Genes, Recessive

基因,隐性
  • 文章类型: Journal Article
    基因SCAPER(位于内质网中的S期细胞周期蛋白A相关蛋白)的突变最近与色素性视网膜炎(RP)和智力障碍(ID)有关。2011年,由于鉴定了导致伊朗家庭ID的纯合突变,首次发现SCAPER可能参与人类疾病。稍后,2019年发表的5项研究描述了常染色体隐性综合征性视网膜色素变性(arRP)伴ID和注意力缺陷/多动障碍(ADHD)的患者.本研究描述了以色列一个阿拉伯近亲家庭的三名患者,其SCAPER综合征的临床特征相似。此外,眼部症状的新表现,眼球震颤,青光眼,和电梯麻痹,被观察到。通过全外显子组测序对患者和父母双方进行的基因检测显示SCAPER中的纯合突变c.2023-2A>G。对文献中描述的所有可用病例进行表型和基因型描述,包括我们目前的3例病例(37例),除了对所有遗传变异进行生物信息学分析。我们的研究证实并扩展了SCAPER相关疾病的临床表现。
    Mutations in the gene SCAPER (S phase Cyclin A-Associated Protein residing in the Endoplasmic Reticulum) have recently been associated with retinitis pigmentosa (RP) and intellectual disability (ID). In 2011, a possible involvement of SCAPER in human diseases was discovered for the first time due to the identification of a homozygous mutation causing ID in an Iranian family. Later, five studies were published in 2019 that described patients with autosomal recessive syndromic retinitis pigmentosa (arRP) accompanied by ID and attention-deficit/hyperactivity disorder (ADHD). This present study describes three patients from an Arab consanguineous family in Israel with similar clinical features of the SCAPER syndrome. In addition, new manifestations of ocular symptoms, nystagmus, glaucoma, and elevator palsy, were observed. Genetic testing of the patients and both parents via whole-exome sequencing revealed the homozygous mutation c.2023-2A>G in SCAPER. Phenotypic and genotypic descriptions for all available cases described in the literature including our current three cases (37 cases) were carried out, in addition to a bioinformatics analysis for all the genetic variants that was undertaken. Our study confirms and extends the clinical manifestations of SCAPER-related disorders.
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  • 文章类型: Letter
    暂无摘要。
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  • 文章类型: Journal Article
    等位基因变异的识别和分析是作物多样性研究的重要依据,性状驯化和分子标记开发。单宁含量是高粱的重要品质性状。在培育耐鸟类损害的品种或用于酿造酒的品种时,通常需要高粱谷中更高的单宁水平。非单宁生产或低单宁生产的高粱材料通常用于食品和饲料。Tan1和Tan2,两个重要的克隆基因,调节高粱单宁的生物合成,一个或两个基因的突变将导致高粱籽粒中单宁含量低或没有单宁含量。即使高粱种质含有显性的Tan1和Tan2,单宁含量也从低到高分布,并且必须有其他已知调节基因的新等位基因或新的未知基因有助于单宁的产生。
    两个父母8R306和8R191没有任何已知的Tan1和Tan2隐性等位基因,并且推测它们可能都具有显性Tan1和Tan2基因型。然而,两个亲本的表型不同;8R306有单宁,8R191有非单宁,所以这两个父母被构建为RIL种群。使用批量分离分析(BSA)来确定Tan1和Tan2的其他新等位基因或新单宁基因座。在野生高粱资源中检测到Tan1和Tan2全长序列和单宁含量,地方品种和品种。
    我们确定了两个新的隐性tan1-d和tan1-e等位基因和四个隐性Tan2等位基因,命名为tan2-d,tan2-e,tan2-f,和tan2-g。这些隐性等位基因导致Tan1和Tan2功能丧失,高粱籽粒中单宁含量低或无单宁含量。tan1-e和tan2-e的功能缺失等位基因仅在中国地方品种中发现,在世界各地种植的地方品种和品种中发现了其他等位基因。在外国地方品种中检测到tan1-a和tan1-b,中国品种和外国品种,但不是在中国的地方品种。
    这些结果表明,Tan1和Tan2隐性等位基因在世界范围内具有不同的地理分布,但并非所有的隐性等位基因都被用于育种。这些新等位基因的发现为粮食和饲料用高粱品种的选育提供了新的种质资源,并用于开发高粱低单宁或非单宁品种辅助育种的分子标记。
    UNASSIGNED: The identification and analysis of allelic variation are important bases for crop diversity research, trait domestication and molecular marker development. Grain tannin content is a very important quality trait in sorghum. Higher tannin levels in sorghum grains are usually required when breeding varieties resistant to bird damage or those used for brewing liquor. Non-tannin-producing or low-tannin-producing sorghum accessions are commonly used for food and forage. Tan1 and Tan2, two important cloned genes, regulate tannin biosynthesis in sorghum, and mutations in one or two genes will result in low or no tannin content in sorghum grains. Even if sorghum accessions contain dominant Tan1 and Tan2, the tannin contents are distributed from low to high, and there must be other new alleles of the known regulatory genes or new unknown genes contributing to tannin production.
