An answer for the patient and their family The massive sequencing of the exome: Approach to the Genetic Diagnosis of Mendelian Diseases a global approach to genetic diagnosis Clinical evaluation There are more than 8,000 Mendelian diseases. The high genetic and / or phenotypic Family history, personal history, signs, symptoms heterogeneity of these syndromes makes it difficult to prioritize the genes to be studied and complementary tests. and requires the simultaneous analysis of all the mutations associated with the disease or disability in an individual. Suspected genetic disease characterized by:

The DNA changes responsible for 85% of all genetic 1,2 Aneuploidies, duplications or Mutations associated with a diseases are located in the exons of an individual . Limited number of recurrent deletions of a specific region. non-specific phenotype and / mutations. or high genetic heterogeneity. Our hereditary information is contained in 19.000 genes which constitutes our genome. Exons are the regions of genes Karyotype aCGH Sanger that contain the information necessary to analysis produce proteins, fundamental elements for living organisms to develop normally The identification of the causal genes allows: . NIMGenetics offers four approaches to the analysis of

• Selection of diagnostic tests and therapeutic measures. The exome is the set of all the exons of

• Establishing a prognosis. the genome.

• Provision of genetic counseling to the patient and their relatives. Targeted Plus Epilepsy Clinical Trio • Understanding the disease, facilitating access to public or private aid. ……..from the sequence of 19,000 genes, an analysis that adapts to the genetic diagnosis of your patient.

Massive sequencing allows the simultaneous analysis of tens to thousands of genes Quickly and Cost-Effectively.

Medical is evolving from gene panels towards massive sequencing of the exome due to its greater diagnostic power. The success of this technology lies in its flexibility and its capacity to adapt to the needs of the patient. From the sequencing of the exome, the genes to be analyzed can be selected (personalized designs) and different phenotypes can be studied simultaneously or sequentially (re-analysis)3-5. Analysis algorithm

Clinically oriented analysis Report

Sequencing and bioinformatic analysis

Identification and annotation of • Clinical recommendations in relation to the management of the patient, variants complementary confirmatory tests and family segregation studies. Proprietary database • Results interpreted in a clinical context, with relevant information obtained from databases and the existent bibliography.

Filtering of variants • Comparison of the variants identified against the databases, allowing • Re-classification of variants based on new evidence. the determination of the relevant genetic information. • Interpretation of variants following the recommendations of the ACMG.

• It includes information regarding the quality of the sequencing and the coverages Prioritization and categorization • Prediction of pathogenicity with bioinformatic algorithms. of the genes studied. • Review of mutation databases and scientific publications. • NIMGenetics specifies and performs the segregation studies necessary to • Categorization of the variants according to the criteria of the ACMG*. determine the causality of the variant and facilitates genetic counseling. Clinical interpretation • Integration of clinical information. • Determination of the association between phenotype and genotype. • Evaluation of the inheritance pattern of the variant. NIMGenetics has a multidisciplinary team with proven experience • Sanger validation of pathogenic easy-to-understand clinical report variants • (*): American College of training in genetic counseling for doctors ExoNIM® Targeted: we work with you wherever you need us What is it?

• Exome: simultaneous sequencing of the 19,000 genes of the patient. Neurology • Targeted: to genes selected for their association with the patient’s phenotype. Pediatrics Indications Dermatology Syndromes with a characteristic clinical presentation and high genetic heterogeneity. Vascular Advantages Immunology • Re-analysis of the sequence, due to: Otorhinolaryngology 1) Emergence of new symptoms. 2) Redefinition of the phenotype. Digestive 3) Inclusion of new genes involved in the studied pathology. Hematology • In concurrent pathologies or overlapping or non-specific phenotypesthe available panels can be combined. Endocrinology • The ExoNIM® Targeted designs are updated periodically, • Personalized designs adapted to each patient. Nephrology based on the most recent literature. • Extension to ExoNIM® Clinical and ExoNIM® Trio without the need to re-sequence the patient sample. At the service of genetic diagnosis A multidisciplinary • NIMGenetics offers advice for choosing the most The exome approach appropriate ExoNIM® Targeted design for your patient. is a dynamic tool Neurology Digestive, endocrine and nephrology Hematology Hereditary polyneuropathies Myopathies and neuromuscular diseases Intrahepatic cholestasis VP110 Amyloidosis VP64 Charcot-Marie Tooth type 2 VP32 Neuromuscular channelopathies VP21 Combined deficit of pituitary hormones and hypothyroidism VP74 Blackfan-Diamond congenital erythroblastopenia VP43 Limb-girdle muscular dystrophy (LGMD) VP39 Charcot-Marie Tooth and hereditary sensory-motor related neuropathies VP3 Neonatal diabetes VP86 Syndromic and non-syndromic congenital neutropenia VP42 Muscular dystrophies VP61 Congenital or chronic early onset diarrhea VP85 Hemolytic uremic syndrome VP14 Distal hereditary neuropathy VP11 Dystrophinopathies VP55 Errors of metabolism with hyperammonemia VP76 Otorhinolaryngology Alterations of movement Dystroglycanopathies VP71 Recurrent fever VP80 Primary ciliary dyskinesia VP25 Spinocerebellar ataxia VP2 Amyotrophic lateral sclerosis and syndromes included in the VP48 Familial hypercholesterolemia VP94 Familial hypoacusis VP9 Ataxias VP36 Neuroacanthocytosis, Wilson's disease and iron deposit disease VP78 Large vestibular aqueduct syndrome VP84 Choreoathetosis VP73 Congenital myasthenia VP70 Chronic pancreatitis VP47 Autosomal recessive deafness VP19 Dystonias VP57 Congenital centronuclear myopathy VP31 VP100 Polymalformative syndromes with or without associated intellectual deficit Alternating hemiplegia of childhood VP97 Myopathy due to fiber-type disproportion and Shprintzen-Goldberg Syndrome VP30 Alport syndrome VP109 Arthrogryposis VP56 Familial hemiplegic migraine VP101 Myopathies VP50 Bartter syndrome and pathologies associated with hydroelectrolytic disorders VP81 Congenital cardiomyopathies VP102 Hereditary spastic paraplegia VP26 Collagen VI hereditary disorders VP20 Tricho-Hepato-Enteric syndrome VP18 Craniosynostosis VP6 Parkinson´s disease VP58 Dementias Bone, vascular, dermatology and immunology Facial dysostosis VP69 Leukodystrophies and other CNS disorders Early-onset Alzheimer´s disease VP28 Genetic alterations of the aorta (aneurysms and dissections) VP75 Hirschsprung disease VP51 Familial cavernous angioma VP35 Frontotemporal dementia VP91 Coffin-Lowry syndrome VP65 Tuberous sclerosis VP8 Spinal muscular atrophy VP82 Neurodevelopmental disorders Connectivopathies VP103 Cleft lip and cleft palate VP93 Lysosomal and peroxisomal diseases VP63 Autism VP83 Cutis laxa VP99 Limb malformation VP87 Fahr´s disease VP62 Intellectual deficit VP7 Ectodermal dysplasias VP68 Hereditary primary and Meier-Gorlin Syndrome VP41 Diseases due to glycogen metabolism disorders VP105 Intellectual deficit (X-linked) VP79 Bone dysplasias VP37 Rasopathies VP12 Leukodystrophies VP27 Angelman syndrome and syndromes included in the differential diagnosis VP98 Joint hypermobility VP33 Bardet-Biedl syndrome VP95 Cerebral lipofuscinosis VP72 Mitochondrial disorders Congenital Ichthyosis VP24 Coffin-Siris syndrome VP59 Aicardi-Goutieres syndrome VP1 Mitochondrial alterations secondary to nuclear DNA mutations VP10 Osteogenesis imperfecta VP66 Cornelia de Lange syndrome VP5 Joubert syndrome VP22 Osteopetrosis VP107 Donnai-Barrow syndrome VP40 Congenital disorders of cerebral morphogenesis VP17 Hyperimmunoglobulinemia E syndrome VP52 Kabuki syndrome VP23 Hereditary hemorrhagic telangiectasia VP46 Robinow syndrome VP67 Rubinstein-Tabi syndrome VP60 Sotos syndrome and related syndromes VP49 Overgrowth and macrocephaly VP96 What is it? What is it? • Exome: simultaneous sequencing of the 19,000 genes of the patient. • Exome: simultaneous sequencing of the 19,000 genes of the patient. • Clinical: analysis directed to more than 5,700 OMIM7 genes. • Trio: Through the genetic information of the parents, the variants responsible for the patient’s phenotype are selected, taking into account both the clinical Indications presentation and the inheritance pattern. Syndromes difficult to orient clinically and characterized by: Indications • High genetic heritability • Diseases with high genetic and / or phenotypic heterogeneity. • High phenotypic heterogeneity or incomplete phenotypes • Differential diagnosis of syndromes that share clinical manifestations or of rare • Previous studies aimed at differential diagnosis inconclusive diseases. Advantages • First choice in cases of ASD and Neurodevelopmental Disorders after negative CGH array. • Analysis of all genes associated with Mendelian diseases. • Used to extend the analysis in cases of negative results from ExoNIM Targeted/ • Possibility of extension to ExoNIM® Trio. Clinical.

• Minimizes the identification of incidental findings or the identification of variants in Advantages genes without a clinically associated phenotype. • Allows the identification of new genes not initially included in the differential Opening the doors diagnosis. A broad spectrum to diagnosis • Maximum diagnostic yield, over 40%. analysis • Allows the determination of the inheritance pattern of the variants.

• Accelerates the diagnostic process and avoids unnecessary tests. SOLICITING ExoNIM® Necessary documentation:

1. Request form*. (*): Available on our website or upon request to our delegates. 2. Informed request*.

3. Medical report.

Why choose NIMGenetics? CONDITIONS AND SAMPLE SHIPPING: • The quality of ExoNIM® is certified (Thermo® Certified Peripheral blood: 3-5 ml in EDTA. Service Provider). For other samples, please consult with our technical management. • NIMGenetics reports have been rated excellent by NIMGenetics has extraction centers in all the countries where it operates (Spain, Brazil, Mexico, etc.). opinion leaders in Neurology, Clinical Genetics and other Consult with the delegate or the central office. specialties. • Company led by a highly qualified multidisciplinary team, BIBLIOGRAPHY: which supports the specialist, offering pre- and post-test 1. Choi M et al. (2009). Proc Natl Acad Sci U S A 106(45):19096-101. advice. 2. Pussegoda KA (2010). Clin Genet 78(1):32-33. • Members accredited by the Spanish Association of Human 3. Lee H et al. (2014). JAMA 312(18): 1880–87. Genetics (AEGH) and with an active participation in the 4. Van Nimwegen KJ et al. (2015). Eur J Paediatr Neurol 19(2):233-39. European Molecular Quality Network (EMQN). 5. Monroe GR et al. (2016). Genet Med 18(9):949-56. [Epub ahead of print]. • Comprehensive solutions. NIMGenetics has a broad 6. Richards S et al. (2015). Genet Med 17(5):405-24. portfolio of molecular genetic tests to meet the needs of 7. Online Mendelian Inheritance in Man (OMIM) http://www.omim.org. each patient. MADRID Parque Científico de Madrid Faraday, 7 (Campus de Cantoblanco) 28049 Madrid Tel.+34 91 804 77 60

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