From the conception of the PRINS to its coronation Régen DROUIN, Geneticist MD, PhD, FACMG, FCCMG Department of Medical Genetics, CHUS & Department de Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Cytogenetics: - Chromosome Cytogenetics - Interphase Cytogenetics - Conventional Cytogenetics - Molecular Cytogenetics Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Molecular Cytogenetic Techniques available: - FISH (Fluorescence In Situ Hybridization) & variants: Q-FISH, express FISH, etc. - PRINS (PRimed IN Situ labeling) - M-FISH (Multicolor-FISH) or SKY (spectral Karyotype) - Band-FISH - CGH (Comparative Genomic Hybridization) Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada PRINS PRimed IN Situ labeling Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada PRINS: Beginning PRINS technique was introduced in 1989 by Koch & al.Dept of Cytogenetics, Société Danoise du CancerAarhus, Danemark Ref. Koch J, Kolvraa S, Petersen K, Gregersen N, Bolund L, Oligonucleotide-priming methods for the chromosomespecific labelling of alpha satellite DNA In Situ.Chromosoma 1989;98:259-65 Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada PRINS: HISTORY Method described 15 years ago, that was applied to respond to questions regarding the structure of the minute chromosomes in the primate -satellite DNA sequence. Development and Applications of PRINS (many variants of the technique have been described) There are more and more targets investigated using PRINS (many species: animals and plants) Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Multi-PRINS and Blocking step, Dual-color PRINS without blocking step New strategy for triple-color PRINS Nucleotids labeled with Bio-dUTP & Dig-dUTP Omission of blocking step Creating new color by mixing colors Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Extended section of chromosome Chromatin fiber of packed nucleosomes‘String-of-beads’ DNA double helix form of chromatin Condensed section of chromosome 10nm 700nm 30nm 300nm 1 400nm 2 nm DNA Condensation and fiberFISH A good PRINS method should have: - An extremely high specificity (extremely low background) - A good sensitivity (good hybridization efficiency) - Unambiguous recognition of the hybridization signal Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada PRINS Annealing Elongation Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada MB PRINS targets : - Metaphase Chromosomes Interphase Nuclei Fixed Tissues Cells in culture Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada METHOD Chromosome banding • Slide preparation and the thermocycler • Add Taq polymerase to the reaction solution • Put the mix solution on the slide + cover slip Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada METHOD Add Taq polymerase to the reaction solution Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada METHOD Put the mix solution on the slide + cover slip support thermocycler METHOD Detection & visualisation • Washings post-PRINS • Detection using a labeled antibody • Washing of the antibody + counterstaining • Observation under a fluorescence microscope Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Applications of the PRINS technique: - Identification of chromosomes - Aneuploidy detection - Analysis centromere DNA - Identification of markers Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Proportions (%) of nuclei carrying two signals of chromosome 8 Comparison of PRINS with FISH in the detection of interphase nuclei carrying two signals of chromosome 8 in 16 control cases 120 100 80 60 PRINS 8 FISH 8 40 20 0 1 2 3 4 5 6 7 8 9 Cases 10 11 12 13 14 15 16 Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Proportions (%) of nuclei carrying two signals of chromosome 7 Comparison of PRINS with FISH in the detection of interphase nuclei carrying two signals of chromosome 7 in 16 control cases 120 100 80 60 PRINS 7 FISH 7 40 20 0 1 2 3 4 5 6 7 8 9 Cases 