    UNASSIGNED: The two parents 8R306 and 8R191 did not have any known recessive alleles for Tan1 and Tan2, and it was speculated that they probably both had dominant Tan1 and Tan2 genotypes. However, the phenotypes of two parents were different; 8R306 had tannins and 8R191 had non-tannins in the grains, so these two parents were constructed as a RIL population. Bulked segregant analysis (BSA) was used to determine other new alleles of Tan1 and Tan2 or new Tannin locus. Tan1 and Tan2 full-length sequences and tannin contents were detected in wild sorghum resources, landraces and cultivars.
    UNASSIGNED: We identified two novel recessive tan1-d and tan1-e alleles and four recessive Tan2 alleles, named as tan2-d, tan2-e, tan2-f, and tan2-g. These recessive alleles led to loss of function of Tan1 and Tan2, and low or no tannin content in sorghum grains. The loss-of-function alleles of tan1-e and tan2-e were only found in Chinese landraces, and other alleles were found in landraces and cultivars grown all around the world. tan1-a and tan1-b were detected in foreign landraces, Chinese cultivars and foreign cultivars, but not in Chinese landraces.
    UNASSIGNED: These results implied that Tan1 and Tan2 recessive alleles had different geographically distribution in the worldwide, but not all recessive alleles had been used in breeding. The discovery of these new alleles provided new germplasm resources for breeding sorghum cultivars for food and feed, and for developing molecular markers for low-tannin or non-tannin cultivar-assisted breeding in sorghum.
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  • 文章类型: Case Reports
    运动障碍,如运动迟缓,震颤,肌张力障碍,舞蹈病,和肌阵挛症最常见于几种神经退行性疾病,伴有基底神经节和白质受累。虽然这些疾病的病理生理学仍未完全了解,经常涉及基底神经节和相关大脑区域的功能障碍。VPS13D基因,VPS13家族的一部分,已经成为神经病理学的关键人物,涉及从运动障碍到Leigh综合征的各种表型。我们在成年女性中介绍了VPS13D相关疾病的临床病例,其中VPS13D基因有两个变异。此病例有助于我们对VPS13D相关疾病的不断发展的理解,并强调了遗传筛查在诊断和管理此类疾病中的重要性。
    Movement disorders such as bradykinesia, tremor, dystonia, chorea, and myoclonus most often arise in several neurodegenerative diseases with basal ganglia and white matter involvement. While the pathophysiology of these disorders remains incompletely understood, dysfunction of the basal ganglia and related brain regions is often implicated. The VPS13D gene, part of the VPS13 family, has emerged as a crucial player in neurological pathology, implicated in diverse phenotypes ranging from movement disorders to Leigh syndrome. We present a clinical case of VPS13D-associated disease with two variants in the VPS13D gene in an adult female. This case contributes to our evolving understanding of VPS13D-related diseases and underscores the importance of genetic screening in diagnosing and managing such conditions.
