourne, Melbourne, 3010, Victoria, Australia
| | - Mark F Bennett
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Heidelberg, 3084, Victoria, Australia; Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, 3052, Victoria, Australia; Department of Medical Biology, University of Melbourne, Melbourne, 3010, Victoria, Australia
| | - Amy L Schneider
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Heidelberg, 3084, Victoria, Australia
| | - Ingrid E Scheffer
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Heidelberg, 3084, Victoria, Australia; Murdoch Children's Research Institute, Parkville, 3052, Victoria, Australia; Department of Paediatrics, University of Melbourne, Royal Children's Hospital, and Florey Institute of Neuroscience and Mental Health, Parkville, 3052, Victoria, Australia
| | - Maria Kibæk
- Children's Hospital of H.C. Andersen, Odense University Hospital, 5000 Odense, Denmark
| | - Britta S Kristiansen
- Department of Clinical Genetics, Odense University Hospital, 5000 Odense, Denmark
| | - Mahmoud Y Issa
- Department of Clinical Genetics, Division of Human Genetics and Genome Research, Center of Excellence for Human Genetics, National Research Centre, Cairo, 12622, Egypt
| | - Mennat I Mehrez
- Department of Oro-dental Genetics, Division of Human Genetics and Genome Research. Center of Excellence for Human Genetics, National Research Centre, Cairo, 12622, Egypt
| | - Samira Ismail
- Department of Clinical Genetics, Division of Human Genetics and Genome Research, Center of Excellence for Human Genetics, National Research Centre, Cairo, 12622, Egypt
| | - Jair Tenorio
- CIBER de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), Madrid, 28029, Spain; Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, Universidad Autónoma, Madrid, 28046, Spain; ITHACA, European Reference Network on Rare Congenital Malformations and Rare Intellectual Disability
| | - Gaoyang Li
- Division for Molecular Nutrition, Institute for Basic Medical Sciences, University of Oslo, Oslo, 0316, Norway
| | - Bjørn Steen Skålhegg
- Division for Molecular Nutrition, Institute for Basic Medical Sciences, University of Oslo, Oslo, 0316, Norway
| | - Ghada A Otaify
- Department of Clinical Genetics, Division of Human Genetics and Genome Research, Center of Excellence for Human Genetics, National Research Centre, Cairo, 12622, Egypt
| | - Samia Temtamy
- Department of Clinical Genetics, Division of Human Genetics and Genome Research, Center of Excellence for Human Genetics, National Research Centre, Cairo, 12622, Egypt
| | - Mona Aglan
- Department of Clinical Genetics, Division of Human Genetics and Genome Research, Center of Excellence for Human Genetics, National Research Centre, Cairo, 12622, Egypt
| | - Aia E Jønch
- Department of Clinical Genetics, Odense University Hospital, 5000 Odense, Denmark
| | - Alessandro De Luca
- Medical Genetics Unit, Casa Sollievo della Sofferenza Foundation, IRCCS, San Giovanni Rotondo, 71013, Italy
| | - Geert Mortier
- Department of Medical Genetics, University of Antwerp, Edegem, 2650, Belgium; Antwerp University Hospital, Edegem, 2650, Belgium
| | - Valérie Cormier-Daire
- Clinical Genetics and Reference Center for Skeletal Dysplasia, AP-HP, Necker-Enfants Malades Hospital, Paris, 75015, France; Université De Paris, INSERM UMR1163, Institut Imagine, Paris, 75015, France
| | - Alban Ziegler
- Biochemistry and Genetics Department, Angers Hospital, Angers Cedex 9, 49933, France; UMR CNRS 6015-INSERM U1083, MitoVasc Institute, Angers University, Angers Cedex 9, 49933, France
| | - Mathew Wallis
- School of Medicine and Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, 7001, Australia; Clinical Genetics Service, Austin Health, Heidelberg, 3084, Victoria, Australia
| | - Pablo Lapunzina
- CIBER de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), Madrid, 28029, Spain; Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, Universidad Autónoma, Madrid, 28046, Spain; ITHACA, European Reference Network on Rare Congenital Malformations and Rare Intellectual Disability
| | - Friedrich W Herberg
- Institute for Biology, Department of Biochemistry, University of Kassel, Kassel, 34132, Germany
| | - Susan S Taylor
- Department of Pharmacology, University of California, San Diego, 9400 Gilman Drive, La Jolla, CA 92093-0654, USA; Department of Chemistry and Biochemistry, University of California, San Diego, 9400 Gilman Drive, La Jolla, CA 92093-0654, USA
| | - Victor L Ruiz-Perez
- Instituto de Investigaciones Biomédicas "Alberto Sols," Consejo Superior de Investigaciones Científicas (CSIC)-Universidad Autónoma de Madrid (UAM), Madrid, 28029, Spain; CIBER de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), Madrid, 28029, Spain; Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, Universidad Autónoma, Madrid, 28046, Spain; ITHACA, European Reference Network on Rare Congenital Malformations and Rare Intellectual Disability.
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4
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Piceci-Sparascio F, Palencia-Campos A, Soto-Bielicka P, D'Anzi A, Guida V, Rosati J, Caparros-Martin JA, Torrente I, D'Asdia MC, Versacci P, Briuglia S, Lapunzina P, Tartaglia M, Marino B, Digilio MC, Ruiz-Perez VL, De Luca A. Common atrium/atrioventricular canal defect and postaxial polydactyly: A mild clinical subtype of Ellis-van Creveld syndrome caused by hypomorphic mutations in the EVC gene. Hum Mutat 2020; 41:2087-2093. [PMID: 32906221 DOI: 10.1002/humu.24112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/04/2020] [Accepted: 09/06/2020] [Indexed: 11/08/2022]
Abstract
Clinical expression of Ellis-van Creveld syndrome (EvC) is variable and mild phenotypes have been described, including patients with mostly cardiac and limb involvement. Whether these cases are part of the EvC phenotypic spectrum or separate conditions is disputed. Herein, we describe a family with vertical transmission of atrioventricular canal defect (AVCD), common atrium, and postaxial polydactyly. Targeted sequencing of EVC, EVC2, WDR35, DYNC2LI1, and DYNC2H1 identified different compound heterozygosity in EVC genotypes in the two affected members, consisting of a nonsense (p.Arg622Ter) and a missense (p.Arg663Pro) variant in the father, and the same nonsense variant and a noncanonical splice-site in-frame change (c.1316-7A>G) in the daughter. Complementary DNA sequencing, immunoblot, and immunofluorescence experiments using patient-derived fibroblasts and Evc-/- mouse embryonic fibroblasts showed that p.Arg622Ter is a loss-of-function mutation, whereas p.Arg663Pro and the splice-site change c.1316-7A>G are hypomorphic variants resulting in proteins that retain, in part, the ability to complex with EVC2. Our molecular and functional data demonstrate that at least in some cases the condition characterized as "common atrium/AVCD with postaxial polydactyly" is a mild form of EvC due to hypomorphic EVC mutations, further supporting the occurrence of genotype-phenotype correlations in this syndrome.
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Affiliation(s)
- Francesca Piceci-Sparascio
- Medical Genetics Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy.,Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Adrian Palencia-Campos
- Instituto de Investigaciones Biomédicas de Madrid, Consejo Superior de Investigaciones Científicas-Universidad Autónoma de Madrid, Madrid, Spain.,CIBER de enfermedades Raras (CIBERER), Insitituto de Salud Carlos III, Madrid, Spain
| | - Patricia Soto-Bielicka
- Instituto de Investigaciones Biomédicas de Madrid, Consejo Superior de Investigaciones Científicas-Universidad Autónoma de Madrid, Madrid, Spain
| | - Angela D'Anzi
- Cellular Reprogramming Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Valentina Guida
- Medical Genetics Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Jessica Rosati
- Cellular Reprogramming Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Jose A Caparros-Martin
- Instituto de Investigaciones Biomédicas de Madrid, Consejo Superior de Investigaciones Científicas-Universidad Autónoma de Madrid, Madrid, Spain.,CIBER de enfermedades Raras (CIBERER), Insitituto de Salud Carlos III, Madrid, Spain
| | - Isabella Torrente
- Medical Genetics Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - M Cecilia D'Asdia
- Medical Genetics Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Paolo Versacci
- Department of Pediatrics, Università Sapienza, Rome, Italy
| | - Silvana Briuglia
- Department of Human Pathology of Adult and Childhood "Gaetano Barresi", Unit of Emergency Pediatrics, University of Messina, Messina, Italy
| | - Pablo Lapunzina
- CIBER de enfermedades Raras (CIBERER), Insitituto de Salud Carlos III, Madrid, Spain.,Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZm Hospital Universitario La Paz, Universidad Autónoma, Madrid, Spain
| | - Marco Tartaglia
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Bruno Marino
- Department of Pediatrics, Università Sapienza, Rome, Italy
| | - M Cristina Digilio
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Victor L Ruiz-Perez
- Instituto de Investigaciones Biomédicas de Madrid, Consejo Superior de Investigaciones Científicas-Universidad Autónoma de Madrid, Madrid, Spain.,CIBER de enfermedades Raras (CIBERER), Insitituto de Salud Carlos III, Madrid, Spain.,Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZm Hospital Universitario La Paz, Universidad Autónoma, Madrid, Spain
| | - Alessandro De Luca
- Medical Genetics Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
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5
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Palencia-Campos A, Martínez-Fernández ML, Altunoglu U, Soto-Bielicka P, Torres A, Marín P, Aller E, Şentürk L, Berköz Ö, Yıldıran M, Kayserili H, Gil-Camarero E, Colli-Lista G, Sanchís-Calvo A, Carretero A, Guillén-Navarro E, López-González V, Ballesta-Martínez M, Rosell J, Aglan MS, Temtamy S, Otaify GA, Cuevas-Catalina L, Torres-Saavedra MN, Nevado J, Tenorio J, Lapunzina P, Bermejo-Sánchez E, Ruiz-Pérez VL. Heterozygous pathogenic variants in GLI1 are a common finding in isolated postaxial polydactyly A/B. Hum Mutat 2019; 41:265-276. [PMID: 31549748 DOI: 10.1002/humu.23921] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/24/2019] [Accepted: 09/17/2019] [Indexed: 12/14/2022]
Abstract
Postaxial polydactyly (PAP) is a frequent limb malformation consisting in the duplication of the fifth digit of the hand or foot. Morphologically, this condition is divided into type A and B, with PAP-B corresponding to a more rudimentary extra-digit. Recently, biallelic truncating variants in the transcription factor GLI1 were reported to be associated with a recessive disorder, which in addition to PAP-A, may include syndromic features. Moreover, two heterozygous subjects carrying only one inactive copy of GLI1 were also identified with PAP. Herein, we aimed to determine the level of involvement of GLI1 in isolated PAP, a condition previously established to be autosomal dominantly inherited with incomplete penetrance. We analyzed the coding region of GLI1 in 95 independent probands with nonsyndromic PAP and found 11.57% of these subjects with single heterozygous pathogenic variants in this gene. The detected variants lead to premature termination codons or result in amino acid changes in the DNA-binding domain of GLI1 that diminish its transactivation activity. Family segregation analysis of these variants was consistent with dominant inheritance with incomplete penetrance. We conclude that heterozygous changes in GLI1 underlie a significant proportion of sporadic or familial cases of isolated PAP-A/B.