10 11 12 Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada 13 14 15 16 Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada A B PRINS 7 FISH 8 PRINS 8 D FISH 7 C E Dual-PRINS 7 (red) and 8 (green) Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada F The development of molecular cytogenetics such as FISH and PRINS are especially important for the study of hematologic disorders. With these approaches, not only dividing cells, but also nondividing cells can be studied for chromosome identification. PRINS technique is a good alternative to FISH to identify chromosomes both in metaphase and in interphase nuclei. Our results showed no significant difference between these two techniques regarding detection sensitivity and specificity. PRINS is more cost-effective, easier and faster than FISH. Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada • Samples preparation: usual techniques • PRINS reaction and detection solutions for three chromosome targets: System Labeling-chromosome 1 Bio- 7 Dig- 8 Bio- 18 2 Dig- 7 Bio- 8 Dig- 18 Detection mix Avidin-fluorescein/ Anti-dig-rhodamine Anti-dig-fluorescein/ Avidin-rhodamine • Triple-PRINS programming: 1st cycle: 62.5C, 10 min with first label, wash in PBS 2 min 2nd cycle: 62.5C, 10 min with second label, wash in PBS 2 min 3rd cycle: 62.5C, 10 min with third label, wash in wash buffer 2 min • Detection, Counterstain and image analysis The results of triple-PRINS using two different labeling orders combined with two different detection systems Detection system 1a Detection system 2b Labeling order 1st signal 2nd signal 3rd signal 1. bio-dig-bio 2. dig-bio-dig Yellow Red ambiguous 1st signal 2nd signal 3rd signal Green ambiguous Yellow Red a: Mix of avidin-fluorescein/anti-dig-rhodamine; b: Mix of anti-dig-fluorescein/avidin-rhodamine. Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Green Primers Name Chromosome Sequence Reference -7 7 GCTTGAAATCTCCACCTGAAATGCCACAGC Koch et al. 1995 8c 18c 8 18 CTATCAATAGAAATGTTCAGCACAGTT ATGTGTGTCCTCAACTAAAG Pellestor et al. 1996 Pellestor et al. 1995 Xc X GTTCAGCTCTGTGAGTGAAA Pellestor et al. 1995 D599 D600 Y Y TGGGCTGGAATGGAAAGGAATCGAAAC TCCATTCGATTCCATTTTTTTCGAGAA Speel et al. 1995 Speel et al. 1995 Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada A: bio-dig-bio labeling order with detection system 1 The first PRINS reaction 3’ 5’ The second PRINS reaction 3’ 5’ 3’ 5’ The third PRINS reaction 3’ 5’ 3’ 3’ 3’ 5’ : Chromosome DNA; : The first primer; : dNTP; The second PRINS site on chromosome 8 The first PRINS site on chromosome 7 The third PRINS site on chromosome 18 5’ The second PRINS site on chromosome 8 5’ The first PRINS site on chromosome 7 : Biotin-dUTP; : The second primer; The first PRINS site on chromosome 7 : Digoxigenin-dUTP; : The third primer; B: dig-bio-dig labeling order with detection system 2 The first PRINS reaction 3’ 5’ The first PRINS site on chromosome 7 5’ The second PRINS site on chromosome 8 5’ The first PRINS site on chromosome 7 The second PRINS reaction 3’ 3’ The third PRINS reaction 3’ 5’ 3’ 3’ 3’ 5’ : Chromosome DNA; : The first primer; : dNTP; 5’ The second PRINS site on chromosome 8 5’ The first PRINS site on chromosome 7 : Biotin-dUTP; : The second primer; The third PRINS site on chromosome 18 : Digoxigenin-dUTP; : The third primer. bio-dig-bio labeling, avidin-fluorescein/ Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada anti-dig-rhodamin detection bio-dig-bio labeling, avidin-fluorescein/ anti-dig-rhodamin detection bio-dig-bio labeling, avidin-fluorescein/ Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada anti-dig-rhodamin detection dig-bio-dig labeling, anti-dig-fluorescein/Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada avidin-rhodamin detection Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada XY normal QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. <==Multi-PRINS QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. FISH==> 