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  • 文章类型: Journal Article
    隐性营养不良性大疱性表皮松解症是由Col7a1基因突变引起的罕见遗传性皮肤病。Col7a1基因编码VII型胶原蛋白,锚定原纤维的主要成分。Col7a1基因的突变可导致VII型胶原的异常形成,导致相关的缺乏或缺乏锚定原纤维。这在临床上表现为慢性起泡,疤痕,和纤维化,经常导致皮肤鳞状细胞癌的发展。患者还经历持续性疼痛和瘙痒。疼痛管理和支持性包扎仍然是主要的治疗选择。隐性营养不良性大疱性表皮松解症的病理最早是在1980年代描述的,此后,开发了许多令人鼓舞的治疗方案。然而,体内研究受到疾病模型不足的阻碍。存在的各种小鼠模型具有寿命和表面积限制,或者没有充分模拟正常的人类疾病状态。在本文中,我们描述了一种新的隐性营养不良性大疱性表皮松解症大鼠模型,该模型为以前的小鼠模型提供了替代方法。在Lewis大鼠的Col7a1基因中诱导了8个碱基对的缺失,随后发现导致下游过早终止密码子。纯合突变体在出生后表现出脆性和慢性起泡的表型。进一步的组织学分析显示表皮下裂开,并且没有锚定原纤维。这种新型模型的产生为研究人员提供了一种易于维护的生物体,该生物体具有更大的表面积,可用于实验局部和输血疗法进行测试。这可能在未来对这种使人衰弱的疾病的研究中提供巨大的效用。
    Recessive dystrophic epidermolysis bullosa is a rare genodermatosis caused by a mutation of the Col7a1 gene. The Col7a1 gene codes for collagen type VII protein, a major component of anchoring fibrils. Mutations of the Col7a1 gene can cause aberrant collagen type VII formation, causing an associated lack or absence of anchoring fibrils. This presents clinically as chronic blistering, scarring, and fibrosis, often leading to the development of cutaneous squamous cell carcinoma. Patients also experience persistent pain and pruritus. Pain management and supportive bandaging remain the primary treatment options. The pathology of recessive dystrophic epidermolysis bullosa was first described in the 1980s, and there has since been a multitude of encouraging treatment options developed. However, in vivo research has been hindered by inadequate models of the disease. The various mouse models in existence possess longevity and surface area constraints, or do not adequately model a normal human disease state. In this paper, we describe a novel rat model of recessive dystrophic epidermolysis bullosa that offers an alternative to previous murine models. An 8-base pair deletion was induced in the Col7a1 gene of Lewis rats, which was subsequently found to cause a premature stop codon downstream. Homozygous mutants presented with a fragile and chronically blistered phenotype postnatally. Further histological analysis revealed subepidermal clefting and the absence of anchoring fibrils. The generation of this novel model offers researchers an easily maintained organism that possesses a larger surface area for experimental topical and transfused therapies to be tested, which may provide great utility in the future study of this debilitating disease.
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  • 文章类型: Journal Article
    背景:在2020年至2022年之间,内布拉斯加州牛群中的八只小牛(复合西门塔尔,红安格斯,Gelbvieh)在强迫活动中表现出运动不耐受。在某些情况下,小牛崩溃了,没有恢复。在所有受影响的小牛中,可用的父系血统包含2-4代内的父系祖先。无法获得小牛\'大坝的学位,然而,这些奶牛是牧场饲养的,并从以前的繁殖季节保留下来,用于繁殖的公牛偶尔有一个共同的祖先。因此,据推测,从头常染色体隐性变异是这些小牛运动不耐受的原因。
    结果:利用来自6只受影响的小牛和715只群马的SNP数据进行全基因组关联分析,随后对2只受影响的小牛进行全基因组测序,从而鉴定出PYGM基因中的变体(BTA29:g.42989581G>A)。变种,证实存在于骨骼肌转录组中,预测会产生过早的终止密码子(p。Arg650*)。PYGM的蛋白质产品,肌磷酸化酶,分解骨骼肌中的糖原.糖原浓度以荧光测定为葡萄糖残基,表明与携带该变体的牛和野生型对照相比,受影响的小牛中的糖原浓度显着升高。通过免疫组织化学和无标记定量蛋白质组学分析证实骨骼肌中不存在PYGM蛋白产物;在活检和尸检样品中证实肌肉变性。收获后骨骼肌糖原持续升高,导致高pH值和深色牛肉,这被消费者负面地感知,并给行业带来经济损失。该变体的携带者在肉质或任何动物健康状况方面均未表现出差异。
    结论:肌磷酸化酶缺乏症对受影响的动物带来福利问题,并对最终产品产生负面影响。隐性基因型与黑切牛肉的关联进一步证明了遗传学不仅对动物健康而且对其产品质量的重要性。尽管该变种的杂合牛可能不会立即影响牛肉产业,确定携带者将能够选择和育种策略,以防止受影响的小牛的生产。
    BACKGROUND: Between 2020 and 2022, eight calves in a Nebraska herd (composite Simmental, Red Angus, Gelbvieh) displayed exercise intolerance during forced activity. In some cases, the calves collapsed and did not recover. Available sire pedigrees contained a paternal ancestor within 2-4 generations in all affected calves. Pedigrees of the calves\' dams were unavailable, however, the cows were ranch-raised and retained from prior breeding seasons, where bulls used for breeding occasionally had a common ancestor. Therefore, it was hypothesized that a de novo autosomal recessive variant was causative of exercise intolerance in these calves.
    RESULTS: A genome-wide association analysis utilizing SNP data from 6 affected calves and 715 herd mates, followed by whole-genome sequencing of 2 affected calves led to the identification of a variant in the gene PYGM (BTA29:g.42989581G > A). The variant, confirmed to be present in the skeletal muscle transcriptome, was predicted to produce a premature stop codon (p.Arg650*). The protein product of PYGM, myophosphorylase, breaks down glycogen in skeletal muscle. Glycogen concentrations were fluorometrically assayed as glucose residues demonstrating significantly elevated glycogen concentrations in affected calves compared to cattle carrying the variant and to wild-type controls. The absence of the PYGM protein product in skeletal muscle was confirmed by immunohistochemistry and label-free quantitative proteomics analysis; muscle degeneration was confirmed in biopsy and necropsy samples. Elevated skeletal muscle glycogen persisted after harvest, resulting in a high pH and dark-cutting beef, which is negatively perceived by consumers and results in an economic loss to the industry. Carriers of the variant did not exhibit differences in meat quality or any measures of animal well-being.
    CONCLUSIONS: Myophosphorylase deficiency poses welfare concerns for affected animals and negatively impacts the final product. The association of the recessive genotype with dark-cutting beef further demonstrates the importance of genetics to not only animal health but to the quality of their product. Although cattle heterozygous for the variant may not immediately affect the beef industry, identifying carriers will enable selection and breeding strategies to prevent the production of affected calves.
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  • 文章类型: Journal Article
    常染色体隐性Nonaka远端肌病是一种罕见的常染色体隐性遗传病,其特征是远端肌肉进行性变性,导致肌肉无力和握力下降。它主要与GNE基因突变有关,其编码唾液酸生物合成的关键酶(UDP-N-乙酰葡糖胺2-差向异构酶/N-乙酰甘露糖胺激酶)。进行这项研究是为了使用全外显子组测序(WES)在6名有或没有周围神经病变的独立远端肌病患者中发现GNE突变。对突变型GNE蛋白进行计算机致病性预测和3D结构变化的模拟。因此,我们确定了五种致病性或可能的致病性错义变体:c.86T>C(p。Met29Thr),c.527A>T(p。Asp176Val),c.782T>C(p。Met261Thr),c.1714G>C(p。Val572Leu),和c.1771G>A(p。Ala591Thr)。五个受影响的个体显示出复合杂合突变,只有一名患者发现纯合突变。两名患者显示未报告的杂合突变组合。我们观察到一些特定的临床特征,如远端肌病与远端遗传性周围神经病变的复杂表型,腿部比手更早出现无力,以及具有相同复合杂合突变组的两名患者之间的临床异质性。我们对这些遗传原因的发现扩大了与GNE突变相关的临床范围,并可以帮助准备治疗策略。
    Autosomal recessive Nonaka distal myopathy is a rare autosomal recessive genetic disease characterized by progressive degeneration of the distal muscles, causing muscle weakness and decreased grip strength. It is primarily associated with mutations in the GNE gene, which encodes a key enzyme of sialic acid biosynthesis (UDP-N-acetylglucosamine 2-epimerase/N-acetylmannosamine kinase). This study was performed to find GNE mutations in six independent distal myopathy patients with or without peripheral neuropathy using whole-exome sequencing (WES). In silico pathogenic prediction and simulation of 3D structural changes were performed for the mutant GNE proteins. As a result, we identified five pathogenic or likely pathogenic missense variants: c.86T>C (p.Met29Thr), c.527A>T (p.Asp176Val), c.782T>C (p.Met261Thr), c.1714G>C (p.Val572Leu), and c.1771G>A (p.Ala591Thr). Five affected individuals showed compound heterozygous mutations, while only one patient revealed a homozygous mutation. Two patients revealed unreported combinations of combined heterozygous mutations. We observed some specific clinical features, such as complex phenotypes of distal myopathy with distal hereditary peripheral neuropathy, an earlier onset of weakness in legs than that of hands, and clinical heterogeneity between two patients with the same set of compound heterozygous mutations. Our findings on these genetic causes expand the clinical spectrum associated with the GNE mutations and can help prepare therapeutic strategies.
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  • 文章类型: Journal Article
    POLE和POLD1的核酸外切酶结构域中的结构杂合致病变体,会影响相应聚合酶的校对活性,导致以胃肠道息肉病风险增加为特征的癌症易感性综合征,结直肠癌,子宫内膜癌和其他肿瘤类型。对于聚合酶ε和δ的校对活性的破坏与癌症发展之间的联系,普遍接受的解释是通过增加体细胞突变率。在这里,我们研究了一个具有致病性POLD1变体c.1421T>Cp的多个成员杂合的扩展家族。(Leu474Pro),与息肉病和癌症表型分离。通过分析患者来源的成纤维细胞集落的突变模式和通过亲本-后代比较获得的从头突变,我们得出的结论是,杂合POLD1L474P只是微妙地增加了体细胞和种系突变负担。相比之下,在POLD1的外切核酸酶结构域中具有杂合突变的个体中发展的肿瘤,包括L474P,具有与签名SBS10d相关的极高突变率(>100mut/Mb)。我们通过观察肿瘤发生涉及野生型POLD1等位基因的体细胞失活,解决了这一矛盾。这些结果表明,聚合酶δ的核酸外切酶缺陷对突变率有隐性影响。
    Constitutional heterozygous pathogenic variants in the exonuclease domain of POLE and POLD1, which affect the proofreading activity of the corresponding polymerases, cause a cancer predisposition syndrome characterized by increased risk of gastrointestinal polyposis, colorectal cancer, endometrial cancer and other tumor types. The generally accepted explanation for the connection between the disruption of the proofreading activity of polymerases epsilon and delta and cancer development is through an increase in the somatic mutation rate. Here we studied an extended family with multiple members heterozygous for the pathogenic POLD1 variant c.1421T>C p.(Leu474Pro), which segregates with the polyposis and cancer phenotypes. Through the analysis of mutational patterns of patient-derived fibroblasts colonies and de novo mutations obtained by parent-offspring comparisons, we concluded that heterozygous POLD1 L474P just subtly increases the somatic and germline mutation burden. In contrast, tumors developed in individuals with a heterozygous mutation in the exonuclease domain of POLD1, including L474P, have an extremely high mutation rate (>100 mut/Mb) associated with signature SBS10d. We solved this contradiction through the observation that tumorigenesis involves somatic inactivation of the wildtype POLD1 allele. These results imply that exonuclease deficiency of polymerase delta has a recessive effect on mutation rate.
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  • 文章类型: Journal Article
    背景:为了研究伊朗早发性进行性小脑共济失调的遗传学,我们在儿童医疗中心(CMC)进行了一项研究,全国儿科疾病的主要转诊中心,从2019年到2022年,为期三年。在这份报告中,我们提供了国家注册中心的初步发现.
    方法:我们选择了所有具有常染色体隐性遗传模式的早发性患者来评估他们的表型,临床旁测试,和基因型。临床数据包括临床特征,共济失调评估和等级量表(SARA)评分,磁共振成像(MRI)结果,电诊断检查(EDX),和生物标志物特征。我们的基因调查包括单基因检测,全外显子组测序(WES),和全基因组测序(WGS)。
    结果:我们的研究纳入了来自我国不同地理区域的162名患者。在我们的亚群中,我们在97个家族的42个基因中发现了已知和新的致病变异.总体遗传诊断率为59.9%。值得注意的是,我们观察到PLA2G6ATM,SACS,以及19、14、12和10个家族的SCA变体,分别。值得注意的是,超过59%的病例归因于这些基因的致病变异.
    结论:伊朗,在中东的十字路口,常染色体隐性遗传性共济失调表现出高度多样化的遗传病因。鉴于这种异质性,预防策略和靶向分子疗法的发展变得至关重要.诊断和管理这些疾病患者的国家指南可以显着帮助推进医疗保健方法和改善患者预后。
    BACKGROUND: To investigate the genetics of early-onset progressive cerebellar ataxia in Iran, we conducted a study at the Children\'s Medical Center (CMC), the primary referral center for pediatric disorders in the country, over a three-year period from 2019 to 2022. In this report, we provide the initial findings from the national registry.
    METHODS: We selected all early-onset patients with an autosomal recessive mode of inheritance to assess their phenotype, paraclinical tests, and genotypes. The clinical data encompassed clinical features, the Scale for the Assessment and Rating of Ataxia (SARA) scores, Magnetic Resonance Imaging (MRI) results, Electrodiagnostic exams (EDX), and biomarker features. Our genetic investigations included single-gene testing, Whole Exome Sequencing (WES), and Whole Genome Sequencing (WGS).
    RESULTS: Our study enrolled 162 patients from various geographic regions of our country. Among our subpopulations, we identified known and novel pathogenic variants in 42 genes in 97 families. The overall genetic diagnostic rate was 59.9%. Notably, we observed PLA2G6, ATM, SACS, and SCA variants in 19, 14, 12, and 10 families, respectively. Remarkably, more than 59% of the cases were attributed to pathogenic variants in these genes.
    CONCLUSIONS: Iran, being at the crossroad of the Middle East, exhibits a highly diverse genetic etiology for autosomal recessive hereditary ataxia. In light of this heterogeneity, the development of preventive strategies and targeted molecular therapeutics becomes crucial. A national guideline for the diagnosis and management of patients with these conditions could significantly aid in advancing healthcare approaches and improving patient outcomes.
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  • 文章类型: Journal Article
    听力损失是一种临床和遗传异质性疾病,有超过148个基因和170个位点与其发病机制相关。因果变异的频谱和频率在不同的遗传祖先之间有所不同,并且在实行近亲婚姻的人群中更为普遍。巴基斯坦具有与非综合征性听力损失相关的常染色体隐性基因发现的丰富历史。自从与巴基斯坦家族的首次连锁分析导致DFNB1基因座在13号染色体上的定位以来,已在该人群中鉴定出与该疾病相关的51个基因。其中,13个最普遍的基因,即CDH23,CIB2,CLDN14,GJB2,HGF,MARVELD2,MYO7A,MYO15A,MSRB3,OTOF,SLC26A4,TMC1和TMPRSS3占所有严重听力损失病例的一半以上,而其他基因的患病率分别低于2%。在这次审查中,我们讨论了巴基斯坦人最常见的常染色体隐性遗传非综合征性听力损失基因,以及用于发现这些基因的遗传图谱和测序方法.此外,我们确定了这51个常染色体隐性遗传非综合征性听力损失基因中涉及的丰富的基因本体论术语和共同通路,以更好地了解潜在机制.建立对该疾病的分子理解可能有助于通过及时诊断和遗传咨询来降低其未来的患病率。导致更有效的听力损失的临床管理和治疗。
    Hearing loss is a clinically and genetically heterogeneous disorder, with over 148 genes and 170 loci associated with its pathogenesis. The spectrum and frequency of causal variants vary across different genetic ancestries and are more prevalent in populations that practice consanguineous marriages. Pakistan has a rich history of autosomal recessive gene discovery related to non-syndromic hearing loss. Since the first linkage analysis with a Pakistani family that led to the mapping of the DFNB1 locus on chromosome 13, 51 genes associated with this disorder have been identified in this population. Among these, 13 of the most prevalent genes, namely CDH23, CIB2, CLDN14, GJB2, HGF, MARVELD2, MYO7A, MYO15A, MSRB3, OTOF, SLC26A4, TMC1 and TMPRSS3, account for more than half of all cases of profound hearing loss, while the prevalence of other genes is less than 2% individually. In this review, we discuss the most common autosomal recessive non-syndromic hearing loss genes in Pakistani individuals as well as the genetic mapping and sequencing approaches used to discover them. Furthermore, we identified enriched gene ontology terms and common pathways involved in these 51 autosomal recessive non-syndromic hearing loss genes to gain a better understanding of the underlying mechanisms. Establishing a molecular understanding of the disorder may aid in reducing its future prevalence by enabling timely diagnostics and genetic counselling, leading to more effective clinical management and treatments of hearing loss.
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