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Title:
MICROHOMOLOGY MEDIATED REPAIR OF MICRODUPLICATION GENE MUTATIONS
Document Type and Number:
WIPO Patent Application WO/2019/213504
Kind Code:
A1
Abstract:
The present invention is directed to the filed of gene therapy. In particular, compositions and methods are disclosed that repair gene microduplication mutations by reversion to a wild type sequence. For example, the creation of a double stranded break by a programmable nuclease protein within a microduplication induces the microhomology mediated end joining DNA repair pathway that in the process of DNA repair removes the microduplication mutation and restores the wild type sequence.

Inventors:
WOLFE, Scot (28 Hollywood Road, Winchester, MA, 01890, US)
EMERSON, Charles (222 Maple Avenue, Shrewsbury, MA, 01545, US)
IYER, Sukanya (222 Maple Avenue, Shrewsbury, MA, 01545, US)
SURESH, Sneha (222 Maple Avenue, Shrewsbury, MA, 01545, US)
MUELLER, Chris (222 Maple Avenue, Shrewsbury, MA, 01545, US)
CHEN, Jennifer (222 Maple Avenue, Shrewsbury, MA, 01545, US)
GUO, Dongsheng (222 Maple Avenue, Shrewsbury, MA, 01545, US)
KING, Oliver (222 Maple Avenue, Shrewsbury, MA, 01545, US)
Application Number:
US2019/030576
Publication Date:
November 07, 2019
Filing Date:
May 03, 2019
Export Citation:
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Assignee:
UNIVERSITY OF MASSACHUSETTS (One Beacon Street, 31st FloorBoston, MA, 02108, US)
International Classes:
C12N15/79; A61K48/00; C12N15/85; C12N15/861; C12Q1/6883
Domestic Patent References:
WO2017193029A22017-11-09
Other References:
LATTANZI, A ET AL.: "Correction of the Exon 2 Duplication in DMD Myoblasts by a Single CRISPR/Cas9 System", MOLECULAR THERAPY: NUCLEIC ACIDS, vol. 7, 10 February 2017 (2017-02-10), pages 11 - 19, XP085172542
CHRISTENSEN, CL ET AL.: "A Prospective Treatment Option for Lysosomal Storage Diseases: CRISPR/Cas9 Gene Editing Technology for Mutation Correction in Induced Pluripotent Stem Cells", DISEASES, vol. 5, no. 1, 24 February 2017 (2017-02-24), pages 6, XP055649711
FINELLI ET AL.: "FISH characterisation of an identical (16)(p11.2p12.2) tandem duplication in two unrelated patients with autistic behavior", JOURNAL OF MEDICAL GENETICS, vol. 41, no. 7, July 2004 (2004-07-01), pages e90, XP055649713
OH, J ET AL.: "Mutation Analysis of Patients with Hermansky-Pudlak Syndrome: A Frameshift Hot - Spot in the HPS Gene and Apparent Locus Heterogeneity", AMERICAN JOURNAL OF HUMAN GENETICS, vol. 62, no. 3, March 1998 (1998-03-01), pages 593 - 398, XP055649720
IYER, S ET AL.: "Precise therapeutic gene correction by a simple nuclease-induced -double-stranded break", NATURE, vol. 568, no. 7753, April 2019 (2019-04-01), pages 561 - 565, XP036900419, DOI: 10.1038/s41586-019-1076-8
Attorney, Agent or Firm:
HOWERTON, Thomas C. et al. (Medlen & Carroll, LLP1440 Broadway, Suite 101, Oakland CA, 94612, US)
Download PDF:
Claims:
Claims

We claim:

1. A programmable nuclease with sequence-specific DNA-binding affinity for a genomic locus, wherein said genomic locus comprises a microduplication mutation.

2. The programmable nuclease of Claim 1, wherein said nuclease further comprises a

protospacer adjacent motif binding domain having said sequence- specific DNA-binding affinity for said genomic locus protospacer adjacent motif sequence.

3. The nuclease of Claim 1, wherein said nuclease is selected from the group consisting of a Class II CRISPR single effector nuclease, a Cas9 nuclease, a Casl2 nuclease, a zinc finger nuclease and a transcription activator-like effector nuclease.

4. The nuclease of Claim 1, wherein a duplicate sequence of said microduplication mutation has a length of between 1 - 40 nucleotides.

5. The nuclease of Claim 1, wherein a duplicate sequence of the microduplication mutation has a length of greater than 40 nucleotides.

6. A microduplication of Claim 1, where the microduplication is in the form of a direct repeat.

7. A method, comprising;

a) providing;

i) a subject comprising a genomic locus having a microduplication mutation; and ii) a pharmaceutical formulation comprising a programmable nuclease, said nuclease having sequence-specific DNA-binding affinity for a region that contains said microduplication mutation within said genomic locus; and b) administering said pharmaceutical formulation to said subject under conditions such that said microduplication mutation is replaced with a wild type sequence of said genomic locus.

8. The method of Claim 6, wherein said wild type sequence replacement comprises a

correction through DNA repair.

9. The method of Claim 7, wherein said DNA repair correction is performed without

assistance of an exogenously supplied donor DNA.

10. The method of Claim 7, wherein said nuclease further comprises a protospacer adjacent motif binding domain having said sequence-specific DNA-binding affinity for said genomic locus protospacer adjacent motif sequence.

11. The method of Claim 7, wherein said genomic locus is selected from the group consisting of TCAP, HPS1, HEXA, DOK7 and RAX2.

12. The method of Claim 7, wherein said subject further exhibits at least one symptom of a disease caused by said target gene microduplication mutation.

13. The method of Claim 7, wherein said disease is selected from the group consisting of limb-girdle muscular dystrophy 2G, Hermanksy-Pudlak syndrome, Tay-Sachs disease, familial limb-girdle myasthenia and cone-rod dystrophy 11.

14. The method of Claim 7, wherein said administering further reduces said at least one symptom of said disease.

15. The method of Claim 7, wherein said nuclease is selected from the group consisting of a Class II CRISPR single effector nuclease, a Cas9 nuclease, a Casl2 nuclease, a zinc finger nuclease and a transcription activator-like effector nuclease. 16. The method of Claim 7, wherein said pharmaceutical formulation comprises an adeno- associated virus encoding said programmable nuclease.

Description:
Microhomology Mediated Repair Of Microduplication Gene Mutations

Field Of The Invention

The present invention is directed to the field of gene therapy. In particular, compositions and methods are disclosed that repair gene microduplication mutations by reversion to a wild type sequence. For example, the creation of a double stranded break within a microduplication by a programmable nuclease protein induces the microhomology mediated end joining DNA repair pathway that in the process of DNA repair removes the microduplication mutation and restores the wild type sequence.

Background

Genome editing by programmable nuclease systems has revolutionized biological research and is rapidly moving towards many clinical applications. In most instances, the successful repair of an aberrant gene to correct a disease entails precise correction of the genetic sequence typically via the Homology Directed Repair (HDR) pathway. This pathway requires not only the use of a programmable nuclease to generate a double-strand break (DSB) at the locus to initiate DNA repair, but also the delivery of exogenous donor DNA to precisely re-write the genomic sequence To date, HDR is inefficient in most cell types, particularly in post-mitotic differentiated cell types such as neurons and muscle [Suzuki, K. et al. In vivo genome editing via CRISPR/Cas9 mediated homology- independent targeted integration. Nature 540, 144-149 (2016).], which are the affected tissues in many devastating genetic disorders. This barrier significantly limits the clinical efficacy of the current generation of nuclease-based gene repair tools.

What is needed in the art are compositions and methods that can safely and efficiently target disease-causing microduplication mutations within a genome and cure the disease by reverting the microduplication mutation to a wild type sequence. Summary

The present invention is directed to the filed of gene therapy. In particular, compositions and methods are disclosed that repair gene microduplication mutations by reversion to a wild type sequence. For example, the creation of a double stranded break within a microduplication by a programmable nuclease protein induces the microhomology mediated end joining DNA repair pathway that in the process of DNA repair removes the microduplication mutation and restores the wild type sequence..

In one embodiment, the present invention contemplates a programmable nuclease having sequence-specific DNA-binding affinity for a target gene or genomic locus, wherein said target gene or genomic locus comprises a microduplication mutation. In one embodiment, said nuclease further comprises a protospacer adjacent motif binding domain having said sequence- specific DNA-binding affinity for said target gene or genomic locus protospacer adjacent motif sequence. In one embodiment, the nuclease includes, but is not limited to, a Class II CRISPR single effector nuclease, a Cas9 nuclease, a Casl2 nuclease, a zinc finger nuclease and/or a transcription activator-like effector nuclease. In one embodiment, a duplicate sequence of the microduplication mutation has a length of between 1 - 40 nucleotides. In one embodiment, a duplicate sequence of the microduplication mutation has a length of greater than 40 nucleotides.

In one embodiment, the present invention contemplates a method, comprising; i) a subject comprising a target gene or genomic locus having a microduplication mutation; and ii) a pharmaceutical formulation comprising a programmable nuclease, the nuclease having sequence- specific DNA-binding affinity for a region that contains said microduplication mutation of the target gene or genomic locus; and b) administering said pharmaceutical formulation to the patient under conditions such that the microduplication mutation is replaced with a wild type sequence of the target gene or genomic locus. In one embodiment, said wild type sequence replacement comprises a correction through DNA repair. In one embodiment, the DNA repair correction is performed without assistance of an exogenously supplied donor DNA. In one embodiment, said nuclease further comprises a protospacer adjacent motif binding domain having said DNA-binding specificity for said target gene or genomic locus protospacer adjacent motif sequence. In one embodiment, the target gene includes, but is not limited to, TCAP, HPS1, HEXA, DOK7 and/or RAX2. In one embodiment, the subject further exhibits at least one symptom of a disease caused by the target gene microduplication mutation. In one embodiment, the disease includes, but is not limited to limb-girdle muscular dystrophy 2G, Hermanksy-Pudlak syndrome, Tay-Sachs Disease, familial limb-girdle myasthenia and/or cone-rod dystrophy 11. In one embodiment, administering further reduces the at least one symptom of the disease. In one embodiment, the nuclease includes, but is not limited to, a Class II CRISPR single effector nuclease, a Cas9 nuclease, a Casl2 nuclease, a zinc finger nuclease and/or a transcription activator-like effector nuclease. In one embodiment, the pharamaceutical formulation comprises an adeno-associated virus encoding said programmable nuclease.

Definitions

To facilitate the understanding of this invention, a number of terms are defined below. Terms defined herein have meanings as commonly understood by a person of ordinary skill in the areas relevant to the present invention. Terms such as“a”,“an” and“the” are not intended to refer to only a singular entity but also plural entities and also includes the general class of which a specific example may be used for illustration. The terminology herein may be used to describe specific embodiments of the invention, but their usage does not delimit the invention, except as outlined in the claims.

The term "about" as used herein, in the context of any of any assay measurements refers to +/- 5% of a given measurement.

As used herein, the term“CRISPRs” or“Clustered Regularly Interspaced Short

Palindromic Repeats” refers to an acronym for DNA loci that contain multiple, short, direct repetitions of base sequences. Each repetition contains a series of bases followed by the same series in reverse and then by 30 or so base pairs known as "spacer DNA". The spacers are short segments of DNA from a virus and may serve as a 'memory' of past exposures to facilitate an adaptive defense against future invasions (PMID 25430774).

As used herein, the term“Cas” or“CRISPR-associated (cas)” refers to genes often associated with CRISPR repeat-spacer arrays (PMID 25430774).

As used herein, the term“Cas9” refers to a nuclease from Type II CRISPR systems, an enzyme specialized for generating double-strand breaks in DNA, with two active cutting sites (the HNH and RuvC domains), one for each strand of the double helix. Jinek combined tracrRNA and spacer RNA into a "single-guide RNA" (sgRNA) molecule that, mixed with Cas9, could find and cleave DNA targets through Watson-Crick pairing between the guide sequence within the sgRNA and the target DNA sequence (PMID 22745249).

As used herein, the term“catalytically active Cas9” refers to an unmodified Cas9 nuclease comprising full nuclease activity.

The term“nickase” as used herein, refers to a nuclease that cleaves only a single DNA strand, either due to its natural function or because it has been engineered to cleave only a single DNA strand. Cas9 nickase variants that have either the RuvC or the HNH domain mutated provide control over which DNA strand is cleaved and which remains intact (Jinek, et al. 2012 (PMID 22745249) and Cong, et al. 2013 (PMID 23287718)).

As used herein, the term“Casl2” (or Cpfl) refers to a nuclease from Type V CRISPR systems, an enzyme specialized for generating double-strand breaks in DNA, with one active cutting sites (the RuvC domain), that cuts both DNA strands. Zetsche demonstrated that when programmed with its crRNA Casl2 (Cpfl), could find and cleave DNA targets through Watson- Crick pairing between the guide sequence within the crRNA and the target DNA sequence (PMED 26422227).

The term,“trans-activating crRNA”,“tracrRNA” as used herein, refers to a small trans- encoded RNA. For example, CRISPR/Cas (clustered, regularly interspaced short palindromic repeats/CRISPR-associated proteins) constitutes an RNA-mediated defense system, which protects against viruses and plasmids. This defensive pathway has three steps. First a copy of the invading nucleic acid is integrated into the CRISPR locus. Next, CRISPR RNAs (crRNAs) are transcribed from this CRISPR locus. The crRNAs are then incorporated into effector complexes, where the crRNA guides the complex to the invading nucleic acid and the Cas proteins degrade this nucleic acid. There are several pathways of CRISPR activation, one of which requires a tracrRNA, which plays a role in the maturation of crRNA. TracrRNA is complementary to base pairs with a pre-crRNA forming an RNA duplex. This is cleaved by RNase III, an RNA-specific ribonuclease, to form a crRNA/tracrRNA hybrid. This hybrid acts as a guide for the

endonuclease Cas9, which cleaves the invading nucleic acid.

The term“nuclease” as used herein, refers to any protein comprising a pre-determined sequence of amino acids that bind to a specific nucleotide sequence and create a double stranded break. Such nucleases can include, but are not limited to, a Class II CRISPR single effector nuclease, a Cas9 nuclease, a Cas 12 nuclease (also known as Cpfl), a zinc finger nuclease (ZFN) protein and/or a transcription activator-like effector nuclease (TALEN). For example, a Class II CRISPR single effector nuclease and/or a Cas9 nuclease may be assembled into a CRISPR complex.

The term“protospacer adjacent motif’ (or PAM) as used herein, refers to a DNA sequence that may be required for a Cas9/sgRNA to form an R-loop to interrogate a specific DNA sequence through Watson-Crick pairing of its guide RNA with the genome.

The term“protospacer adjacent motif recognition domain” as used herein, refers to a nuclease C-terminus amino acid sequence having specific DNA-binding specificity to a target gene PAM sequence.

The term“target gene” as used herein, refers to a specific genomic region, usually comprising at least one allele, whose dysfunction is associated with a disease. For example, a target gene may have a microduplication mutation that is a causative factor for a disease. A microduplication can be composed of a tandem repeat. Tandem repeats in DNA are a pattern of one or more nucleotides that are repeated and the repetitions are directly adjacent to each other.

As used herein, the term“sgRNA” refers to single guide RNA used in conjunction with CRISPR associated systems (Cas). sgRNAs are a fusion of crRNA and tracrRNA and contain nucleotides of sequence complementary to the desired target site (Jinek, et al. 2012 (PMID 22745249)). Watson-Crick pairing of the sgRNA with the target site permits R-loop formation, which in conjunction with a functional PAM permits DNA cleavage or in the case of nuclease- deficient Cas9 allows binds to the DNA at that locus.