47,XX,+18 QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. <==Multi-PRINS QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. FISH==> Main advantages of the PRINS technique: Semi-automated Protocole because of the use of thermocycler Simple, reproducible and reliable method Very good ratio cost benefit Short duration of the reaction (on the average) Availability of any primers (automatic synthesizer) The specificity and small size of the primers (18 à 35 mer) does not generate cross reaction Specificity of centromeric sequences of chromosomes 13 and 21 More efficient in some cells with more condensed nuclei: the size of primer is much smaller than the size of the probe thus making it easier to pass the nuclear membrane and hybridize to the target DNA Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Main advantages of the PRINS technique: Detection of unique intragenic sequences Very low background because of the absence of labeling directly on the primer and the rapidity of the reaction Good preservation of the integrity of the chromosome structure due to the short incubation time Multi-target detection: it is very easy to do multi-color PRINS or combine with FISH to simultaneously detect different chromosomes in the same cells. Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada CONCLUSIONS Technique PRINS Powerful technique, simple and universal Represents a very good alternative to FISH Future Perspectives Detection of fusion genes Detection of female foetal cells using the technique of PRINS-RNA Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Applications of the FISH and PRINS techniques: - Identification of chromosomes - Détection of aneuploïdies - Analysis of centromeric DNA - Identification of marker chromosomes Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada A good PRINS method should have: - An extremely high specificity (extremely low background) - A good sensitivity (good hybridization efficiency) - Unambiguous recognition of the hybridization signal Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Same nucleus in both panels is shown with the opposite colours Simultaneous FISH analysis using sex chromosome Simultaneous reverse FISH analysis using specific probes: the red signal correspond to the sex chromosome specific probes: the red X chromosome and the blue signal to the Y signal correspond to the Y chromosome and chromosome the blue signal to the X chromosome FISH technique (LSI-21 probe) combined to PRINS reaction (Y primer sequence) Male fetal cell with 3 copies of Chromosome 21 (red signals) and 1 copy of the Y chromosome (green signal) PRINS technique Qu ickTi me ™ a nd a TIFF (Un co mpre ssed ) d eco mp re ssor are n ee de d to se e thi s pi cture . Male fetal cell with trisomy 18 Fetal cell with trisomy 18 detected by PRINS technique Fetal triploid cell detected by PRINS technique using centromeric PRINS (primer oligonucleotide centromeric oligonucleotide primer specific 8 to the chromosome 7Fetal (the cell nucleus with with triploidy three red signals) PRINS technique Triploidic fetal cell with 3 copies of chromosome 7 FETAL CELLS PROJECT: QUANTIFICATION OF ALL F ETAL NUCLEATED CELLS FROM PERIPHERAL BLOOD OF PREGNANT WOMEN BEARING ANEUPLOID CONCEPTUS USING MOLECULAR CYTOGENETIC TECHNIQUES (FISH AND PRINS TECHNIQUES) Table II: Clinical data of the patients and the number of fetal cells per mL of maternal blood in 12 cases of male trisomy 21 Patient No. Number Number Pare ntal Grav idity Indi cation for Week of Parity Family history of of fetal age amniocentesis* gestation slides/ml cells/ml Abortion Mat. Pat. 1 42 41 G4P1A2 AMA Hypo thyroidy 18 3/7 42 32 2 32 35 G3P1A1 Antecedents T21 / S B 18 42 24 3 34 32 G2P0A1 Antecedents Cardiac defects 19 45 11 4 26 27 G2P1A0 NT Pyloric steno sis 17 3/7 31 8 5 36 39 G5P3A1 AMA 47,XXY 19 4/7 27 10 6 37 41 G3P2A0 AMA / NT C. V. Pb 21 31 14 7 35 32 G5 P4A0 AMA 18 2/7 24 10 8 42 43 G5P2A2 AMA Nil 15 4/7 25 11 9 39 34 G1P0A0 AMA SB / Others 20 20 8 10 40 37 G4P1A2 AMA Diabetes / Cance r 17 1/2 27 6 11 38 36 G2P1A0 AMA Thyroiditis / Cri du chat 13 19 9 AVC / Hypercholeste rol. Paternal 20 7 18 Ysat Legend: *AMA: Advanced maternal age; AVC: Atrio Ventricular Canal; CV pb: Cardio Vascular Problem ; CPC: Choroid Plexus Cyst; NT: Nuchal translus cency; SB: Spina Bifida. 