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Affiliation(s)
- Adrián Palencia-Campos
- Instituto de Investigaciones Biomédicas "Alberto Sols", CSIC-UAM, Madrid, Spain.,CIBER de Enfermedades Raras (CIBERER), Institute of Health Carlos III, Spain
| | - María-Luisa Martínez-Fernández
- ECEMC (Spanish Collaborative Study of Congenital Malformations), Research Unit on Congenital Anomalies, Institute of Health Carlos III, Madrid, Spain
| | - Umut Altunoglu
- Medical Genetics Department, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | | | - Antonio Torres
- Paediatric Unit, Hospital San Juan de La Cruz, Úbeda, Spain
| | - Purificación Marín
- Dysmorphology and Neonatology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Elena Aller
- CIBER de Enfermedades Raras (CIBERER), Institute of Health Carlos III, Spain.,Genetic Unit, Hospital La Fe, Valencia, Spain
| | - Leyli Şentürk
- Medical Genetics Department, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ömer Berköz
- Department of Reconstructive and aesthetic Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Mehmet Yıldıran
- Department of Reconstructive and aesthetic Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Hülya Kayserili
- Medical Genetics Department, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.,Medical Genetics Department, Koç University School of Medicine, Istanbul, Turkey
| | | | | | | | - Alba Carretero
- Instituto de Investigaciones Biomédicas "Alberto Sols", CSIC-UAM, Madrid, Spain
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- Paediatric Units from different hospitals, all part of ECEMC (Spanish Collaborative Study of Congenital Malformations) Clinical Network, Spain
| | - Encarna Guillén-Navarro
- CIBER de Enfermedades Raras (CIBERER), Institute of Health Carlos III, Spain.,Genetic Medicine Unit, Paediatric Unit, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain
| | - Vanesa López-González
- CIBER de Enfermedades Raras (CIBERER), Institute of Health Carlos III, Spain.,Genetic Medicine Unit, Paediatric Unit, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain
| | - María Ballesta-Martínez
- CIBER de Enfermedades Raras (CIBERER), Institute of Health Carlos III, Spain.,Genetic Medicine Unit, Paediatric Unit, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain
| | - Jordi Rosell
- CIBER de Enfermedades Raras (CIBERER), Institute of Health Carlos III, Spain.,Genetic Unit, Hospital Son Espases, Palma de Mallorca, Spain
| | - Mona S Aglan
- Department of Clinical Genetics, Human Genetics and Genome Research Division, Centre of Excellence of Human Genetics, National Research Centre, Cairo, Egypt
| | - Samia Temtamy
- Department of Clinical Genetics, Human Genetics and Genome Research Division, Centre of Excellence of Human Genetics, National Research Centre, Cairo, Egypt
| | - Ghada A Otaify
- Department of Clinical Genetics, Human Genetics and Genome Research Division, Centre of Excellence of Human Genetics, National Research Centre, Cairo, Egypt
| | - Lourdes Cuevas-Catalina
- ECEMC (Spanish Collaborative Study of Congenital Malformations), Research Unit on Congenital Anomalies, Institute of Health Carlos III, Madrid, Spain
| | - María-Nieves Torres-Saavedra
- ECEMC (Spanish Collaborative Study of Congenital Malformations), Research Unit on Congenital Anomalies, Institute of Health Carlos III, Madrid, Spain.,CS Federica Montseny, Unidad Asistencial Sureste, Madrid, Spain
| | - Julian Nevado
- Institute of Medical and Molecular Genetics (INGEMM)-IdiPAZ, Hospital Universitario La Paz-UAM, Madrid, Spain
| | - Jair Tenorio
- CIBER de Enfermedades Raras (CIBERER), Institute of Health Carlos III, Spain.,Institute of Medical and Molecular Genetics (INGEMM)-IdiPAZ, Hospital Universitario La Paz-UAM, Madrid, Spain
| | - Pablo Lapunzina
- CIBER de Enfermedades Raras (CIBERER), Institute of Health Carlos III, Spain.,Institute of Medical and Molecular Genetics (INGEMM)-IdiPAZ, Hospital Universitario La Paz-UAM, Madrid, Spain
| | - Eva Bermejo-Sánchez
- ECEMC (Spanish Collaborative Study of Congenital Malformations), Research Unit on Congenital Anomalies, Institute of Health Carlos III, Madrid, Spain.,Institute of Rare Diseases Research (IIER), Institute of Health Carlos III, Madrid, Spain
| | - Víctor L Ruiz-Pérez
- Instituto de Investigaciones Biomédicas "Alberto Sols", CSIC-UAM, Madrid, Spain.,CIBER de Enfermedades Raras (CIBERER), Institute of Health Carlos III, Spain
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