The term "patient" or“subject”, as used herein, is a human or animal and need not be hospitalized. For example, out-patients, persons in nursing homes are "patients." A patient may comprise any age of a human or non-human animal and therefore includes both adult and juveniles ( i.e ., children). It is not intended that the term "patient" connote a need for medical treatment, therefore, a patient may voluntarily or involuntarily be part of experimentation whether clinical or in support of basic science studies.

The term“affinity” as used herein, refers to any attractive force between substances or particles that causes them to enter into and remain in chemical combination. For example, an inhibitor compound that has a high affinity for a receptor will provide greater efficacy in preventing the receptor from interacting with its natural ligands, than an inhibitor with a low affinity. As used herein, the term“orthogonal” refers to targets that are non-overlapping, uncorrelated, or independent. For example, if two orthogonal Cas9 isoforms were utilized, they would employ orthogonal sgRNAs that only program one of the Cas9 isoforms for DNA recognition and cleavage (Esvelt, et al. 2013 (PMID 24076762)). For example, this would allow one Cas9 isoform (e.g. S. pyogenes Cas9 or spCas9) to function as a nuclease programmed by a sgRNA that may be specific to it, and another Cas9 isoform (e.g. N. meningitidis Cas9 or nmCas9) to operate as a nuclease dead Cas9 that provides DNA targeting to a binding site through its PAM specificity and orthogonal sgRNA. Other Cas9s include S. aureus Cas9 or SaCas9 and A. naeslundii Cas9 or AnCas9.

The term“truncated” as used herein, when used in reference to either a polynucleotide sequence or an amino acid sequence means that at least a portion of the wild type sequence may be absent. In some cases truncated guide sequences within the sgRNA or crRNA may improve the editing precision of Cas9 (Fu, et al. 2014 (PMID 24463574)).

The term“base pairs” as used herein, refer to specific nucleobases (also termed nitrogenous bases), that are the building blocks of nucleotide sequences that form a primary structure of both DNA and RNA. Double stranded DNA may be characterized by specific hydrogen bonding patterns, base pairs may include, but are not limited to, guanine-cytosine and adenine-thymine) base pairs.

The term“genomic locus” or“target gene” as used herein, refers to any pre-determined nucleotide sequence capable of binding to a Cas9 protein contemplated herein. The target may include, but may be not limited to, a nucleotide sequence complementary to a programmable DNA binding domain or an orthogonal Cas9 protein programmed with its own guide RNA, a nucleotide sequence complementary to a single guide RNA, a protospacer adjacent motif recognition sequence, an on-target binding sequence and an off-target binding sequence.

The term“on-target binding sequence” as used herein, refers to a subsequence of a specific genomic target that may be completely complementary to a programmable DNA binding domain and/or a single guide RNA sequence.

The term“off-target binding sequence” as used herein, refers to a subsequence of a specific genomic target that may be partially complementary to a programmable DNA binding domain and/or a single guide RNA sequence. The term“cleavage” or“break” as used herein, may be defined as the generation of a break in the DNA. This could be either a single-stranded break or a double- stranded break depending on the type of nuclease that may be employed.

As used herein, the term“edit”,“editing” or“edited” refers to a method of altering a nucleic acid sequence of a polynucleotide (e.g., for example, a wild type naturally occurring nucleic acid sequence or a mutated naturally occurring sequence) by selective deletion of a specific genomic target or the specific inclusion of new sequence through the use of an exogenously supplied DNA template. Such a specific genomic target includes, but may be not limited to, a chromosomal region, mitochondrial DNA, a gene, a promoter, an open reading frame or any nucleic acid sequence.

The term“delete”,“deleted”,“deleting” or“deletion” as used herein, may be defined as a change in either nucleotide or amino acid sequence in which one or more nucleotides or amino acid residues, respectively, are, or become, absent.

As used herein, the terms "complementary" or "complementarity" are used in reference to "polynucleotides" and "oligonucleotides" (which are interchangeable terms that refer to a sequence of nucleotides) related by the base-pairing rules. For example, the sequence "C-A-G- T," may be complementary to the sequence "A-C-T-G." Complementarity can be "partial" or "total." "Partial" complementarity may be where one or more nucleic acid bases may be not matched according to the base pairing rules. "Total" or "complete" complementarity between nucleic acids may be where each and every nucleic acid base may be matched with another base under the base pairing rules. The degree of complementarity between nucleic acid strands has significant effects on the efficiency and strength of hybridization between nucleic acid strands. This may be of particular importance in amplification reactions, as well as detection methods which depend upon binding between nucleic acids.

The terms "homology" and "homologous" as used herein in reference to nucleotide sequences refer to a degree of complementarity with other nucleotide sequences. There may be partial homology or complete homology (i.e., identity). A nucleotide sequence which may be partially complementary, i.e., "substantially homologous," to a nucleic acid sequence may be one that at least partially inhibits a completely complementary sequence from hybridizing to a target nucleic acid sequence. The inhibition of hybridization of the completely complementary sequence to the target sequence may be examined using a hybridization assay (Southern or Northern blot, solution hybridization and the like) under conditions of low stringency. A substantially homologous sequence or probe will compete for and inhibit the binding (i.e., the hybridization) of a completely homologous sequence to a target sequence under conditions of low stringency. This may be not to say that conditions of low stringency are such that nonspecific binding may be permitted; low stringency conditions require that the binding of two sequences to one another be a specific (i.e., selective) interaction. The absence of non-specific binding may be tested by the use of a second target sequence which lacks even a partial degree of complementarity (e.g., less than about 30% identity); in the absence of non-specific binding the probe will not hybridize to the second non-complementary target.

The terms“homology” and“homologous” as used herein in reference to amino acid sequences refer to the degree of identity of the primary stmcture between two amino acid sequences. Such a degree of identity may be detected in a portion of each amino acid sequence, or along the entire length of the amino acid sequence. Two or more amino acid sequences that are“substantially homologous” may have at least 50% identity, preferably at least 75% identity, more preferably at least 85% identity, most preferably at least 95%, or 100% identity.

An oligonucleotide sequence which may be a "homolog" may be defined herein as an oligonucleotide sequence which exhibits greater than or equal to 50% identity to a sequence, when sequences having a length of 100 bp or larger are compared.

As used herein, the term "gene" means the deoxyribonucleotide sequences comprising the coding region of a structural gene and including sequences located adjacent to the coding region on both the 5' and 3' ends for a distance of about 1 kb on either end such that the gene

corresponds to the length of the full-length mR A. The sequences which are located 5' of the coding region and which are present on the mRNA are referred to as 5' non-translated sequences. The sequences which are located 3’ or downstream of the coding region and which are present on the mRNA are referred to as 3' non-translated sequences. The term "gene" encompasses both cDNA and genomic forms of a gene. A genomic form or clone of a gene contains the coding region interrupted with non-coding sequences termed "introns" or "intervening regions" or "intervening sequences." Introns are segments of a gene which are transcribed into

heterogeneous nuclear RNA (hnRNA); introns may contain regulatory elements such as enhancers. Introns are removed or "spliced out" from the nuclear or primary transcript; introns therefore are absent in the messenger RNA (mRNA) transcript. The mRNA functions during translation to specify the sequence or order of amino acids in a nascent polypeptide.

The term“gene of interest” as used herein, refers to any pre-determined gene for which deletion may be desired.

The term“allele” as used herein, refers to any one of a number of alternative forms of the same gene or same genetic locus.

The term“protein” as used herein, refers to any of numerous naturally occurring extremely complex substances (as an enzyme or antibody) that consist of amino acid residues joined by peptide bonds, contain the elements carbon, hydrogen, nitrogen, oxygen, usually sulfur. In general, a protein comprises amino acids having an order of magnitude within the hundreds.

The term“peptide” as used herein, refers to any of various amides that are derived from two or more amino acids by combination of the amino group of one acid with the carboxyl group of another and are usually obtained by partial hydrolysis of proteins. In general, a peptide comprises amino acids having an order of magnitude within the tens.

The term "polypeptide", refers to any of various amides that are derived from two or more amino acids by combination of the amino group of one acid with the carboxyl group of another and are usually obtained by partial hydrolysis of proteins. In general, a polypeptide comprises amino acids having an order of magnitude within the tens or larger.

"Nucleic acid sequence" and "nucleotide sequence" as used herein refer to an

oligonucleotide or polynucleotide, and fragments or portions thereof, and to DNA or RNA of genomic or synthetic origin which may be single- or double-stranded, and represent the sense or antisense strand.

The term "an isolated nucleic acid”, as used herein, refers to any nucleic acid molecule that has been removed from its natural state (e.g., removed from a cell and may be, in a preferred embodiment, free of other genomic nucleic acid).

The terms "amino acid sequence" and "polypeptide sequence" as used herein, are interchangeable and to refer to a sequence of amino acids.

As used herein the term "portion" when in reference to a protein (as in "a portion of a given protein") refers to fragments of that protein. The fragments may range in size from four amino acid residues to the entire amino acid sequence minus one amino acid. The term "portion" when used in reference to a nucleotide sequence refers to fragments of that nucleotide sequence. The fragments may range in size from 5 nucleotide residues to the entire nucleotide sequence minus one nucleic acid residue.

As used herein, the term "hybridization" may be used in reference to the pairing of complementary nucleic acids using any process by which a strand of nucleic acid joins with a complementary strand through base pairing to form a hybridization complex. Hybridization and the strength of hybridization (i.e., the strength of the association between the nucleic acids) may be impacted by such factors as the degree of complementarity between the nucleic acids, stringency of the conditions involved, the T m of the formed hybrid, and the G:C ratio within the nucleic acids.

As used herein the term "hybridization complex" refers to a complex formed between two nucleic acid sequences by virtue of the formation of hydrogen bounds between complementary G and C bases and between complementary A and T bases; these hydrogen bonds may be further stabilized by base stacking interactions. The two complementary nucleic acid sequences hydrogen bond in an antiparallel configuration. A hybridization complex may be formed in solution (e.g., Co t or R 0 1 analysis) or between one nucleic acid sequence present in solution and another nucleic acid sequence immobilized to a solid support (e.g., a nylon membrane or a nitrocellulose filter as employed in Southern and Northern blotting, dot blotting or a glass slide as employed in in situ hybridization, including FISH (fluorescent in situ hybridization)).

As used herein, the term "T m " may be used in reference to the "melting temperature."

The melting temperature may be the temperature at which a population of double-stranded nucleic acid molecules becomes half dissociated into single strands. As indicated by standard references, a simple estimate of the T m value may be calculated by the equation: T m = 81.5 +

0.41 (% G+C), when a nucleic acid may be in aqueous solution at 1M NaCl. Anderson et al., “Quantitative Filter Hybridization” In: Nucleic Acid Hybridization (1985). More sophisticated computations take structural, as well as sequence characteristics, into account for the calculation of T m .

As used herein the term "stringency" may be used in reference to the conditions of temperature, ionic strength, and the presence of other compounds such as organic solvents, under which nucleic acid hybridizations are conducted. "Stringency" typically occurs in a range from about T m to about 20°C to 25°C below T m . A“stringent hybridization” can be used to identify or detect identical polynucleotide sequences or to identify or detect similar or related

polynucleotide sequences. For example, when fragments are employed in hybridization reactions under stringent conditions the hybridization of fragments which contain unique sequences (i.e., regions which are either non-homologous to or which contain less than about 50% homology or complementarity) are favored. Alternatively, when conditions of "weak" or "low” stringency are used hybridization may occur with nucleic acids that are derived from organisms that are genetically diverse (i.e., for example, the frequency of complementary sequences may be usually low between such organisms).

As used herein, the terms "restriction endonucleases" and "restriction enzymes" refer to bacterial enzymes, each of which cut double-stranded DNA at or near a specific nucleotide sequence.

DNA molecules are said to have "5' ends" and "3' ends" because mononucleotides are reacted to make oligonucleotides in a manner such that the 5' phosphate of one mononucleotide pentose ring may be attached to the 3' oxygen of its neighbor in one direction via a

phosphodiester linkage. Therefore, an end of an oligonucleotide may be referred to as the "5' end" if its 5' phosphate may be not linked to the 3' oxygen of a mononucleotide pentose ring. An end of an oligonucleotide may be referred to as the "3' end" if its 3' oxygen may be not linked to a 5' phosphate of another mononucleotide pentose ring. As used herein, a nucleic acid sequence, even if internal to a larger oligonucleotide, also may be said to have 5' and 3' ends. In either a linear or circular DNA molecule, discrete elements are referred to as being "upstream" or 5' of the "downstream" or 3' elements. This terminology reflects the fact that transcription proceeds in a 5' to 3' fashion along the DNA strand. The promoter and enhancer elements which direct transcription of a linked gene are generally located 5' or upstream of the coding region. However, enhancer elements can exert their effect even when located 3' of the promoter element and the coding region. Transcription termination and polyadenylation signals are located 3' or

downstream of the coding region.

As used herein, the term "an oligonucleotide having a nucleotide sequence encoding a gene" means a nucleic acid sequence comprising the coding region of a gene, i.e. the nucleic acid sequence which encodes a gene product. The coding region may be present in a cDNA, genomic DNA or RNA form. When present in a DNA form, the oligonucleotide may be single-stranded (i.e., the sense strand) or double-stranded. Suitable control elements such as enhancers/promoters, splice junctions, polyadenylation signals, etc. may be placed in close proximity to the coding region of the gene if needed to permit proper initiation of transcription and/or correct processing of the primary RNA transcript. Alternatively, the coding region utilized in the expression vectors of the present invention may contain endogenous enhancers/promoters, splice junctions, intervening sequences, polyadenylation signals, etc. or a combination of both endogenous and exogenous control elements.

As used herein, the terms "nucleic acid molecule encoding", "DNA sequence encoding," and "DNA encoding" refer to the order or sequence of deoxyribonucleotides along a strand of deoxyribonucleic acid. The order of these deoxyribonucleotides determines the order of amino acids along the polypeptide (protein) chain. The DNA sequence thus codes for the amino acid sequence.

The term "bind",“binding”, or“bound” as used herein, includes any physical attachment or close association, which may be permanent or temporary. Generally, an interaction of hydrogen bonding, hydrophobic forces, van der Waals forces, covalent and ionic bonding etc., facilitates physical attachment between the molecule of interest and the analyte being measuring. The "binding" interaction may be brief as in the situation where binding causes a chemical reaction to occur. That may be typical when the binding component may be an enzyme and the analyte may be a substrate for the enzyme. Reactions resulting from contact between the binding agent and the analyte are also within the definition of binding for the purposes of the present invention.

Brief Description Of The Figures

The file of this patent contains at least one drawing executed in color. Copies of this patent with color drawings will be provided by the Patent and Trademark Office upon request and payment of the necessary fee.

Figure 1 shows an overview of several naturally occurring mutagenic DNA repair pathways. Microhomology Mediated End Joining (MMEJ) mediated repair is the center pathway involving a 5’ end resection and annealing of homologous sequences.

Figure 2 presents exemplary sequences of microduplication targets within a TCAP gene and a HSP1 gene. The microduplicated sequences in each exon are highlighted in green and yellow. The target sites for SpCas9 are shown below each sequence with the GG PAM element in bold and the spacer (guide) sequence underlined. The position of the DSB in the sequence is indicated

Figure 3 presents exemplary data of a TIDE analysis of sanger sequence chromatogram from SpCas9 treated LGMD2G iPSCs. The estimated mutagenesis rate is 87% with 53% of the alleles containing an 8 bp deletion (oval), which would be consistent with a reversion to the WT sequence.

Figure 4 presents exemplary data of an ICE analysis of sanger sequence chromatogram from SpCas9 treated HPS1 B-EBV cells. The estimated mutagenesis rate is 41% with 30% of the alleles containing a 16 bp deletion (oval), which would be consistent with a reversion to the WT sequence.

Figure 5 presents exemplary data of a deep sequencing analysis of the editing rates and outcomes at TCAP in iPSCs or iPSC derived myoblasts that have an 8 bp duplication in both alleles. More than 50% of the alleles are either the precise 8 bp deletion or are mutations that produce an in frame sequence.

Figure 6 presents exemplary data of TIDE analyses of sanger sequencing of individual iPSC clones from the 8 bp duplication TCAP line following treatment with a TCAP targeting SpCas9 RNP. In these four instances at least one allele was converted to the wild-type sequence.

Figure 7 presents exemplary data for a phenotype prediction iPSC clones based on the genotypes that were observed from the sequencing of the Cas9 modified alleles. 75% of the clones that could be conclusively characterized contained at least one wild-type TCAP sequence.

Figure 8 presents an overview of duplicated repeat collapse by MMEJ-mediated DNA repair pathways. A nuclease targeted near the center of the duplicated segment can lead to the collapse of the duplication. As disclosed herein, the present method targets this collapse and restores the wild-type sequence.

Figure 9 presents exemplary data showing that a mutant HPS1 allele contains a 16 bp duplication (annotation as in Figure 2).

Figure 10 shows that MMEJ -based repair efficiently and precisely corrects TCAP allele containing an 8-bp duplication.

Figure 10 A: Schematic of MMEJ -based pathway for repair of a microduplication.

A DSB at the centre of a microduplication (in red and blue) is expected to initiate

5’ end resection to expose the microhomologies on each side. These repeats anneal with each other and are repaired via the MMEJ pathway to yield the wild- type (WT) sequence.

Figure 10B: The pathogenic 8-bp microduplication within TCAP (bold red and blue text) with the SpyCas9 protospacer-adjacent motif (PAM) sequence in the magenta box and the protospacer sequence underlined. A SpyCas9-induced DSB (magenta carets) is expected to drive MMEJ repair to revert the mutant allele to the wild-type sequence (half red/half blue text).

Figure 10C: Percentage of 8-bp deletion (green bars) and total indels (blue bars) resulting from SpyCas9 RNP treatment of LGMD2G iPSCs homozygous for the 8-bp microduplication or wild-type iPSCs. Bars denote mean and dots indicate individual data points n = 3 biological replicates.

Figure 10D: Genotype analysis of 22 LGMD2G iPSC clones after treatment with SpyCas9 RNPs. Hypo, hypomorphic allele.

Figure 10E: Percentage of 8-bp deletion (green bars) and total indels (blue bars) resulting from SpyCas9 treatment of myoblasts derived from patient-derived LGMD2G iPSCs. Bars denote mean and dots indicate individual data points n =

3 biological replicates.

Figure 11 shows that MMEJ-based repair efficiently and precisely corrects HPS1 allele containing 16-bp microduplication.

Figure 11 A: The 16-bp microduplication repeats are shown in bold red and blue text. For six SpyCas9 guides targeting the microduplication, the PAM sequence is demarcated in the magenta box and the protospacer sequence is underlined. A DSB (magenta carets with distance from the repeat centre indicated) is expected to drive reversion to the wild-type sequence (half red/half blue text). Sequence underlined with red and blue bold lines in target site 6 indicates an alternate 16-bp microhomology within this repeat.

Figue 11B: Percentage of 16-bp deletions (green) and total indels (blue) for guides shown in a based on UMI-based Illumina sequencing. B rs denote mean and dots indicate individual data points, n = 3 biological replicates. Figure 11C: Percentage of wild-type reverted alleles (16-bp deletion) among all alleles with insertions or deletions (indels) from b. Mean ± s.e.m., dots indicate individual data points n = 3 biological replicates.

Figure 12 presents exemplary data showing that PARP-1 inhibition decreases efficiency of MMEJ-based repair.

Figure 12 A: Experimental design. HPS1 B-LCL cells were treated with rucaparib 24 h before and after electroporation with SpyCas9 RNPs targeting the HPS1 locus and collected for subsequent UMI-based Illumina sequencing 15 .

Figure 12B: Percentage of microhomology (MH)-mediated deletion (green) and total indels (blue) in cells treated with SpyCas9 in the presence of 0, 10 or 20 mM rucaparib, measured by UMI-based Illumina deep sequencing. Bars denote mean and dots indicate individual data points n = 3 biological replicates.

Figure 12C: Percentage of microhomology- mediated deletion alleles among all other alleles with indels from Figure 12B. Mean ± s.e.m., dots indicate individual data points, n = 3 biological replicates. ****P = 0.00003, unpaired two tailed t- test.

Figure 12D: Left, alignment of resulting sequences observed by Illumina sequencing upon SpyCas9 RNP treatment of HPS1 B-LCL cells. Right, heatmap showing percentage of alleles generated by SpyCas9 for cells exposed to 0, 10 or 20 mM rucaparib. Gradient scale indicates the percentage occurrence of that sequence.

Figure 13 presents exemplary data showing that MMEJ-based approach efficiently achieves precise collapse of endogenous microduplications across various repeat lengths.

Figure 13 A: Non-pathogenic endogenous microduplications ranging in size from 4 bp to 36 bp. Microduplication repeats are shown as bold red and blue text. The SpyCas9 PAM sequence is shown in the magenta box and the LbaCasl2a PAM sequence is shown in the orange box. Anticipated DSBs produced by SpyCas9 and LbaCasl2a are denoted by magenta and orange carets, respectively.

Figure 13B: Percentage of microhomology-mediated deletion (green) and total indels (blue) produced at each endogenous site following SpyCas9 treatment, calculated using UMI-based Illumina sequencing. Bars denote mean and dots indicate individual data points n = 3 biological replicates.

Figure 13C: Percentage of microhomology-mediated deletions (green) and total indels (blue) produced at three endogenous sites when treated with SpyCas9 or LbaCasl2a. Bars denote mean and dots indicate individual data points n = 3 biological replicates.

Figure 14 show the disease-causing GATA microduplication (red-blue tandem segment) in the Tay-Sachs HEXA gene.

Figure 15 presents exemplary data showing indel/deletion ratios subsequent to HEXA gene editing with Casl2a RNPs in a Tay-Sachs patient-derived B-EBV cells with a Cas9:sgRNA concentration ratio of 60 pmol protein to 120 pmol guide RNA.

Figure 16 presents exemplary data showing representative sequence chromatograms of the edited HEXA genes, where sequencing is on the complementary strand.

Figure 17 presents exemplary data showing indel/deletion ratios subsequent to HEXA gene editing with Casl2a RNPs in a Tay-Sachs patient-derived B-EBV cells with a Cas9:sgRNA concentration ratio of 90 pmol protein to 180 pmol guide RNA.

Figure 18 presentes exemplary data showing the effect of rucaparib on the profile of microhomology- mediated deletion products at AAVS1 locus in patient-derived HPS1 B-LCL cells.

Figure 18 A: Schematic of two prominent DNA double-strand break repair pathways. A DSB can be repaired through various pathways that produce different DNA sequence end-products. The NHEJ pathway is the dominant DSB repair pathway in most cells. The MMEJ pathway uses end-resection to discover small homologies on each side of the break that can be used to template the fusion of the broken ends. PARP-1 regulates DSB flux through the MMEJ pathway. Treatment of cells with rucaparib— an inhibitor of PARP-1— attenuates DSB flux down the MMEJ repair pathway.

Figure 18B: Percentage of microhomology- mediated deletions (green) and total indels (blue) resulting from SpyCas9 treatment of cells in the presence of 0, 10 and 20 mM rucaparib. Bars show mean and dots show individual data points from three biological replicates based on UMI-based Illumina deep sequencing. Figure 18C: Percentage of 1-bp insertions (purple), microhomology mediated deletions (green) and other deletions (grey) produced by SpyCas9 RNP with a sgRNA targeting the AAVS1 locus with the addition of increasing amounts of rucaparib. Mean ± s.e.m. from three biological replicates based on UMI-based Illumina deep sequencing.

Figure 18D: Percentage of microhomology-mediated deletions out of total indels in cells treated with SpyCas9 in the presence of rucaparib. Mean ± s.e.m., dots represent individual data points from three biological replicates. P values determined using two-tailed unpaired t-test. ***P = 0.0004, ****P = 6.5 x 10 7 . Figure 18E: Left, alignment of allele sequences obtained from deep sequencing analysis from samples treated with SpyCas9 RNP in the presence of different rucaparib concentrations. Microhomologies present at the AAVS1 locus are shown in by red, green and blue. Microhomology-mediated deletion is indicated by two-toned text. Magenta carets indicate site of DSB created by SpyCas9. Inserted bases (ins) are shown in purple, deleted bases (del) are shown as black dashes. Right, heatmap depicting the percentage of alleles generated after SpyCas9 treatment of cells in the presence of different concentrations of rucaparib (0, 10 or 20 mM). The blue colour gradient scale indicates the percentage of occurrence of that sequence. Heatmap represents mean values from a total of three independent biological replicates.

Figure 19 presents exemplary data showing gene editing with SpyCas9 and LbCasl2a at endogenous microduplications.

Figure 19A: Percentage of microhomology-mediated deletions out of total indels at endogenous sites in cells treated with SpyCas9 and LbaCasl2a. Mean ± s.e.m., dots represent individual data points from three biological replicates.

Figure 19B: Schematic of endogenous site containing a 24-bp microduplication for SpyCas9 target sites 1-3. The 24-bp microduplication repeats are shown in bold red and blue. The PAM sequence is outlined in magenta and the protospacer sequence is underlined. Magenta carets indicate the site of DSB.

Figure 19C: Percentage of alleles with 24-bp deletion (green) and total indels (blue) for all three guides from TIDE analysis. Guide 3 produces primarily 23-bp deletions, but not 24-bp deletions, probably because it recuts the collapsed DNA sequence. Bars shows the mean from n = 3 biological repeats, individual data points are represented by dots.

Figure 19D: Proportion of the 24-bp deletion out of total indels as individual data points (dots), with mean ± s.e.m. n = 3 biological repeats.

Figure 19E: Schematic of endogenous site containing a 27-bp microduplication for SpyCas9 target sites 1 and 2.

Figure 19F: Percentage of alleles with 27-bp deletion (green) and total indels (blue) for both guides from UMI-based Illumina deep sequencing. Bars show the mean from n = 3 biological repeats, individual data points are represented by dots. Figure 19G: Proportion of the 27 -bp deletion out of total indels as individual data points (dots) with mean ± s.e.m. n = 3 biological replicates.

Figure 20 presents exemplary data showing indel populations resulting from SpyCas9 editing at the TCAP locus.

Figure 20A: Indel percentages resulting from SpyCas9 RNP treatment in patient- derived iPSCs homozygous for the 8-bp microduplication or in wild-type iPSCs. Mean ± s.e.m. from three biological replicates.

Figure 20B: Breakdown of indel classes resulting from SpyCas9 treatment of myoblasts derived from patient-derived LGMD2G iPSCs. Mean ± s.e.m. from three biological replicates.

Figure 20C: Sequence alignment of the edited alleles resulting from SpyCas9 RNP treatment of LGMD2G iPSCs. Red and blue text indicates DNA repeats that constitute the microduplication, and collapse is indicated by half red and half blue text. Dashes indicate deleted bases and purple text indicates inserted bases. Data are from one biological replicate out of three independent biological replicates. Figure 20D: Sequence alignment of the edited alleles resulting from SpyCas9 RNP treatment of myoblasts derived from patient-derived LGMD2G iPSCs. Data are from one biological replicate out of three independent biological replicates. Figure 21 presents exemplary data showing PacBio long-read sequencing analysis for SpyCas9-edited LGMD2G iPSCs at the TCAP locus. Figure 21A: Percentage of gene modification observed from PacBio sequencing (one replicate from Fig. 10C out of three biological replicates). Green, alleles containing the 8-bp deletion; grey, other small indels (<100 bp); blue, large insertions (0.14%, not visible on the graph); maroon, large deletions (>100 bp). Figure 21B: IGV graphs depicting representative reads obtained for unedited (top) and edited (bottom) LGMD2G iPSCs, spanning a genomic region of about 2,035 bp surrounding the TCAP target site. Red carat indicates the 8-bp deletion site. Data represent one replicate out of three independent biological replicates.

Figure 22 presents exemplary data showing PacBio long-read sequencing analysis of SpyCas9-edited LGMD2G iPSCs clones and a complex colony at the TCAP locus. IGV graphs depicting representative reads obtained for clonal isolates of edited LGMD2G iPSCs (Figure 10D), spanning a genomic region of about 2,035 bp surrounding the TCAP target site. The genotype of the clones (deduced by Illumina deep sequencing) is indicated beside an

enlargement of the TCAP target region within the PacBio data. The sequences of the two alleles (listed above the IGV plot) obtained from sequencing are shown with repeats in red and blue. Alleles that reverted to wild-type as a result of collapse of microduplication are half red/half blue. Bottom, IGV plot for one complex iPSC colony that appears to have been nucleated by more than one cell, with large deletions present in the genome (sizes indicated).

Figure 23 presents exemplary data showing Detection of telethonin expression by flow cytometry in patient-derived cells treated with SpyCas9.

Figure 23 A; Contour plots from a representative flow cytometry assay to detect telethonin expression in healthy control cells (TCAP +/+ ), patient cells (TCAP /_ ), and SpyCas9-treated homozygous and heterozygous iPS clone-derived myoblasts differentiated for 10 days in culture. Plots are representative of three independent replicates.

Figure 23 B: Histograms from a representative flow cytometry assay to detect telethonin expression. Left, overlay of anti-telethonin antibody staining for four representative samples for different TCAP genotypes. Right, comparison between patient cells and healthy control cells, and SpyCas9-treated homozygous and heterozygous iPS clone-derived myoblasts differentiated for 10 days in culture. Histograms are representative of three independent replicates. Figure 23C: Cells were selected by removing cell debris first as shown by gate PI, and then single cells were selected from Pl by removing clustered cells as shown by gate P2. The cells in gate P2 were used for flow analysis. Plots are representative of one biological replicate.

Figure 23D: Average percentage of telethonin-expressing cells from two technical replicates of three biological replicates. Error bars indicate s.e.m (n = 6) and circles represent individual data points. P values (0.33 for patient versus heterozygous and 0.04 for patient versus homozygous clones) were calculated by two-sided Student’s t-test.

Figure 23E: Western blot showing validation of anti-telethonin antibody (Santa Cruz Biotechnology). Human muscle lysate and lysate from HEK293T cells transfected with haemagglutinin-tagged-telethonin expression construct were separated on an SDS 4-12% acrylamide gradient gel and the resulting blot was probed with anti-telethonin antibody.

Figure 24 presents exemplary data showing a standard curve generated with genomic DNA of wild-type and HPS1 mutant B-LCLs from UMI-based Illumina deep sequencing.

Genomic DNA from wild-type cells and HPS1 cells homozygous for the 16-bp microduplication were mixed at different ratios (x-axis). These mixed DNAs were used for the construction of a UMI-based Illumina library to determine the ratio of the alleles through deep sequencing (y- axis). These data are fitted to a regression line with the R2 value reported n = 1 biological replicate.

Figure 25 presents exemplary data showing an Indel spectrum generated by SpyCas9 editing at the HPS1 locus in HPS1 B-LCL cells. Indel spectra of SpyCas9 nuclease cells treated with different sgRNAs determined by UMI-based Illumina deep sequencing. Red bar indicates l6-bp deletion that corresponds to the deletion of one of the microduplication repeats. Data show indel spectra from one representative biological replicate out of three independent biological replicates.

Figure 25A: Target site 1.

Figure 25B: Target site 2.

Figure 25C: Target site 3.

Figure 25D: Target site 4. Figure 25E: Target site 5.

Figure 25F: Target site 6.

Figure 26 presents exemplary data showing pathogenic microduplications and their prevalence in human populations.

Figure 26A: Number of insertion variants of length >1 bp that are annotated as Pathogenic or Pathogenic/likely pathogenic in ClinVar. Variants are binned by length, with all those of length 40 bp or greater combined. The insertions (grey) are stratified into progressively finer categories: duplications (red);‘simple’ duplications (described in text, orange); and the subset of these observed at least once in gnomAD exome/genome databases (green).

Figure 26B: Number of insertion variants of length >1 bp that are observed at least once in the‘coding’ regions of the gnomAD exome/genome databases. As above, insertions (grey) are stratified into progressively finer categories;

duplications (red);‘simple’ duplications (orange); the subset of these listed in ClinVar (cyan); and the subset annotated as Pathogenic or Pathogenic/likely pathogenic in ClinVar (green). Cyan and green bars are not visible at this resolution.

Figure 27 presents an exemplary bioinformatics pipeline for identification of disease alleles. Schematic shows the bioinformatics pipeline used to identify all microduplications amendable to efficient MMEJ -mediated collapse from the‘coding’ regions

(exome_calling_regions.vl; mainly exons plus 50 flanking bases) in the gnomAD genome and exome databases (version 2.0.2). Insertion variants observed in both databases were used for analysis (variants occurring in both databases were counted once). Insertions that do not add a repeat-unit to an existing tandem repeat and are not themselves a perfect repeat were filtered to constrain only duplications that spanned 2-40 bp in length and are amendable to CRISPR-Cas9 targeting. This data set was then cross-referenced against the ClinVar database

(clinvar_20l 80225. vcf) to apply further filters for variants reported as pathogenic, which ultimately yielded 143 likely disease-causing microduplications. Detailed Description Of The Invention

The present invention is directed to the field of gene therapy. In particular, compositions and methods are disclosed that repair gene microduplication mutations by reversion to a wild type sequence. For example, the creation of double stranded breaks by a nuclease protein induces the microhomology mediated end joining DNA repair pathway that corrects the microduplication back to the wild type sequence without the assistance of an exogenously supplied donor DNA.

In one embodiment, the present invention contempates a subset of disease-causing alleles within the human population that are the product of small duplications (microduplications of 1 to 40 base pairs) within a gene sequence. These alleles occur in human subpopulations with substantial frequencies and result in rare diseases such as Limb Girdle Muscular Dystrophy 2G (LGMD2G) [Nigro, V. & Savarese, M. Genetic basis of limb-girdle muscular dystrophies: the 2014 update. Acta Myol 33, 1-12 (2014)], Tay-Sachs Disease[Femandes Filho, J. A. & Shapiro, B. E. Tay-Sachs disease. Arch. Neurol. 61, 1466-1468 (2004).], and Hermansky-Pudlak syndrome (HPS)[ El-Chemaly, S. & Young, L. R. Hermansky-Pudlak Syndrome. Clin. Chest Med. 37, 505-511 (2016).] among others (Table 1).

In one embodiment, the present invention contemplates a method demonstrating that disease- causing microduplications can be reverted to the wild-type sequence simply through the generation of a DSB near the center of the duplication, enabling development of simplified Cas9- based therapeutic interventions tailored to each disorder. Our discovery was based initially on the theoretical idea that a nuclease-generated DSB would harness a common cellular DNA repair pathway - microhomology mediated end joining (MMEJ). Sfeir et al.,“Microhomology- Mediated End Joining: A Back-up Survival Mechanism or Dedicated Pathway?” Trends

Biochem Sci 40:701-714 (2015). MMEJ utilizes small regions of sequence homology on each side of the break to collapse the DNA sequence. See, Figure 8. The idea of microhomology collapse of sequences has been observed in programmable nuclease editing data for some time. Bae et al.,“Microhomology-based choice of Cas9 nuclease target sites” Nature Methods 11:705- 706 (2014). However, the realization that it could be applied to disease correction to achieve highly efficient reversion to the wild-type sequence has not been described.

The data presented herein demonstrates a successful, efficient correction of disease-causing alleles in patient-derived cell lines harboring microduplications including, but not limited to, TCAP (LGMD2G) and HPS1 (HPS). The data shows that this correction can be successfully performed in iPSC, stem cell progenitor cells and adult somatic cells, opening up multiple route for the delivery of a nuclease-based therapy. Based on a computational analysis of human allele variants described herein, more than 100 diseases have been identified that should be amenable to this type of genetic correction. As the introduced nuclease is programmed to target a mutant DNA sequence, the reverted wild-type sequence is not a substrate, and thus should be stable even in the presence of the nuclease. Furthermore, microhomolgy-mediated correction does not require a DNA cassette to regenerate the wild-type sequence, only the transient delivery of the nuclease (e.g. Cas9 and its sgRNA) to target the locus. The demonstrated high rate of correction for these two distinct genetic disorders suggests that our correction approach will have broad application to a wide variety of important genetic disorders associated with microduplications for which there are no therapeutics currently available, providing patients with a definitive cure.

Although it is not necessary to understand the mechanism of an invention, it is believed that targeting a double strand break to a microduplication can cause the collapse of the microduplication back to the wild-type sequence with high efficiency and that this might be used to correct disease alleles without the need for a DNA repair template.

Current programmable nuclease-based methods (for example, CRISPR-Cas9) for precise correction of a disease-causing genetic mutation harness the homology-directed repair pathway. However, this repair process requires co-delivery of an exogenous DNA donor to recode the sequence and can be inefficient in many cell types. In some embodiments, the present invention contemplates disease-causing frameshift mutations resulting from microduplications which can be efficiently reverted to the wild-type sequence simply by generating a double-stranded break near the centre of the duplication. It has been demonstrated herein using patient-derived cell lines: for example, limb-girdle muscular dystrophy 2G (LGMD2G) 1 , Hermansky-Pudlak syndrome type 1 (HPS1) 2 and Tay-Sachs Disease. Clonal analysis of inducible pluripotent stem cells (iPSCs) from the LGMD2G cell line, which contain a mutation in TCAP, treated with the Streptococcus pyogenes Cas9 (SpyCas9) nuclease revealed that about 80% contained at least one wild-type TCAP allele; this correction also restored TCAP expression in LGMD2G iPSC- derived myotubes. SpyCas9 also efficiently corrected the genotype of an HPS1 patient-derived B-lymphoblastoid cell line. Inhibition of polyADP-ribose polymerase 1 (PARP-1) suppressed the nuclease-mediated collapse of the microduplication to the wild-type sequence, confirming that precise correction is mediated by the microhomology-mediated end joining (MMEJ) pathway. Analysis of editing by SpyCas9 and Lachnospiraceae bacterium ND2006 Casl2a (LbaCasl2a) at non-pathogenic 4-36-base pair microduplications within the genome indicates that the correction strategy is broadly applicable to a wide range of microduplication lengths and can be initiated by a variety of nucleases. Finally, LbaCasl2a was employed to achieve precise correction of the four base pair duplication in HEXA Tay-Sachs patient-derived B- lymphoblastoid cell line. The simplicity, reliability and efficacy of this MMEJ-based therapeutic strategy should permit the development of nuclease-based gene correction therapies for a variety of diseases that are associated with microduplications.

I. Double Stranded Deoxyribonucleotide Break Repair Mechanisms

MMEJ is an error-prone double-stranded break (DSB) DNA repair pathway that uses regions of microhomology (2-25 bp) on each side of a DSB to define the boundaries at which DNA segments are rejoined . This mutagenic process generates deletions that result in the loss of one of the repeat sequences and the intervening region. See Figures 10A and 18. Hallmarks of MMEJ repair on DNA products generated through editing of programmable nucleases have been observed in a variety of cell types and their effect on gene inactivation rates has been

appreciated 4,5 . The MMEJ pathway has also been harnessed for the targeted insertion of exogenous donor DNAs in mammalian cells and zebrafish and frog embryos 67 . Herein, a nuclease-based therapeutic approach is described that harnesses the MMEJ pathway to precisely correct frameshift mutations resulting from microduplications (e.g., tandem duplications). It was reasoned that MMEJ-based repair of a programmable nuclease-induced DSB near the centre of a disease-causing microduplication would achieve precise reversion to the wild-type genomic sequence. This strategy might be an effective alternative to homology-directed repair-based gene correction approaches and would not require co-delivery of a donor DNA. Furthermore, the reverted wild-type sequence would no longer be complementary to the single-guide RNA (sgRNA) targeting the microduplication, leading to stable correction even in the presence of Cas9 nuclease.

To evaluate the efficacy of the presently contemplted MMEJ-based correction strategy, LGMD2G and HPS1 were selected as exemplary diseases that affect different human tissues and whose causes include pathogenic microduplications of different lengths. Both of these diseases are autosomal recessive disorders that are represented at modest frequencies in different human subpopulations and currently have no treatments. One of the disease alleles identified in LGMD2G patients features an 8-bp duplication in exon 1 of TCAP, a mutation that is found in the East Asian population at a frequency of approximately 1 in 1,000 alleles. TCAP encodes the telethonin protein, a l9-kDa cardiac and striated muscle-specific structural protein located in the Z-disc of sarcomeres that links titin proteins to stabilize the contractile apparatus for muscle contraction 8 . Homozygous or compound heterozygous inactivating mutations in TCAP manifest as severe muscle atrophy and cardiomyopathy that typically develop during late adolescence into early adulthood 1,9 .

The double strand breaks (DSBs) that are generated within the genomes of eukaryotic systems are potentially repaired by a number of different DNA-damage response pathways such as canonical non-homologous end joining (cNHEJ), homologous recombination (HR), and alternate non-homologous end joining (aNHEJ). McVey et al.,“MMEJ repair of double-strand breaks (director's cut): deleted sequences and alternative endings” Trends in Genetics 24:529- 538 (2008). cNHEJ is a precise repair pathway where ends are rejoined and typically reconstitute the original DNA sequence. HR uses a DNA template with homology to sequences flanking the DSB to copy a homologous sequence to repair the broken site. aNHEJ is a mutation prone process that utilizes resection of 5’ ends of the DSB to complete the repair. The

Microhomology Mediated End Joining (MMEJ) pathway involves rejoining the DNA ends using short regions of homology on each side of the break (e.g., usually >2 bases) where the intervening sequence is deleted. See, Figure 1.

When artificial nucleases are introduced into the cell to target the genome, the DSBs that are generated are likely to proceed down the cNHEJ pathway where they are precisely repaired, which restores the existing nuclease target sequence, whether wild type or mutated. Eventually, however, mutations are inevitably generated that disrupt the target site. Sequencing information on these deletions suggests that in many instances the resulting deletion mutations are generated by MMEJ, due to the sequence scars that contain microhomologies that are are both sides of the break. Analysis of Cas9 nuclease DNA target sequences suggests that there is a correlation between the efficiency of collapse and the length of the microhomology on each side of the break. Bae et al.,“Microhomology-based choice of Cas9 nuclease target sites” Nature Methods 11:705-706 (2014). DSBs at most genomic sites are repaired primarily through the NHEJ pathway, which can produce small insertions or deletions during imprecise repair (for example, AAVS1). 28 See, Figure 18. The data presented herein, which span DSBs in twelve sequences, indicate that microduplications are preferentially repaired via the MMEJ pathway, which yields predictable and efficient collapse. For this class of pathogenic mutations, precise repair via the MMEJ pathway provides a favourable alternative to homology-directed repair, which is inefficient in many cell types 29 . Consistent with the present findings, MMEJ-mediated repair was recently used to efficiently correct the pathogenic microduplication associated with HPS1 30 . Although the use of allele frequencies from gnomAD can help to prioritize potential targets for MMEJ- based repair, this underestimates the extent of genetic diseases— particularly dominant ones— caused by microduplications.

II. Microhomology Mediated End Joining Disease Mutation Repair

To test the generality of the presently contemplated MMEJ-based repair approach and the range of sequence lengths over which duplication collapse is efficient, editing products generated by SpyCas9 targeting endogenous microduplications within the human genome were evaluated.

A bioinformatic analysis was peformed to identify non-pathogenic, unique endogenous microduplications ranging from 4 bp to 36 bp in length in the human genome. See, Figure 13 A. The efficiency of microduplication collapse resulting from a SpyCas9 produced DSB at the centre of the microduplications in HEK 293T cells at these sites was examined. Although the bulk editing rate varied across these target sites, it was consistently found that duplication collapse was the major end-product within the edited alleles (ranging from 45% to 93%), regardless of the microduplication length. See, Figure 13B and Figure 19A. Consistent with the analysis at an HPS 1 locus, a decrease in the duplication collapse efficiency was observed for 24- and 27-bp-long microduplications as cut sites were moved away from the centre. See, Figures 19B - 19G.

Whereas SpyCas9 generates blunt DSBs, the type V CRISPR-Cas nuclease Casl2a generates DSBs with 5’ overhangs 19 . It was then investigated whether LbaCas 12a- generated breaks might be preferentially repaired by a resection-dependent pathway such as MMEJ by comparing the efficiency of microduplication collapse engendered by SpyCas9 and LbaCas 12a nucleases at three endogenous sites. Efficient repeat collapse (50-90% of edited alleles) could be achieved with LbaCasl2a at all three of these sites, with efficiencies similar to those of SpyCas9. See, Figure 13C and Figure 19A. In addition, LbaCasl2a could drive repeat collapse for the four base pair duplication in HEXA that is associated with Tay-Sachs Disease. See, Figures 14 - 17. Overall, these data demonstrate that the MMEJ-based editing approach can be used to efficiently collapse microduplications up to lengths of at least 36 bp using either Cas9 or Casl2a programmable nucleases.

Recently, an algorithm has been developed to more reliably predict target loci that would be predisposed to generate a more homogeneous mutant allele population through MMEJ. Ata et al.,“Toward Precision Molecular Surgery: Robust, Selective Induction of Microhomology- mediated End Joining in vivo” BioRxiv, (posted online Mar. 28, 2018). Thus, the goal of this algorithm was to identify sites in genes where the generation of a double strand break (DSB) will be repaired through the use of microhomologies on each side of the break to collapse the DNA sequence such that it is out-of-frame with regards to its translation and thus will not produce a functional protein. Termed the“MENTHU” algorithm, it appears primarily to be a way of post processing predictions generated from an earlier reported algorithm (Bae et al.,

nature.com/articles/nmeth.30l5 (2014)) to improve the prediction for when a DSB will be repaired by MMEJ in a fairly homogeneous way. This is useful if one wants to do precision genome editing, whereas Bae et al were considering the blunter application of making (any) out- of-frame deletions for gene knock-out.

The Ata et al. paper invites users to access this algorithm to facilitate the scanning of reference wild-type genes using Genbank IDs or RefSeq IDs to identify sites that will collapse primarily through a single MMEJ event down to a specific sequence genesculpt.org/menthu/. The Ata et al. algorithm is designed for the primary application of making knockouts in model organisms, e.g. the source-code repository for MENTHU has the subtitle "MENTHU knockout site recommender". Consequently, Ata et al. discloses making mutants in zebrafish embryos through the injection of a programmable nuclease (TALENs or SpCas9), and then analyzing the resulting genetic products and phenotypes of these mutant animals.

Although the MENTHU algorithm appears to be set up to analyze genes, in principle any DNA sequence can be evaluated, e.g. with variant alleles and flanking sequence, but this is user dependent - not a function of the algorithm. In addition, most of the known pathogenic variant alleles that are duplications cause frame-shifts, and the algorithm is not set up to define going from an out-of-frame sequence to an in-frame sequence, let alone restoring the wild-type sequence.

In some embodiments, the present invention contemplates an alternative method that is focused on capturing abutting duplications within the ExAC database or gnomAD databases - a database of variants identified in whole-genome and whole-exome sequencing data aggregated from many large-scale projects (and subsuming the earlier ExAC exome-only database) - that may be suitable for MMEJ repair. Importantly, the basic representation of variants in gnomAD lists the genomic position, reference (REF) sequence starting at that position, and alternate (ALT) sequence starting at that position; it is not typically readily apparent if a variant is a duplication, as typically only the base immediately preceding an insertion is used as the reference allele, whereas to establish whether the inserted sequence is a duplication requires examining more of the flanking reqions (e.g. the HEXA duplication has REF=G, ALT=GGATA, where only a single copy of the duplication is present). See, Tables 5 and 6 Furthermore, the gnomAD webpages and downloadable vcf files are not compatible with the MENTHU program in their raw form: the webpages for variants show surrounding genomic reference sequence only as a PNG graphic (not in text form) or via links to the UCSC genome browser for the reference genome; the vcf files sometime indicate when variants are duplications in the HGVSc fields added by Ensembl VEP, but again these files do not directly provide sequence of the duplication (both reference-copy and extra inserted copy) together with enough genomic flanking sequence to use for identifying cleavage sites that would be suitable for MMEJ. This alternative technology rebuilt the surrounding genomic sequence and identified common positions for nuclease cleavage around these duplications that could be tested to achieve collapse of the duplication and restore the wild-type sequence. Never is this concept mentioned in the

MENTHU manuscript or algorithm.

In addition, the present invention - unlike the Ata et al. algorithm captures allele frequencies that allow the prioritization of potential targets based on the associated diseases, where the information on pathogenicity is extracted from the ClinVar database and combined with gnomAD and 1000 Genome Project phase 3 databases to determine how common the variants are overall and in specific human subpopulations.

Thus, the embodiments contemplated herein represent a completely novel analysis of a human genome variant database to extract information of disease alleles that may be amenable to gene correction by replacing microduplication mutations sequences with their requisite wild type sequences via an MMEJ strategy.

III. Gene Microduplication Diseases

There are a number of diseases that have causative alleles within the human population that are associated with microduplications within the genome. See, Table 1.

Table 1: Exemplary Disease alleles associated with microduplications

There are likely to be many more microduplications that are associated with diseases. But most disease phenotypes have not been linked to a specific microduplication. For example, -90%

GW AS disease-associated SNPs are found in non-coding sequences, though which variants are themselves causal, as opposed to being in linkage disequilibrium with causal varaints, is in many cases not yet known. Hindorff et al.,“Potential etiologic and functional implications of genome- wide association loci for human diseases and traits” Proceedings of the National Academy of Sciences 106:9362-9367 (2009). In addition, repeat expansion diseases (e.g., Huntington’s disease, ALS [C90RF72], etc.) could be thought of as extended microduplications as well.

In one embodiment, the present invention contemplates a method for reverting a gene comprising a nucleotide microduplication mutation to a wild-type sequence. In one embodiment, the method comprises generating a DSB near the center of the nucleotide microduplication. In one embodiment, the nucleotide microduplication causes a disease. In one embodiment, the DSB is created by targeting a nuclease to the nucleotide microduplication center. In one embodiment, the nuclease includes, but is not limited to Cas9, CRISPR, Casl2 (Cpfl), zinc finger nucleases and/or TALEN. Although it is not necessary to understand the mechanism of an invention, it is believed that since the nuclease is targeting a mutated sequence, once the mutation reversion to a wild type sequence has occurred, the repaired target sequence would no longer be recognized by the nuclease, and thus remains a wild type sequence in the presence of the repairing nuclease. It is further believed that a correction DNA cassette is not needed for an MMEJ repair back to the wild-type sequence, only the nuclease (e.g. Cas9) and a targeting moiety having affinity for the mutant locus (e.g. sgRNA).

The data presented herein describes successful correction of disease causing alleles in patient-derived cell lines harboring microduplications in TCAP and HPS1. A high rate of correction is achieved in patient cells lines through the delivery of a nuclease suggesting that nuclease-induced MMEJ repair of microduplications within a genome can be programmed for other gene microduplication targets causing other diseases (e.g. HEXA - Tay-Sachs syndrome, other diseases in Table 1) leading to cures for these diseases.

A. TCAP and HSP1 Microdu plication Repair

The site-specific nuclease, S. pyogenes Cas9 (SpCas9) was used in the following therapeutic gene editing method. Jinek et al.,“A programmable dual-RNA-guided DNA endonuclease in adaptive bacterial immunity” Science 337:816-821 (2012). Nonetheless, it is contemplated herein that similar results can be obtained using any Cas9 (or CRISPR), a Cpfl nuclease or any other programmable nuclease system including, but not limited to, zinc finger nucleotide (ZFN), TALEN, mega-TAL or meganuclease all of which can be targeted to a gene microduplication sequence. The data presented herein show two different proof-of-principle targets (TCAP and HSP1) that may have therapeutic value. Both of these diseases are associated with substantial morbidity, and no curative therapies are currently available.

The mutant TCAP allele contains an 8 base duplication that leads to an out of frame coding sequence. UCSC: genome.ucsc.edu/cgi-bin/hgTracks?db=hgl9&highlight=hgl9.

chrl 7%3A37821635-37821635 &position=chrl 7%3A37821610-37821660. This TCAP allele has a frequency of ~1 in 1000 in the east Asian population gnomad.broadinstitute.org/ variant/17-37821635-G-GCGAGGTGT. Individuals with homozygous inactivating mutations in TCAP have Limb Girdle Muscular Dystrophy 2G (LGMD2G).

The mutant HPS1 allele contains a 16 bp duplication that leads to an out of frame coding sequence, gnomad.broadinstitute.org/variant/ 10-100183554-T-TGGGCCTCCCCTGCTGG. This allele has a frequency of ~l in 21 in populations within Puerto Rico. MPH, S. E.-C. M. & MD, L. R. Y. Hermansky-Pudlak Syndrome 1-7 (2017). Individuals with homozygous inactivating mutations in HPS1 have Hermanksy-Pudlak syndrome (HPS1).

B-EBV cells were obtaned from a patient that contains a homozygous 16 bp

microduplication in the HPS1 gene with SpCas9 by nucleofection. ICE (similar to TIDE 16 ) analysis of sanger sequence chromatogram from SpCas9 treated HPS1 B-EBV cells. The estimated mutagenesis rate is 41% with 30% of the alleles containing a 16 bp deletion (red arrow), which is a reversion to the wild-type sequence. Zero (x-axis) is no change in the length or composition of the 16 bp microduplication. See, Figure 9.

Patient-derived cells were obtained to test the potential for a nuclease targeting these deletions to revert the duplicated mutant allele. For TCAP, iPSCs were derived from fibroblasts from an individual that is a homozygous carrier of the 8 bp duplication. See, Figure 3. For HPS1, B-EBV cells were purchased from Coriell generated from a patient that is homozygous for the 16 bp duplication in HPS1 [GM14606]. For the nuclease system, a 3xNLS-SpCas9 protein was used complemented with sgRNAs (Synthego) for the target sequences. See, Table 2.

Table 2: Guide Sequences in sgRNAs targeting duplications

These Cas9-sgRNA complexes (e.g., Cas9 RNPs) were delivered by nucleofection to LGMD2G iPSCs, myoblast derived from LGMD2G iPSCs, or to the HPS1 B-EBV line. Following recovery and expansion of the nuclease-treated cells in culture the target genomic region was amplified by PCR from the population of treated cells and the mutagenic products were characterized by TIDE or ICE analysis of the sequence chromatograms. Brinkman et al.,“Easy quantitative assessment of genome editing by sequence trace decomposition” Nucleic Acids Research (2014). TIDE analysis of Cas9 RNP treated LGMD2G iPSCs revealed that -53% of the alleles were converted back to a wild-type length. See, Figure 3. ICE (Synthego) analysis of SpCas9 treated HPS1 B-EBV cells revealed that -30% of the alleles were converted back to a wild-type length in the context of a -41% total editing rate. See, Figure 4. In summary, approximately 75% of the edited HPS1 alleles were converted to wild-type length.

To confirm the TIDE analysis of TCAP alleles a deep sequencing analysis was performed on SpCas9 RNP treated iPSCs and iPSC derived myoblasts. See, Figure 5. The iPSC data is from two biological replicates and the myoblast data is from a single experiment. The data confirm that the majority of the editing products are micro-homology mediated deletion of one of the duplicate sequences. There are also a large number of additional sequence that have been shifted back in frame through mutagenesis - although they are not the wild-type coding sequence. These mutant in-frame sequences may also be functional.

Individual iPSC clones were taken from a SpCas9 RNP treated TCAP microduplication cell population and expanded to determine the genotype. A variety of different genotypes were observed within the clones that were analyzed. See, Figure 6. Two of the 24 clones that were analyzed were homozygous for the wild type (WT) allele. Six“clones” could not be defined conclusively - likely because the colonies were initiated from 2 cells generating more than 2 allele sequences. Overall the analysis of 18 clones demonstrate that the majority of iPSC clones (-75%) contain at least one corrected allele of wild type sequence. See, Figure 7.

In one embodiment, the present invention contemplates a method of differentiating SpCas9 treated iPSC clones into myoblasts to determine the number that display expression of the TCAP encoded protein telethonin.

The methods disclosed herein show an ability to precisely revert a microduplication back to its parental (e.g., wild type) sequence that can correct genetic microduplication mutations underlying of a number of diseases. Aside from those listed in Table 1 (supra) - there may be a number of diseases that stem from microduplications given the limited depth of genomic data that is associated with rare diseases.

An sgRNA was designed and tested for SpyCas9 to generate a DSB one base pair away from the middle of the TCAP 8-bp microduplication. See, Figure 10B. Purified SpyCas9 protein was complexed with a synthetic sgRNA (RNP) and electroporated into iPSCs homozygous for the TCAP microduplication that were derived from patients with LGMD2G. After four days, deep sequencing analysis was used to analyse the genomic region of interest for insertions and deletions (indels). Robust gene editing (about 80% indel rate) was observed, indicating that the SpyCas9 RNP can efficiently generate DSBs at this site. Closer examination of the sequence variants revealed that on average about 57% of the alleles contained a precise 8-bp deletion corresponding to the wild-type allele. See, Figure 10C and Figure 20A.

Notably, when introduced into wild-type cells containing functional TCAP, the SpyCas9 RNPs did not cause measurable editing at the TCAP allele, indicating that the corrected allele in the mutant cells is not subject to unintended damage following MMEJ-mediated reversion. See, Figure 10C. In addition to the precise 8-bp deletion, it was also observed that an additional approximately 17% of the alleles contained in-frame mutations, and therefore may encode hypomorphic alleles with some restoration of function. See, Figures 20A and 20C. Genotyping of 22 clones generated from a nuclease-treated LGMD2G iPSC population revealed that 77% contained at least one wild-type allele, indicating that the majority of nuclease-treated cells would be phenotypically corrected. See, Figure 10D. To independently verify the duplication collapse rates observed in edited iPSCs by Illumina short-read sequencing, a 2-kb amplicon was sequenced spanning the TCAP locus from a population of SpyCas9-edited iPSCs using the Pacific Biosciences long-read sequencing platform (PacBio). Analysis of these reads revealed that 67% of the edited alleles with insertions or deletions below 100 bp in length corresponded to the 8-bp collapse, which is similar to the 73% rate of 8-bp collapse determined by Illumina sequencing for this sample. See Figure 21. Treatment of cells with Cas9 nuclease can produce large deletions (>100 bp) at the target locus at a modest frequency 10 . Consistent with these findings, the PacBio analysis revealed the presence of large deletions (100-1,000 bp) that would not have been detected by Illumina sequencing at a frequency of about 2% in bulk edited iPSCs. A genotypically complex iPS cell colony was also isolated that harboured two large deletions at the TCAP locus. See, Figure 22.

To demonstrate the translatability of the present approach to muscle cell types, LGMD2G iPSCs were differentiated into proliferative skeletal myoblasts that can be induced to terminally differentiate into myotubes 11 . iPSC-derived myoblasts can repair damaged muscle in a similar way to myogenic satellite cells (one of the primary targets of gene therapy for myopathies). Myoblasts were electroporated with SpyCas9 RNPs programmed to target the 8-bp

microduplication. Following editing, about 45% of the alleles were precisely repaired back to the wild-type sequence. See, Figure 10E and Figures 20B & 20D. Immunostaining of myotubes derived from corrected LGMD2G iPSC clones with an anti-telethonin antibody showed that genetic correction restored telethonin expression. See, Figure 23. Collectively, these data show that introducing a DSB close to the centre of microduplication can efficiently achieve precise in vitro correction of the 8-bp microduplication associated with LGMD2G in iPSCs and in myoblasts that mimic cell populations that would be therapeutically targeted in vivo.

The present approach was further tested on a 16-bp pathogenic microduplication in exon 15 of HPS1, which is associated with HPS1 and leads to the production of a truncated protein responsible for this autosomal recessive disease 12 . HPS1 has a high prevalence in the Puerto Rican population, with a carrier rate of approximately 1 in 21 in the northwest region 2 . HPS proteins are involved in the biogenesis of lysosome-related organelle complexes (BLOCs), which are necessary for the proper trafficking of cargo to melanosomes, dense granules and

lysosomes . HPS1 patients suffer from albinism, bleeding disorders, vision loss and progressive pulmonary fibrosis, which leads to premature death 14 .

Gene correction efficacy was determined in a patient-derived B lymphocyte cell line (B- LCL) homozygous for the 16-bp microduplication by electroporating these cells with SpyCas9 RNPs programmed to cleave two base pairs away from the centre of the microduplication. See, Figure 11A (target site 1). To accurately assess the observed editing rates, unique molecular identifiers (UMIs) were added to the PCR amplicons during Illumina library construction to allow the removal of any amplification bias 15 . It was confirmed that this approach accurately captured the relative percentage of HPS 1 microduplication and wild-type alleles present in a series of test populations. See, Figure 24. At HPS1 target site 1, editing was observed at about 46% of the alleles with around 35% restored to the wild-type sequence. See, Figures 11B &

11C.

The effect of the position of the DSB within the microduplication was further examined on the efficiency of MMEJ-mediated repair by designing five additional sgRNAs that targeted the DSB to different positions relative to the centre of the microduplication See, Figure 11 A (target sites 2-6). As the break site was shifted away from the centre, there was a decrease in the efficiency of achieving the precise 16-bp deletion. See, Figures 11B & 11C. However, target sites 3 and 6 were notable exceptions to this trend. Target site 3 was observed to be quite efficient at generating indels to the exclusion of the l6-bp deletion, probably because the wild- type sequence, once regenerated, can also be targeted by this sgRNA for further mutagenesis. See, Figure 25. On the other hand, target site 6 achieved efficient deletion of the 16-bp microduplication (more than 50% of the modified alleles), despite being the most distal of the cleavage sites (10 bp from the centre of the microduplication). Its efficiency may be due to the extended regions of homology that surround the cleavage site at this end of the microduplication. See, Figure 11A (target site 6). Overall, these results demonstrate that the cleavage position within the microduplication and the presence of alternate regions of microhomology can influence the production of the desired wild-type end product. See, Figure 11C.

To investigate whether nuclease-mediated collapse of a microduplication occurs via the MMEJ pathway, a DNA repair factor (P ARP-1) that regulates DSB flux through this pathway was inhibited. PARP-l influences the repair of a DSB through resection-dependent DNA repair pathways, such as MMEJ 3 16 , which are in competition with the non-homologous end joining pathway (NHEJ) for DSB repair 17 . See Figure 18A. Inhibition of the catalytic activity of PARP- 1 by rucaparib reduces DSB flux through the MMEJ pathway, resulting in a decrease in microhomology-based deletion products in the resulting repair events 18 . See, Figure 18A.

Patient-derived HPS1 B-LCL cells were treated with 10 mM or 20 mM rucaparib before and after treatment with SpyCas9 RNP to suppress MMEJ-mediated repair of DSBs. See, Figure 12A.

An overall reduction in editing rates was observed at the HPS 1 locus upon rucaparib treatment. See, Figure 12B. These lower editing rates were primarily the result of a reduction in the 16-bp deletion product, which decreased from about 50% in untreated cells to around 15% and 6% in cells treated with 10 pM and 20 pM rucaparib, respectively. See, Figures 12B - 12D. A similar reduction in microhomology-based deletions was observed with SpyCas9 RNP targeting the AAVS1 locus in patient-derived HPS1 B-LCL cells. See, Figure 18. Thus, the MMEJ pathway underlies the robust correction of the microduplications for LGMD2G and HPS 1 in the presence of a targeted DSB.

B. Tay-Sachs Disease (HEXA gene)

In one embodiment, the present invention contemplates a method for HEXA editing by Casl2a to correct a mutated sequence of the Tay-Sachs locus.

Two different Casl2a (also known as Cpfl) orthologs (LbCasl2a and FnCasl2a) were tested for their ability to drive microhomology-mediated end joining (MMEJ) to collapse the common GATA microduplication in HEXA that is associated with Tay-Sachs disease. The GATA'GATA duplication (red and blue segments) results in a frameshift within the gene that inactivates it and leads to Tay-Sachs if both HEXA alleles are disrupted). See, Figure 14. This allele occurs with a frequency of ~1 in 100 individuals in some Jewish populations. crRNAs were designed to target Casl2a cleavage to the region spanning the microduplication to revert it to the wild-type sequence through MMEJ repair. One crRNA was designed for FnCasl2a to utilize a TTC PAM (FnCasl2a Guide). See, Figure 14. Two crRNAs were designed for LbCasl2a to utilize either a CTTC PAM (LbCasl2a Guide 1) or a TTCC PAM (LbCasl2a Guide 2). See, Figure 14. For LbCasl2a, these PAMs are not the optimal TTTV sequence, which may result in lower activity.

crRNAs (120 pmol) were complexed with 60 pmol of purified FnCasl2a-2xNLS or LbCasl2a-2xNLS protein and then electroporated into a B-EBV cell line that is homozygous for the GATA microduplication in HEXA (Coriell GM11852). See, Table 3.

Table 3: crRNA Sequences for crRNAs targeting HEXA duplication

In the crRNA sequences the constant region is in bold. Double underline indicates the base pairing regions of the hairpin stem. Single underlined sequence is the guide sequence (23nt) After 72 hours the genomic DNA from treated cells were harvested and the genomic region of interest within HEXA was PCR amplified and submitted for Sanger sequencing. Mutation rates were determined by TIDE analysis (tide.deskgen.com) in comparison to an unedited sequence chromatogram from the same genomic region. Total indels were modest (~5 to 10%). See, Figure 15 (blue bars). A reversion to the wild-type sequence was observed in all of the samples (brown bars), where for LbCasl2a guide 2 the majority of the alleles that were edited restored the desired wild-type sequence. The experiment was performed in biological triplicate, where the error bars represent the standard error of the mean.

Representative sequence chromatograms show sequencing on the complementary strand. See, Figure 16. The TATC duplication (complement of GATA) is boxed in magenta and the respective guide target sequences for each nuclease are underlined in green.

The concentration of the delivered Casl2a:crRNA was then increased for each nuclease: guide combination from 90pmol to 180pmol. The editing rates after electroporation of the HEXA GATA duplication in the B-EBV line in a single experiment were improved (cyan bars) and the rate of wild-type sequence reversion was also increased, reaching nearly 10% for the LbCasl2a guide 2 treated cells (orange bars). See, Figure 17. These data demonstrate the feasibility of reverting the mutant allele to the wild-type DNA sequence through the introduction of a targeted double-strand break without the need of a donor DNA sequence (or homology directed repair) for this restoration.

Those in the art would appreciate that the current data showing the correction disease- causing alleles for two different diseases provides an expectation that the technology has widespread applicability. Furthermore, as more diverse programmable nuclease systems are defined (e.g., CRISPR systems) that have broader targeting range and better delivery properties, this type of approach will become easier to perform in vivo. Although it is not necessary to understand the mechanism of an invention, it is believed that this approach may also work efficiently for genetic diseases based upon repeat expansion mutations if DSBs can be targeted just inside the edges of the repeat elements to allow the induction of long-range microhomology mediated repair.

IV. Genomic Microduplication Variants

To investigate whether this MMEJ-based therapeutic strategy can be applied more broadly for correcting human genetic disorders, a bioinformatic analysis was performed to gauge the prevalence of disease-causing microduplications in human populations. The ClinVar database includes about 4,700 duplications that are annotated as‘pathogenic’ or

‘pathogenic/likely pathogenic’ . See, Figure 26A. Duplications of lengths ranging from 2 to 40 bp were of particular interest because the data presented herein indicate that microhomologies within this range can be precisely repaired via the MMEJ pathway. See, Figure 13. ‘Simple’ duplications— those for which the duplicated sequence is not part of a more complex repeat structure— were also evaluated as to whether they improve the odds that the primary homology- based collapse would result in the desired wild-type sequence. Finally, all duplications in ‘coding’ regions (mainly exons plus 50 flanking bases) were examined from the gnomAD exome and genome sequencing databases to prioritize pathogenic duplications according to their frequencies in human populations. See, Figures 26A and 27. The present analysis yielded 143 likely disease-causing microduplications of lengths 2-40 bp that were observed at least once in gnomAD, some of which occur in specific subpopulations at substantial frequencies (for example, Tay-Sachs disease), See, Figure 26B.

To facilitate the utilization of a bioinformatics analysis, the present invention was accompanied by the creation of an interactive, searchable webtool

(rambutan.umassmed.edu/duplications/). This bioinformatices analysis also included the identification of potential Cas9 and Casl2a cleavage sites within these microduplications 22 . As shown within the tool,‘tiling’ data across HPS1 microduplications and endogenous

microduplication sites, the position of the DSB break within the duplication, and the use of a guide design that avoids cleavage of the wild-type allele, facilitate an efficient, stable collapse of microduplications. Rapid advances are being made in characterizing nucleases with alternate specificities ’ and in engineering nucleases with alternate or expanded recognition

25_97

preferences , which will make correction of disease-causing microduplications using the MMEJ-based approach even more effective.

The results below for the most part are based on the files of“coding” variants from gnomAD genomes and exomes, version 2.0.2. gnomad.broadinstitute.org/downloads.

This database comprises variants in the intervals used for the ExAC database. Most of these intervals correspond to exons plus 50 flanking bases on each side, and they collectively cover 60 million bases, about 2% of the genome. Note that there are no variant calls for the Y

chromosome, and these are not strictly all coding variants, as some are in introns, UTRs, miRNA, ncRNA.

The 1000 Genome Project data was taken from ftp.1000genomes.ebi.ac.uk

/voll/ftp/release/20130502/. The vc/ files there include precomputed allele-frequencies for five broad super-populations and allele-frequencies for 26 more-specific populations computed from the per-individual genotypes in the vcf files aggregated using the population assignments from the file integrated_call_samples_y3.20130502.ALL.panel.

The ClinVar annotations were taken from the file ftp.ncbi.nlm.nih.gov/pub/clinvar/ vcf_GRCh37/clinvar_20180225. vcf. gz. Here, the variants have been normalized (trimmed and left-aligned) for the purpose of matching them up, but the HGNC notation used at ClinVar may follow the right- aligned (3’ -most position) convention, in which duplications are taken to occur immediately after the repeated sequence rather than immediately before the repeated sequence. The gnomAD genome files contain a total of 4851138 distinct variant alleles, of which 145892 (~3%) are insertions. The gnomAD exome files above contain a total of 17009588 distinct variant alleles, of which 414576 (-2.4%) are insertions. Note that many of these variants are common to both the exomes and genomes, but in the tables below variants that occur in both are counted only once.

Table 4 below focuses on the insertions, and in particular the duplications. The second column (insertions) gives the counts of all the distinct insertion variant alleles, binned by the length of the insertion (length), with all variants of length at least 40 combined into one bin. Subsequent columns give the number of variants that satisfy additional criteria, as follows: dup: the insertion is an exact duplication of the immediately adjacent sequence in the GRCh37 reference genome (immediately 3’ with this normalization). Note that there may be polymorphism in this adjacent sequence that affect whether an insertion is indeed a perfect duplication for any given individual.

dup2: the insertion does not add a repeat-unit to what is already a (two-or-more unit) tandem repeat in the reference genome. This eliminates e.g. the duplication of CCCGGG in RAX2, as the reference genome already has two immediately adjacent (3’) tandem copies of this: https://www.ncbi.nlm.nih.gov/projects/SNP/snp_ref.cgi?rs=rs5 49932754 dup2i: the insertion satisfies the previous constraints and is not itself a perfect tandem repeat (e.g., for a duplicated six-mer, it is not of the form XXXXXX, XYXYXY or XYZXYZ). Note that even if a duplicated sequence is not in itself a perfect tandem repeat it may contain internal tandem repeats - e.g. the AGGAGG in the duplicated

AAGGAGGATC in NCF4— so depending on where the Cas9 cleavage site is this may need to be considered, to prevent a shorter internal microduplication from being collapsed instead of the full duplication.

dup2iC: the variant satisfies the previous constraints and is also listed in ClinVar. dup2iL: the variant satisfies the previous constraints and is reported in Clinvar as “Pathogenic”,“Pathogenic/Likely_pathogenic”,“Likel y_pathogenic” or

“Conflicting_interpretations_of_pathogenicity”

dup2iP: the variant satisfies the previous constraints and is reported in Clinvar as “Pathogenic” or“Pathogenic/Likely_pathogenic” Table 4: Microduplication Variant Characteristics In ClinVar And gnomAD Databases

Table 4 Totals:

Note that the filters used in columns dup2 and dup2i are included to increase the chances of MMEJ restoring the duplication to exactly its wild-type form, via removal of exactly one complete copy of the duplicated sequence, but these filters may not be strictly necessary when suitable positions in the duplication can be specifically targeted for cleavage.

A lot of duplications, do not appear annotated as“Pathogenic” in ClinVar. Certainly there are many variants listed in ClinVar that are not observed in either the gnomAD genomes or exomes, so are not accounted for in the table above, and this includes 2189 duplications that satisfy all the additional conditions for being in column dup2iP above. But 2183 of these are in these“coding” intervals, so if the variants had been observed at all in gnomAD they would have been reported in these vcfs. It also wouldn’t be surprising to miss variants that are extremely rare in general, or even not-terribly-rare variants that are concentrated in populations without many samples: with only -100 subjects per population in the TGP data one would expect to miss out on -13% of alleles with frequency 0.01 in these populations. And a few other possibilities:

• Subjects known to have severe pediatric disease were not included in the gnomAD dataset, so variants that cause these diseases may be under-represented, in particular those with dominant inheritance.

• About 8% of the genome was masked during the gnomAD variant calling (e.g. some repetitive sequence), so any ClinVar variants the fall in these regions will not be reported in gnomAD. But it appears that only one of the -13000 insertions from ClinVar falls in one of these masked region— a benign variant in SHOX1 which is masked since it’s in a PAR on the Y chromosome.

• gnomAD doesn’t report variants on the Y chromosome at all, whether in masked regions or not. But the only“Pathogenic” duplication on the Y chromosome in ClinVar is a single-base insertion, Y:2655380:C/CT in the gene SRY:

ncbi. nlm. nih. gov/clinvar/variation/470195/

The longest insertion reported in the gnomAD coding regions has length 621 , and there are 1431 insertions of length at least 100, but it’s possible that the detection sensitivity may decline for longer insertions.

The above described variants are listed below; they are mainly variants in UTRs or in intronic regions >50 bases from the nearest exons (and hence not in the“coding” intervals list). gnomAD and TGP vcfs are mainly variants in UTRs or in intronic regions >50 bases from the nearest exons. These sequences are expected to represent“Pathogenic” duplications with a length of at least 100 from ClinVar that satisfy the conditions of the column dup2iP above, none of which are observed in gnomAD. See, Table 5. The First base in the reference allele, the subequent bases are the inserted sequence

Table 5: Duplications Not Contained In“Coding“ Inverval List Or Having Length At Least 100 That Are In ClinVar But Not Present In Either ClinVar Or gnomAD Databases

Duplication variants were identified as annotated as“Pathogenic” or

“Pathogenic/Likely_pathogenic” in the ClinVar database (Table 4, dup2iP column), and observed in the gnomAD exome database. See, Table 6.

Table 6 has the following headings:

SEQ_DUP shows the duplicated sequence in upper-case (including the extra copy on the variant allele), and flanking sequence in lower case.

DUP_NUM labels the copies of the duplicated segment (1 for first copy, 2 for second). these positions are also color-coded yellow and cyan in the html table, but the colors are lost when exporting the table as a CSV or Excel file.

Cas9_Wa shows cleavage sites for Cas9 and xCas9 enzymes on the Watson strand, 3 bases left of PAM starts from PAM_FW_* columns.

Cas9_Cr shows cleavage sites for Cas9 enzymes and xCas9 on the Crick strand, 4 bases right of PAM starts from PAM_RC_* columns.

Cpfl_Wa shows approximate cleavage sites for Cpfl enzymes on the Watson strand, 19 bases right of PAM ends (from the PAM starts in PAM_FW_* columns and adjusted for motif widths).

Cpfl_Cr shows approximate cleavage site for Cpfl enzymes on the Crick strand, 18 bases left of PAM ends (from the PAM starts in PAM_FW_* and adjusted for motif widths). Table 6: Selected Genes Having Microduplication Variants

The +/-1 base differences in shifts between Watson and Crick tracks is so that cleavage positions are to the immediate left of the indicated base in both cases (which wouldn’t be an issue if we were labelling the spaces between bases rather than the bases themselves).

The Cpfl cleavage sites are staggered on the two strands, leaving an overhang in the double- stranded break, not indicated in these schematics

The cleavage sites are labeled according to the Legend column in the table of PAM sequences below, Table 9 with an upper-case letter is it’s the only matching PAM sequence, and a lower- case letter if it’s the first of more-then-one matching PAM sequence.

Motifs are scanned for in flanking regions of size 50 and the table includes flanking regions of size 25, so cleavage sites should be shown even if the PAM site itself does not fall within the displayed sequence (as the distance between the cleavage site and the furthest position in the PAM site is no more than 25 bases). The above tracks, from top to bottom are shown for specific genes: See, Table 6

The variants identified in Table 6 with insertion lengths between 2 and 40 were then prioritized for therapeutic applications where the following microduplications were identified. See, Table 7. The headings of Table 7 are as follows: Sequence ID: Arbitrary number assigned to each sequence. VARIANT: of the form CHR-POS-REF-ALT, where CHR is the chromosome and POS is the start position of the reference (REF) allele in GRCh37, and ALT is the alternate allele; variants have been left-normalized with vt. genome.sph.umich.edu/wiki/Vt.

INSERT_LENGTH: length in nucleotides of the inserted sequence in the variant. (This is one less than the number of characters in ALT, as the first character of ALT is the REF base within the genome.)

ALLELE_ID: allele ID from the ClinVar VCF (version clinvar_20l80225.vcf.gz)

GENEJNFO: of the form SYMBOL:ENTREZID, from the ClinVar VCF. Note: some variants have more than one gene listed in GENEINFO, and this column just shows the first of them, in the interest of space.

CLNDN: the associated disease name from the ClinVar vcf; if there is more than one disease listed in the vcf just the first is shown here in the interest of space.

MAX_AF: allele frequency for the variant from the gnomAD genomes or exomes (version 2.0.2), whichever one is larger.

Microduplication Sequences: The information on potential CRISPR cut-sites that shows the duplicated sequence, the two copies are enclosed by square brackets and separated by a vertical bar, with 5 flanking bases on either side. A base is shown in lower case if there is a predicted CRISPR cleavage site immediately to the left of the base.

Table 7: Preferred Microduplication Sequences For Clinical Application

As noted earlier there are over 2000 duplications annotated as pathogenic in ClinVar that do not appear in gnomAD at all, and hence are not listed in table 6 above, but may nonetheless be promising candidates for MMEJ. In particular the developers of gnomAD have“made every effort to exclude individuals with severe pediatric diseases from the gnomAD data set”

(gnomad.broadinstitute.org/faq), and because of this, allele frequencies for dominant diseases in particular may be underestimated in gnomAD, or the variants may be entirely absent.

To illustrate some of the potential MMEJ candidates of this sort, in Table 8 below we list those duplications of length 4-20 that satify all of the conditions from column dup2iP from Table 4 except they are absent from gnomAD, and for which the OMIM ID associated with the ClinVar entry in listed as having an autosomal dominant mode of inheritance. The columns are the same as for Table 7, although the MAX_AF column is excluded, as these variants do not appear in gnomAD.

Table 8: Additonal Microduplication Sequences Associated with Autosomal Dominant Diseases

IV. Protospacer Adjacent Motif (PAM) sequences

Below are exemplary PAM sequences. addgene.org/crispr/guide/#pam-table. blog.addgene.org/xcas9-engineering-a-crispr-variant-with-pam -flexibility Table 9. Table 9: Exemplary PAM Sequences

V. Adeno-Associated Virus Nucleic Acid Delivery Platforms

Adeno-associated virus (AAV) is a small virus which infects humans and some other primate species. AAV is not currently known to cause disease. In many cases, AAV vectors integrate into the host cell genome, making it useful as gene therapy delivery platform. Gene therapy vectors using AAV can infect both dividing and quiescent cells and persist in an extrachromosomal state without integrating into the genome of the host cell, although in the native virus some integration of virally carried genes into the host genome does occur. Deyle et al., (August 2009). "Adeno-associated virus vector integration". Current Opinion in Molecular Therapeutics ll(4):442-447. These features make AAV a very attractive candidate for creating viral vectors for gene therapy. Grieger et al., (2005). "Adeno-associated virus as a gene therapy vector: vector development, production and clinical applications" Advances in Biochemical Engineering/Biotechnology. Advances in Biochemical Engineering/Biotechnology 99:119-145 Recent human clinical trials using AAV for gene therapy in the retina have shown promise. Maguire et al., (May 200B) "Safety and efficacy of gene transfer for Leber's congenital amaurosis" The New England Journal of Medicine 358(21): 2240-2248. AAV belongs to the genus Dependoparvovirus, which in turn belongs to the family Parvoviridae. The virus is a small (20 nm) replication-defective, nonenveloped virus.

Wild-type AAV has attracted considerable interest from gene therapy researchers due to a number of features. Chief amongst these is the virus's apparent lack of pathogenicity. It can also infect non-dividing cells and has the ability to stably integrate into the host cell genome at a specific site (designated AAVS1) in the human chromosome 19. Kotin et al., (March 1990). "Site-specific integration by adeno-associated virus". PNAS USA 87(6):2211—2215; and Surosky et al., (October 1997) "Adeno-associated virus Rep proteins target DNA sequences to a unique locus in the human genome" Journal of Virology 71(10):7951-7959. This feature makes it somewhat more predictable than retroviruses, which present the threat of a random insertion and of mutagenesis, which is sometimes followed by development of a cancer.

The AAV genome integrates most frequently into the site mentioned, while random incorporations into the genome take place with a negligible frequency. Development of AAVs as gene therapy vectors, however, has eliminated this integrative capacity by removal of the rep and cap from the DNA of the vector. The desired gene together with a promoter to drive

transcription of the gene is inserted between the inverted terminal repeats (ITR) that aid in concatemer formation in the nucleus after the single-stranded vector DNA is converted by host cell DNA polymerase complexes into double-stranded DNA. AAV-based gene therapy vectors form episomal concatemers in the host cell nucleus. In non-dividing cells, these concatemers remain intact for the life of the host cell. In dividing cells, AAV DNA is lost through cell division, since the episomal DNA is not replicated along with the host cell DNA. Random integration of AAV DNA into the host genome is detectable but occurs at very low frequency. AAVs also present very low immunogenicity, seemingly restricted to generation of neutralizing antibodies, while they induce no clearly defined cytotoxic response. This feature, along with the ability to infect quiescent cells present their dominance over adenoviruses as vectors for human gene therapy. Daya et ah, (October 2008). "Gene therapy using adeno-associated virus vectors" Clinical Microbiology Reviews 21(4):583— 593; Chirmule et ah, (September 1999) "Immune responses to adenovirus and adeno-associated virus in humans" Gene Therapy 6(9):1574— 1583; Hernandez et ah, (October 1999) "Latent adeno-associated virus infection elicits humoral but not cell-mediated immune responses in a nonhuman primate model". Journal of Virology

73(10):8549— 8558; and Ponnazhagan et ah, (April 1997) "Adeno-associated virus 2-mediated gene transfer in vivo: organ-tropism and expression of transduced sequences in mice" Gene 190 (1):203-210.

VI. Pharmacuetical Formulations And Compositions

The present invention further provides pharmaceutical compositions (e.g., comprising the nucleases described above). The pharmaceutical compositions of the present invention may be administered in a number of ways depending upon whether local or systemic treatment is desired and upon the area to be treated. Administration may be topical (including ophthalmic and to mucous membranes including vaginal and rectal delivery), pulmonary (e.g., by inhalation or insufflation of powders or aerosols, including by nebulizer; intratracheal, intranasal, epidermal and transdermal), oral or parenteral. Parenteral administration includes intravenous, intraarterial, subcutaneous, intraperitoneal or intramuscular injection or infusion; or intracranial, e.g., intrathecal or intraventricular, administration.

Pharmaceutical compositions and formulations for topical administration may include transdermal patches, ointments, lotions, creams, gels, drops, suppositories, sprays, liquids and powders. Conventional pharmaceutical carriers, aqueous, powder or oily bases, thickeners and the like may be necessary or desirable.

Compositions and formulations for oral administration include powders or granules, suspensions or solutions in water or non-aqueous media, capsules, sachets or tablets. Thickeners, flavoring agents, diluents, emulsifiers, dispersing aids or binders may be desirable.

Compositions and formulations for parenteral, intrathecal or intraventricular

administration may include sterile aqueous solutions that may also contain buffers, diluents and other suitable additives such as, but not limited to, penetration enhancers, carrier compounds and other pharmaceutically acceptable carriers or excipients.

Pharmaceutical compositions of the present invention include, but are not limited to, solutions, emulsions, and liposome-containing formulations. These compositions may be generated from a variety of components that include, but are not limited to, preformed liquids, self-emulsifying solids and self-emulsifying semisolids.

The pharmaceutical formulations of the present invention, which may conveniently be presented in unit dosage form, may be prepared according to conventional techniques well known in the pharmaceutical industry. Such techniques include the step of bringing into association the active ingredients with the pharmaceutical carrier(s) or excipient(s). In general the formulations are prepared by uniformly and intimately bringing into association the active ingredients with liquid carriers or finely divided solid carriers or both, and then, if necessary, shaping the product.

The compositions of the present invention may be formulated into any of many possible dosage forms such as, but not limited to, tablets, capsules, liquid syrups, soft gels, suppositories, and enemas. The compositions of the present invention may also be formulated as suspensions in aqueous, non-aqueous or mixed media. Aqueous suspensions may further contain substances that increase the viscosity of the suspension including, for example, sodium carboxymethylcellulose, sorbitol and/or dextran. The suspension may also contain stabilizers.

In one embodiment of the present invention the pharmaceutical compositions may be formulated and used as foams. Pharmaceutical foams include formulations such as, but not limited to, emulsions, microemulsions, creams, jellies and liposomes. While basically similar in nature these formulations vary in the components and the consistency of the final product. Agents that enhance uptake of oligonucleotides at the cellular level may also be added to the pharmaceutical and other compositions of the present invention. For example, cationic lipids, such as lipofectin (U.S. Pat. No. 5,705,188), cationic glycerol derivatives, and polycationic molecules, such as polylysine (WO 97/30731), also enhance the cellular uptake of

oligonucleotides.

The compositions of the present invention may additionally contain other adjunct components conventionally found in pharmaceutical compositions. Thus, for example, the compositions may contain additional, compatible, pharmaceutically-active materials such as, for example, antipruritics, astringents, local anesthetics or anti-inflammatory agents, or may contain additional materials useful in physically formulating various dosage forms of the compositions of the present invention, such as dyes, flavoring agents, preservatives, antioxidants, opacifiers, thickening agents and stabilizers. However, such materials, when added, should not unduly interfere with the biological activities of the components of the compositions of the present invention. The formulations can be sterilized and, if desired, mixed with auxiliary agents, e.g., lubricants, preservatives, stabilizers, wetting agents, emulsifiers, salts for influencing osmotic pressure, buffers, colorings, flavorings and/or aromatic substances and the like which do not deleteriously interact with the nucleic acid(s) of the formulation.

Dosing is dependent on severity and responsiveness of the disease state to be treated, with the course of treatment lasting from several days to several months, or until a cure is effected or a diminution of the disease state is achieved. Optimal dosing schedules can be calculated from measurements of drug accumulation in the body of the patient. The

administering physician can easily determine optimum dosages, dosing methodologies and repetition rates. Optimum dosages may vary depending on the relative potency of individual oligonucleotides, and can generally be estimated based on EC 50S found to be effective in in vitro and in vivo animal models or based on the examples described herein. In general, dosage is from 0.01 pg to 100 g per kg of body weight, and may be given once or more daily, weekly, monthly or yearly. The treating physician can estimate repetition rates for dosing based on measured residence times and concentrations of the drug in bodily fluids or tissues. Following successful treatment, it may be desirable to have the subject undergo maintenance therapy to prevent the recurrence of the disease state, wherein the compound is administered in maintenance doses, ranging from 0.01 pg to 100 g per kg of body weight, once or more daily, to once every 20 years. Experimental

Example I

Human Subjects

Cells for reprogramming TCAP iPSC lines were recovered, with consent, from a skin biopsy from a patient with LGMD2G under a UMMS-IRB -approved protocol and assigned a de- identified ID number unlinked to the patient’s medical record. The consent process included conditions for sharing de-identified samples and information with other investigators. No PHI will be shared at any time per HIPAA guidelines.

Example II

Cell Culture

LGMD2G primary dermal fibroblasts were isolated from a skin biopsy from a patient with LGMD2G as described 31 . Fibroblasts were reprogrammed using the CytoTune 2.0 iPS Sendai Virus Reprogramming Kit (Thermo-Fisher) according to the manufacturer’s directions. Clonal lines were expanded for 6-10 passages before banking. Immunostaining was performed to confirm the absence of Sendai virus and expression of OCT4. Human iPSCs were cultured in iPS-Brew XF medium (Miltenyi Biotec) and passaged every 3-5 days with Passaging Solution (Miltenyi Biotec) according to the manufacturer’s directions.

Myoblasts were induced from iPSCs using a modification of the Genea Biocells protocol 11 . Following the generation of differentiated myotubes as described, cells were reseeded and cultured in human primary myoblast medium . CD56+ cells were purified by FACS using an anti-CD56-APC antibody (BD Biosciences) or MACS (Miltenyi Biotec) according to the manufacturer’s directions. Myogenicity was confirmed by immunostaining myoblast and myotube cultures using the mouse monoclonal antibodies MyoD clone 5.8 (Dako) and MF20 (DSHB) (data not shown).

A lymphoblastoid cell line from B lymphocytes (B-LCL) derived from a patient with HPS1 who was homozygous for the l6-bp microduplication was purchased from Coriell (Catalog GM14606). A lymphoblastoid cell line from B lymphocytes (B-LCL) derived from a patient with Tay-sachs who was homozygous for the GATA microduplication in HEXA was purchased from Coriell (Catalog GM11852) These cell lines was cultured following the recommended procedure using RPM1 1640 with 2 mM L-glutamine, 15% FBS and 1% penicillin/streptomycin.

HEK293T cells were cultured following the recommended procedure using Dulbecco’s modified Eagle’s medium (DMEM), 10% FBS and 1% penicillin/streptomycin.

All cultures were maintained in a humidified incubator with 5% C0 2 at 37 °C.

Example III

Purification Of SpyCas9 And LbaCasl2a

Protein purification for 3xNLS-SpCas9 and LbaCasl2a-2xNLS followed a common protocol. The generation and characterization of the 3xNLS-SpCas9 (Addgene #114365) and LbaCasl2a-2xNLS (Addgene #114366) constmcts have been described (Wu et al. Nature Medicine (in press) & Liu et al. Nucleic Acids Research (PMID 30892626). The pET2la plasmid backbone (Novagen) is used to drive the expression of a hexa-His-tagged version of each protein. The plasmid expressing 3xNLS-SpCas9 (or LbaCasl2a-2xNLS) was transformed into Escherichia coli Rosetta (DE3)pLysS cells (EMD Millipore) for protein production. Cells were grown at 37 °C to an OD600 of ~0.2, then shifted to 18 °C and induced at an OD600 of -0.4 for 16 h with isopropyl b-D-l-thiogalactopyranoside (IPTG, 1 mM final concentration).

Following induction, cells were pelleted by centrifugation and then resuspended with Ni- NTA buffer (20 mM TRIS pH 7.5, 1 M NaCl, 20 mM imidazole, 1 mM TCEP) supplemented with HALT Protease Inhibitor Cocktail, EDTA-Free (lOOx) (ThermoFisher) and lysed with M- 110s Microfluidizer (Microfluidics) following the manufacturer’s instructions. The protein was purified from the cell lysate using Ni-NTA resin, washed with five volumes of Ni-NTA buffer and then eluted with elution buffer (20 mM TRIS, 500 mM NaCl, 500 mM imidazole, 10% glycerol, pH 7.5). The 3xNLS-SpCas9 (or LbaCasl2a protein) was dialysed overnight at 4 °C in 20 mM HEPES, 500 mM NaCl, 1 mM EDTA, 10% glycerol, pH 7.5.

Subsequently, the protein was step dialysed from 500 mM NaCl to 200 mM NaCl (final dialysis buffer: 20 mM HEPES, 200 mM NaCl, 1 mM EDTA, 10% glycerol, pH 7.5). Next, the protein was purified by cation exchange chromatography (5 ml HiTrap-S column, buffer A: 20 mM HEPES pH 7.5, 1 mM TCEP; buffer B: 20 mM HEPES pH 7.5, 1 M NaCl, 1 mM TCEP; flow rate 5 ml/min, column volume (CV) 5 ml) followed by size-exclusion chromatography (SEC) on a Superdex-200 (16/60) column (isocratic size-exclusion running buffer: 20 mM HEPES pH 7.5, 150 mM NaCl, 1 mM TCEP for 3xNLS-SpCas9 or 20 mM HEPES pH 7.5, 300 mM NaCl, 1 mM TCEP for LbCpfl-2xNLS).

The primary protein peak from the SEC was concentrated in an Ultra- 15 Centrifugal Filters Ultracel-30K (Amicon) to a concentration around 100 mM based on absorbance at 280 nm. The purified protein quality was assessed by SDS-PAGE/Coomassie staining to be >95% pure and protein concentration was quantified with a Pierce BCA Protein Assay Kit

(ThermoFisher Scientific). Protein was stored at - 80 °C until further use.

Example IV

In Vitro Transcription Of Guide RNAs

The DNA cassette containing the U6 promoter and the sgRNA framework for SpyCas9 was cloned from pLKOl-puro vector 33 into pBluescript SK 11+ backbone (Liu et al., Nucleic Acids Research, submitted). Plasmids expressing each guide RNA from the U6 promoter were constructed by annealing oligonuleotides encoding guide RNA and cloning it into BfuAI cleavage sites in this vector. Templates for in vitro transcription of SpyCas9 guides were amplified from the cognate plasmids using NEB Q5 High-Fidelity DNA Polymerase for 30 cycles (98 °C, 15 s; 65 °C 25 s; 72 °C 20 s) using primer sets designed to include the T7 scaffold.

To generate CRISPR RNA (crRNA) for LbaCasl2a, templates for in vitro transcription were generated by PCR amplification of oligonucleotides designed to include the T7 scaffold along with the guide RNA and a l5-mer overlap sequence to allow annealing between the oligos. The oligonucleotides encoded the full-length direct repeat crRNA sequence (Liu et al. Nucleic Acids Research, (PMID 30892626). Thirty cycles of amplification were conducted using NEB Q5 High-Fidelity DNA polymerase (98 °C, 15 s; 60 °C 25 s; 72 °C 20 s). The PCR products were purified using Zymo DNA Clean & Concentrator Kit (Zymo Cat. #D4005).

In vitro transcription reactions were performed using the HiScribe T7 High Yield RNA Synthesis Kit using 300 ng of PCR product as template (NEB Cat. #E2040S). After incubation for 16 h at 37 °C, samples were treated with DNase I for 40 min at 37 °C to remove any DNA contamination. Each guide RNA was purified using the Zymo RNA Clean and Concentrator Kit. Final RNA concentration was measured using Nanodrop and RNA was stored at - 80 °C until further use. Example V

Electroporation Of Cell Lines

3xNLS-SpyCas9 protein was precomplexed with sgRNAs either purchased from

Synthego or made in-house by T7 transcription and electroporated into cells using the Neon transfection system (Thermo Fisher).

Electroporation of IPSCs

After washing with PBS, iPSCs were dissociated into single cells with 3:1 TrypLE:0.5 mM EDTA and neutralized with Ham’s F10+20% FBS. To form RNP complexes, 20 pmol 3xNLS-SpyCas9 protein and 25 pmol gRNA were combined in 10 pl Neon Buffer R and incubated for 10 min at room temperature. iPSCs (l x 10 5 ) were resuspended in 10 pl RNP- Buffer R mix and then nucleofected as follows: pulse voltage 1,500 V, pulse width 20 ms, pulse number 1.

After transfection, the cells were plated onto Matrigel-coated 24-well plates with iPS Brew XF supplemented with 10 mM Y27632 for expansion and grown in a humidified incubator at 37 °C, 5% C0 2 , for 4 days before harvesting them for analysis. iPSC-derived myoblasts were electroporated using two pulses of 1,400 V and 20 ms width and plated onto a 24- well dish containing pre-warmed antibiotic-free human primary myoblast growth medium and cultured for four to six days before analysis.

Electroporation of HPS1 patient-derived B-LCL cells

Forty (40) pmol of 3xNLS-SpyCas9 protein was precomplexed with 50 pmol of sgRNA in buffer R for 10-20 min at room temperature in a final volume of 12 mΐ. Three hundred thousand cells per reaction were resuspended in 10 mΐ of RNP-buffer R mix and electroporated with 2 pulses at 1,700V for 20 ms using the 10-m1 tip. Cells were then plated in 24- well plates with 500 mΐ of pre-equilibrated antibiotic-free culture medium and grown in a humidified incubator at 37 °C and 5% C0 2 for 7 days before indel analysis.

For the PARP-1 inhibition experiments, 300,000 HPS1 patient-derived B-LCL cells were treated with 10 mM or 20 mM rucaparib camsylate (Sigma-Aldrich PZ0036) in standard growth medium for 24 h. Treated cells were electroporated with SpyCas9 RNPs following previously described protocol. Following another 24 h incubation in mcaparib-containing medium, cells were resuspended in PARP-1 inhibitor-free medium and harvested for analysis after 7 days.

Electroporation of HEK293T cells

Twenty (20) pmol of 3xNLS-SpyCas9 protein and 25 pmol of in vitro transcribed sgRNA were pre-complexed in Neon Buffer R for 10-20 min at room temperature. One hundred thousand cells per reaction were resuspended in 10 pl of RNP-buffer R mix and nucleofected with SpyCas9 guide RNA complex using two pulses at 1,150 V for 20 ms using the 10-pl tip. Cells were then plated in 24- well plates with 500 mΐ of pre-equilibrated antibiotic-free culture medium and grown for 3 days before analysis. F or Casl2a editing experiments at endogenous microduplications, 80 pmol of LbaCasl2a protein was pre-complexed with 100 pmol of in vitro transcribed crRNA and 100,000 cells per reaction were nucleofected as described above.

Example VI

Indel Analysis By TIDE

Genomic DNA was extracted from HEK293T cells using GenElute Mammalian Genomic DNA Miniprep Kit (Sigma Aldrich) according to the manufacturer’s instructions. The DNA region containing the 24-bp microduplication was amplified using genomic DNA as template and primers using NEB Q5 High-Fidelity DNA Polymerase (98 °C, 15 s; 67 °C 25 s; 72 °C 20 s) x 30 cycles. See, Table 10.

Table 10: List of primers used to amplify genomic regions for TIDE analysis

Primer name Primer Sequence

Endo_24bp_F GAAGCGCTACCTGATTCCAATTC

Endo_24bp_R TGGCAGTTAGGAAGGTTGTATCG

Subsequently, the PCR product was purified using the DNA Clean & Concentrator-5 kit (Zymo research) and sequenced. Sanger sequencing trace data were analysed using the TIDE webtool at tide.nki.nl/ to infer the compositions of indels created at the sites of DSBs34. Example VII

Library Construction For Illumina Deep Sequencing

Library construction for deep sequencing was performed using a modified version of a previously described protocol 26 . In brief, iPSCs and myoblasts were harvested following nuclease treatment and genomic DNA was extracted using the GenElute Mammalian Genomic DNA Miniprep Kit (Sigma G1N350). Genomic loci spanning the target sites were PCR amplified with locus-specific primers carrying tails complementary to the TruSeq adapters (Deepseq_TCAP_primer_fwd and Deepseq_TCAP_primer_rev). Fifty (50) nanograms of input genomic DNA was PCR amplified with Q5 High-Fidelity DNA Polymerase (New England Biolabs): (98 °C, 15 s; 67 °C, 25 s; 72 °C, 20 s) x 30 cycles. Next, 0.1 pl of each PCR reaction was amplified with barcoded primers to reconstitute the TruSeq adaptors using Q5 High-Fidelity DNA Polymerase (New England Biolabs): (98 °C, 15 s; 67 °C, 25 s; 72 °C, 20 s) x 10 cycles. Products were qualitatively analysed by gel electrophoresis. Equal amounts of the products were pooled and gel-purified using QIAquick Gel Extraction Kit (Qiagen Cat. #28704). The purified library was deep sequenced using a paired-end 150-bp Illumina MiSeq run.

Example VIII

Illumina Deep Sequencing Analysis

MiSeq data analysis was performed using Unix-based software tools. First, d FastQC (version 0.11.3; bioinformatics.babraham.ac.uk/projects/fastqc/) was used to determine the quality of paired-end sequencing reads (Rl and R2 fastq files). Next, a paired-end read merger (PEAR; version 0.9.8) 35 was used to pool raw paired-end reads and generate single merged high- quality full-length reads.

Reads were then filtered according to quality via FASTQ for a mean PHRED quality score above 30 and a minimum per base score above 24. After that, BWA (version 0.7.5) and SAMtools (version 0.1.19) were used to align each group of filtered reads to a corresponding reference sequence.

To determine lesion type, frequency, size and distribution, all edited reads from each experimental replicate were combined and aligned, as described above. Lesion types and frequencies were then catalogued in a text output format at each base using bam-readcount. For each treatment group, the average background lesion frequencies (based on lesion type, position and frequency) of the triplicate negative control group were subtracted to obtain the nuclease- dependent lesion frequencies.

Example IX

Library Construction For UMI-Based Illumina Deep Sequencing

The construction of the UMI-based library used a linear amplification step to incorporate UMIs within the amplicons from the target locus 15 . HPS1 B-LCL cells and HEK293Ts were harvested following nuclease treatment for genomic DNA extraction using the GenElute Mammalian Genomic DNA Miniprep Kit (Sigma G1N350).

Randomized unique molecular identifiers (UMIs) were incorporated within the 5’ locus- specific primers carrying tails complementary to TruSeq adaptors. In brief, 50 ng of input genomic DNA was linear amplified with NEB Q5 High-Fidelity DNA Polymerase (98 °C, 15 s; 67 °C, 25 s; 72 °C, 20 s) for 10 cycles using the 5’ locus-specific primer with TruSeq adaptor conjugated with a UMI sequence.

Next a 5’ constant primer along with the 3’ locus-specific primer with TruSeq adaptor were added and further amplified for 30 cycles. Indexes were then incorporated using barcoded primers to diluted PCR products using NEB Q5 High-Fidelity DNA Polymerase (98 °C, 15 s; 67 °C, 25 s; 72 °C, 20 s) for 10 cycles. Products were qualitatively analysed by gel electrophoresis. Equal amounts of the products were pooled and gel-purified using QIAquick Gel Extraction Kit (Qiagen Cat. #28704) for DNA recovery. The purified library was deep sequenced using a paired-end 150-bp Illumina MiSeq run.

Example X

UMI-Based Deep Sequencing Analysis

The analysis of the UMI-tagged deep sequencing reads was adapted from a previous protocol 15 . Initially, BWA (version 0.7.5) and SAMtools (version 0.1.19) were used to align each group of filtered merged-read pairs to a corresponding reference sequence, ignoring the unique molecular barcodes. Next, a custom Python and PySAM script was used to process mapped reads into counts of UMI-labelled reads for each target. The mapped reads were filtered by requiring a mapping value (MAPQ) larger than 30. Alignments were categorized into different categories of indels using VarScan 237. Next, UMI duplicates were identified to create a minimal set of amplicons that can account for the full set of reads with unique UMIs. For each unique UMI, a minimum of five observations of the same sequence was required to consider the sequence to have a low likelihood of being an artefact (sequencing error in the UMI element). For sequences that met this threshold, all common sequences associated with the UMI were consolidated to one read for analysis of the distribution of sequence modifications that were present at a locus. The resulting UMI number tables, which describe the type of each sequence modification and its length, were concatenated and loaded into GraphPad Prism 7 for data visualization. Microsoft Excel version 16.21.1 was used for statistical analysis.

Example XI

PacBio Library Preparation

Single molecule, real-time (SMRT) sequencing is modified from Pacific Biosciences (PacBio). Nuclease-treated patient-derived iPSCs were harvested for genomic DNA extraction with GenElute Mammalian Genomic DNA Miniprep Kit (Sigma G1N350). In brief, regions that flanked the TCAP target site were PCR amplified using locus-specific primers. See, Table 10. The forward primer was designed to have the barcode sequence followed by the UMI and locus- specific primer sequence. The reverse primer contains the barcode followed by the locus-specific primer sequence. Input DNA (25-50 ng) was PCR amplified with Phusion High Fidelity DNA Polymerase (New England Biolabs): (98 °C, 15 s; 65 °C, 25 s; 72 °C, 18 s) x 30 cycles. The products were qualitatively analysed by gel electrophoresis and subsequently gel purified with QIAquick Gel Extraction Kit (Qiagen Cat. #28704). The purified products sequenced at the UMASS Medical School Deep Sequencing Core for SMRTbell Library Preparation using a Pacific Biosciences Sequel Instrument.

Example XII

PacBio Sequencing Data Analysis

For PacBio sequencing data analysis, Minimap2 (version 2.1438,) was used to align the raw Consensus_ROI (reads_of_insert.fastq) data to the 2-kb reference sequence. Alignment quality control and filtering were performed using custom Perl script to remove errors and filter out alignments with poor quality. For variation calling, a custom Python script was used to extract deletions or insertions larger than 5 bp for each read from the SAM files. Subsequently, deletions or insertions were classified into different groups on the basis of their length.

IGV(version 2.4.16) was used for alignment visualization of the aligned reads using Quick consensus mode 39 .

Example XIII

Clonal Analysis Of iPSCs

Following confirmation of MMEJ-mediated correction in the population of LGMD2G iPSCs, clonal analysis was performed. Cells from the corrected population were seeded into 96- well plates in the presence of Y27632 at a frequency of 0.8 cells per well. iPSC clones were cultured for several weeks in iPS Brew XF (Miltenyi Biotec) before being collected for sequence analysis by deep-sequencing.

Example IVX

Myoblast Differentiation And Detection Of Telethonin Expression iPSC-derived myoblasts were plated into 0.1% gelatin-coated 6-well plates at a density of 100,000 cells per well in myoblast expansion medium containing Ham’s F-10 (Cellgro) supplemented with 20% fetal bovine serum (Hyclone, SH30071.03), 1.2 mM CaCl 2 (EMD OmniPur 3000) and 1% chick embryo extract isolated from day 12 SPF Premium Fertilized White Leghorn Chicken Eggs (Charles River, North Franklin, CT). After 4 days of expansion, the cells were incubated with myotube differentiation medium including DMEM/F12 (Thermo- Fisher) supplemented with 1% N 2 (Thermo-Fisher, 17502-048) and 1% insulin-transferrin- selenium (Thermo-Fisher, 41400045).

After 10 days of differentiation, the cells were dissociated into single cells using TrypLE. Subsequently the cells were fixed with 2% PFA for 15 min and blocked with PBS including 2% BSA, 2% horse serum, 2% goat serum and 2% Triton X-100 for 20 min. The cells were then incubated with anti-telethonin antibody (Santa Cmz, sc-25327, 1:50) at 4 °C for 2 days and IgG goat anti-mouse secondary antibody labelled with Alexa 488 fluorophore (Invitrogen, A11017, 1:800) at room temperature for 1 h. The cells were suspended in flow buffer (PBS including 0.2 % FBS) and flow cytometry was performed using a BD FACSAria IIu (UMMS Flow Cytometry Core Laboratory). Roughly 20,000 cells were included for analysis. FlowJo software (version 7.6) was used for data analysis.

Example XV

Survey Of Microduplications In ClinVar And In Human Reference Populations

Annotations of pathogenicity from ClinVar (ftp.ncbi.nlm.nih.gov/pub/clinvar/ vcf_GRCh37/clinvar_20180225. vcf.gz) 20 were combined with annotations of allele-frequencies from gnomAD console.cloud.google.com/storage/browser/gnomad-public/relea se/2.0.2/vcf) 21 and from the 1000 Genome Project ftp.l000genomes.ebi.ac.uk/ voll/ftp/release/20l30502/) 40 using the annotate function in bcf tools 41 (1.9), after decomposition of multi-allelic sites and normalization of variants with vt42 (v0.5772) against a reference genome

(broadinstitute.org/ftp/pub/seq/references/ Homo_sapiens_assemblyl9.fasta). Most analyses were restricted to the intervals in ftp.broadinstitute.org/pub/ExAC_release/releasel/resources/ exome_calling_regions. vl .interval_list.

Insertions were extracted using vt (view -h -f“VTYPE==INDEL&&DLEN>0”); then duplications were identified, repeat units counted, internal shift-symmetries determined, and flanking genomic regions extracted using a modified version of the vt function annotate_indels. Additional processing (filtering, finding maximal allele frequencies among different populations, scanning for PAM sites and so on) was performed using R (3.4.3), including the

Variant Annotation (1.24.5) package 43 .

Exact tandem repeats in the reference genome were identified using the Tandem Repeats Finder program (4.09)44 and checked for exact matches elsewhere in the genome with bwa fastmap (0.7.17)45. Examples of different lengths were manually selected to use for the tests of collapse of endogenous microduplications.

Example XVI

Code Availability Statement

Data analysis used a combination of publicly available software and custom code, as detailed in the Methods. Custom python (CRESA-lpp.py) and R (indel_background_ filtering.R) scripts used in the Illumina data analysis and the shell script (Tcap_pacbio_ analysis. sh) used for the analysis of the PacBio data are hosted on GitHub (github.com/ locusliu/PCR_Amplicon_target_deep_seq). Scripts for the bioinformatic analysis of pathogenic microduplications are hosted at rambutan.umassmed.edu/duplications/.

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