12 26 33 G1P0A0 NT Table III: Clinical data of the patients and the number of fetal cells per mL of maternal blood in 7 cases of male trisomy 18 Parental age Gravidity Indication for Parity amniocentesis* Abortion Family history Mat. Pat. 41 ? G3P0A2 AMA / IUGR + Multi ple Defects Nil 38 33 G2P1A0 AMA / IUGR Cardiac Defects 26 24 G1P0A0 Nil 28 29 G2P0A1 30 31 40 38 Week of gestation Number Number of of fetal slides/ml cells/ml 3/7 26 11 17 23 20 Nil 21 3/7 26 7 Cystic Hyg roma Crohn disease/ Diabetes 18 25 4 G2 P1A0 Omphalocele/ strawberry-like head Nil 17 2/7 18 12 ? G3 P1A1 AMA Nil 17 6/7 20 4 ? G1P0A0 AMA / TT + / Cardiac malformations Twin pregn + Multiple Sclerosis 22 5/7 20 4 18 Legend: *AMA: Advanced Maternal Age; IUGR: Intra-Uterin e Growth Retardation; TT+: Triple test + Table IV: Clinical data of the patients and the number of fetal cells per mL of maternal blood in 7 different other cases of aneuploidies Different aneuploidies Parental age Gravidity Indication for Parity amniocentesis* Abortion Family history Weeks of gestation Number Number of of fetal slides/ml cells/ml Mat. Pat. 69,XXX 27 29 G2P1A0 IUGR C V pb 19 21 25 69,XXX 27 29 G1P0A0 2 ombili cal vessels Cance r + CV pb 21 5/7 20 10 47,XXX 38 35 G3P2A0 AMA Cancer 3/7 18 16 47,XXY 32 31 G3P1A1 TT= 1/146 Diabetes 20 22 19 47,XYY 38 37 G7P2A4 AMA HTA 17 26 26 46,XY,r(22) 39 38 G4 P2A1 Congenital defects mat 16qh+ pat 9 peri inv 27 39 10 47,XY,+13 161/2 ? G1P0A0 CL + CD Nil 24 20 9 Legend: *AMA: Advanced Maternal Age; CD: Cardiac Defect; CL: Cleft lip; IUGR: Intra Uterin e Growth Retardation; TT: Triple test; OPD: Oculo-Ph aryngeal Dystrophy 21 CONCLUSIONS It is possible to detect fetal cells in every pregnant woman during the pregnancy. Using molecular cytogenetic approaches, (FISH and PRINS), we showed that there were between 2 and 6 fetal cells per mL of maternal blood The low fluctuation between the 12 pregnant women we studied is likely due to personal characteristics specific to each of the women. The number of fetal cells in the maternal blood does not appear to be influenced by previous pregnancies. CONCLUSION It is possible to detect fetal cells between millions of maternal blood cells (our previous results : 2 to 6 fetal cells per mL of maternal blood, see ref.3) using molecular cytogenetic techniques (FISH et PRINS) In agreement with several reports, our preliminary results obtained with 14 pregnant women show a 5-fold higher number of fetal cells in pregnancies associated with aneuploid conceptuses (see Tables 1, 2 & 3) This finding provides an interesting perspective for the development of a safe and convenient non-invasive molecular cytogenetic prenatal diagnosis for the most common fetal chromosomal aneuploidies (13, 18, 21, X and Y). However, this procedure is time consuming and labour intensive. More studies are needed to confirm the robustness of this methodology and automation will be required before widespread application. Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Telomere Simple DNA sequence (T2AG3) tandemly repeated, of variable length, located at the extremities of the chromosomes. Telomeres are essential elements that protect the extremities of the chromosomes from degradation and ligation. Shortening Incomplete Replication Nuclease Activity Equilibrium Elongation Addition of repetitions T2AG3 by the telomerase Senescence Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Telomeres • Specialized structures made of DNA and PROTEINS • Repeated DNA sequence: 2 à 15 kb • Maintain the chromosome stability TTAGGG TTAGGG TTAGGG AATCCC AATCCC AATCCC • Around 30 to 120 bp are lost per somatic cell division • Too short : cellular senescence and genetic instability Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Measurement of telomeres Average length of telomeres : • Measurement of terminal restriction fragments. – Digestion using restriction enzymes of purified DNA – Visualization and measurements of telomeric fragments by Southern blot • Cleavage of telomeres at variable distance • No information individual telomeres Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Measurement of telomeres Length of individual telomeres : Quantitative FISH (Q-FISH) Hybridization telomeric PNA probes Measurements of the signal intensity Length Profil of individual telomeres Variation of hybridization efficiency ??? Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada The PRINS reaction PRINS Marquage par synthèse in situ amorcée Appariement The primer sequence is complementary to the telomeric sequence: (CCCTAA)7 Élongation Tissus Koch et al., 1995 Terkelsen et al., 1995 Cellules Chromosomes Fibres d’ADN Figure 3: Wrn ∆hel/ ∆hel 11-dUTP-digoxigénine Department of Medical Genetics, CHUS & Department of Pediatrics, 62.5 °C, 10 minutes Université de Sherbrooke, Sherbrooke, Quebec, Canada Le double-PRINS • To increase the efficiency of the telomere labeling using PRINS, Dr Ju Yan developed an innovative double-labeling technique : two complementary primers, (CCCTAA)7 et (TTAGGG)7, are used to label both DNA strands of the telomere sequences. : (TTAGGG)7 A A : (CCCTAA)7 C B B C Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Materials & méthods PRINS Reaction 1. The PRINS mixture is put on the slide : dNTP, labeled dUTP (biotine or digoxigenine), primers, Taq buffer & Taq polymerase 2. Hybridization and elongation : 20 minutes at 63°C, on a thermocycler. Materials & methods Double-PRINS Procedure 1. 1st PRINS reaction : primer (CCCTAA)7. 2. Brief washings (washing buffer then PBS 1x ). 3. 2nd PRINS reaction : primers (TTAGGG)7. 4. Washings (washing buffer : 5 min. at 45oC and 2 x 5 min. at room To). 5. Revelation of the signals : fluorescent antibodies. Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Materials & methods Image Analysis 40 metaphases per case, 10 for each type of signals : - green signals only - red signals only - double color signals - double green signals Analyzed using the ISIS 2 software of Metasystems Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Results 1. Comparison between simple PRINS and PNA-FISH One PRINS cycle PNA-FISH Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Results 2. Double-PRINS double color Results 3. Comparison between simple PRINS and double-PRINS Red only Green only Double color Results 4. Comparison between double-green double-PRINS & PNA-FISH Double-vert PNA-FISH Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Results Efficacité moyenne de marquage (%) 100 90 80 70 60 50 Vert Rouge Double Double PNA couleur vert Vert Rouge Double Double PNA couleur vert Marquage des chromatides bras des chromosomes Department of Medical Genetics, CHUSMarquage & Departmentdes of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Telomere signals on chromatin fibers (arrows) detected by double-green labelling using PRINS. Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada Fig. 4: Single-copy sequence detected by multi-primer PRINS technique. Locus: AL672294, 37kb on chromosome 1q subtelomere, 28 primers. Labeling: Biotin-dUTP Detection: Avidin-FITC Team of Dr Régen DROUIN Cytogenetics Molecular Genetics • Walid DRIDI Macoura GADJI Kada KRABCHI Josée LAVOIE • Sandrine LACOSTE Stéphane OUELLET Patrick ROCHETTE François VIGNEAULT • Éric BOUCHARD Marc BRONSARD • Ju YAN • Nathalie BASTIEN Mélissa FERLAND Isabelle PARADIS Department of Medical Genetics, CHUS & Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada