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Silva IMW, Gil-da-Silva-Lopes VL. Comprehensive insights into health services accessibility and quality of life of families with individuals with 22q11.2 deletion syndrome in Brazil. Orphanet J Rare Dis 2024; 19:255. [PMID: 38971792 PMCID: PMC11227184 DOI: 10.1186/s13023-024-03273-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 07/01/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND The 22q11.2 Deletion Syndrome (22q11.2 DS) presents unique healthcare challenges for affected individuals, families, and healthcare systems. Despite its rarity, 22q11.2 DS is the most common microdeletion syndrome in humans, emphasizing the need to understand and address the distinctive healthcare requirements of those affected. This paper examines the multifaceted issue of health service access and caregivers' quality of life in the context of 22q11.2 DS in Brazil, a condition with diverse signs and symptoms requiring multidisciplinary care. This study employs a comprehensive approach to evaluate health service accessibility and the quality of life of caregivers of individuals with 22q11.2 DS. It utilizes a structured Survey and the WHOQOL-bref questionnaire for data collection. RESULTS Individuals with 22q11.2 DS continue to receive incomplete clinical management after obtaining the diagnosis, even in the face of socioeconomic status that enabled an average age of diagnosis that precedes that found in sample groups that are more representative of the Brazilian population (mean of 3.2 years versus 10 years, respectively). In turn, caring for individuals with 22q11.2 DS who face difficulty accessing health services impacts the quality of life associated with the caregivers' environment of residence. CONCLUSIONS Results obtained help bridge the research gap in understanding how caring for individuals with multisystem clinical conditions such as 22q11.2 DS and difficulties in accessing health are intertwined with aspects of quality of life in Brazil. This research paves the way for more inclusive healthcare policies and interventions to enhance the quality of life for families affected by this syndrome.
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Affiliation(s)
- Isabela Mayá Wayhs Silva
- Department of Translational Medicine, Medical Genetics and Genomic Medicine Area, Universidade Estadual de Campinas (Unicamp), Tessália Vieira de Camargo Street, 126, Campinas, Sao Paulo, SP, 13083-887, Brazil
| | - Vera Lúcia Gil-da-Silva-Lopes
- Department of Translational Medicine, Medical Genetics and Genomic Medicine Area, Universidade Estadual de Campinas (Unicamp), Tessália Vieira de Camargo Street, 126, Campinas, Sao Paulo, SP, 13083-887, Brazil.
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Diniz BL, Santos AS, Glaeser AB, Guaraná BB, Lorea CF, Josahkian JA, Huber J, Rosa RFM, Zen PRG. Congenital Heart Defects and Dysmorphic Facial Features in Patients Suspicious of 22q11.2 Deletion Syndrome in Southern Brazil. J Pediatr Genet 2020; 9:227-234. [PMID: 32733742 PMCID: PMC7384886 DOI: 10.1055/s-0040-1713155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/05/2020] [Indexed: 10/24/2022]
Abstract
22q11.2 deletion syndrome (22q11.2DS) is considered one of the most frequently observed chromosomal abnormalities in association with congenital heart disease (CHD), which can also include some combination of other features. Thus, the aim of this work was to verify the profile of dysmorphic features and heart defects found in patients referred to a reference center in Southern Brazil with clinical findings suggestive of 22q11.2DS. In the overall sample group, only patients with dysmorphic facial features (skull, eyes, ear, and nose) associated with CHD (obstructive pulmonary valve ring, truncus arteriosus, and bicuspid aortic valve associated with atrial septal defect and/or right aortic arch) had a 22q11.2 deletion. These findings proved to be reliable clinical criteria for referral to perform fluorescent in situ hybridization investigation for 22q11.2 deletion.
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Affiliation(s)
- Bruna Lixinski Diniz
- Department of Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | | | - Andressa Barreto Glaeser
- Department of Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - Bruna Baierle Guaraná
- Department of Internal Medicine, Clinical Genetics, UFCSPA and Irmandade Santa Casa de Misericórdia de Porto Alegre (ISCMPA), Porto Alegre, RS, Brazil
| | - Cláudia Fernandes Lorea
- Child and Adolescent Health Care Unit, Hospital Escola da Universidade Federal de Pelotas (HE-UFPEL), Pelotas, RS, Brazil
| | - Juliana Alves Josahkian
- Department of Clinical Medicine, Hospital Universitário de Santa Maria (HU-SM), Santa Maria, RS, Brazil
| | - Janaína Huber
- Department of Congenital and Pediatric Heart Disease, Instituto de Cardiologia/Fundacão Universitária de Cardiologia, Porto Alegre, RS, Brazil
| | - Rafael Fabiano Machado Rosa
- Department of Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
- Department of Internal Medicine, Clinical Genetics, UFCSPA and Irmandade Santa Casa de Misericórdia de Porto Alegre (ISCMPA), Porto Alegre, RS, Brazil
| | - Paulo Ricardo Gazzola Zen
- Department of Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
- Department of Internal Medicine, Clinical Genetics, UFCSPA and Irmandade Santa Casa de Misericórdia de Porto Alegre (ISCMPA), Porto Alegre, RS, Brazil
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Chen R. Primary Immunodeficiency. Rare Dis 2020. [DOI: 10.5772/intechopen.89624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Sgardioli IC, Paoli Monteiro F, Fanti P, Paiva Vieira T, Gil-da-Silva-Lopes VL. Testing criteria for 22q11.2 deletion syndrome: preliminary results of a low cost strategy for public health. Orphanet J Rare Dis 2019; 14:123. [PMID: 31159889 PMCID: PMC6547599 DOI: 10.1186/s13023-019-1098-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 05/19/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The clinical heterogeneity of the 22q11.2 Deletion Syndrome (22q11.2DS - OMIM, #188400 and #192430) is a universal challenge leading to diagnostic delay. The aim of this study was to evaluate a low cost strategy for the diagnosis of this condition based upon clinical criteria previously reported. Health professionals, who collected clinical data, from twelve centers were trained in those criteria, which were summed through an online application (CranFlow). RESULTS Clinical and laboratorial data of 347 individuals registered from 2008 to 2017 in the Brazilian Database on Craniofacial Anomalies/22q11.2 Deletion Syndrome, were reviewed. They were divided in two groups: (I) 168 individuals investigated before the definition of the criteria and (II) 179 individuals investigated after the criteria application. All of them were investigated for 22q11.2DS by Fluorescent in situ Hybridization (FISH) and/or Multiplex Ligation Probe-dependent Amplification (MLPA), detecting 98 cases with 22q11.2DS. Among the individuals with 22q11.2DS in Group II, 42/53 (79.25%) fulfilled the proposed criteria against 11/53 (20.75%) who did not fulfill them (p < .0001). The association of congenital heart diseases with high predictive value for 22q11.2DS and hypernasal voice were significantly associated to the presence of 22q11.2DS (p = 0.0172 and p < .0001, respectively). In addition, 22q11.2DS was confirmed 3.82 more times when the individuals fulfilled the proposed criteria. Of the 249 cases negative for the typical deletion in 22q11.2, Chromosomal Microarray Analysis (CMA) was performed in 132 individuals and detected pathogenic alterations at other genomic regions in 19 individuals, and variants of uncertain clinical significance in 31 cases. CONCLUSIONS Therefore, a locus-specific approach could be used to individuals with positive criteria as a cost-effective alternative for 22q11.2DS diagnosis. The authors discuss advantages and suggest ways of implementing this approach to investigate 22q11.2DS in a public health system.
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Affiliation(s)
- Ilária Cristina Sgardioli
- Department of Medical Genetics and Genomic Medicine, Faculty of Medical Science, State University of Campinas (Unicamp), Tessália Vieira de Camargo Street, 126, Campinas, SP 13083-887 Brazil
| | - Fabíola Paoli Monteiro
- Department of Medical Genetics and Genomic Medicine, Faculty of Medical Science, State University of Campinas (Unicamp), Tessália Vieira de Camargo Street, 126, Campinas, SP 13083-887 Brazil
- Association of Parents and Friends of the Exceptional from Sao Paulo (Associação de Pais e Amigos dos Excepcionais de São Paulo – APAE-SP), Campinas, SP Brazil
| | - Paulo Fanti
- Department of Statistics, Faculty of Medical Science, State University of Campinas (Unicamp), Campinas, SP Brazil
| | - Társis Paiva Vieira
- Department of Medical Genetics and Genomic Medicine, Faculty of Medical Science, State University of Campinas (Unicamp), Tessália Vieira de Camargo Street, 126, Campinas, SP 13083-887 Brazil
| | - Vera Lúcia Gil-da-Silva-Lopes
- Department of Medical Genetics and Genomic Medicine, Faculty of Medical Science, State University of Campinas (Unicamp), Tessália Vieira de Camargo Street, 126, Campinas, SP 13083-887 Brazil
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Palmer L, Butcher NJ, Boot E, Hodgkinson KA, Heung T, Chow EWC, Guna A, Crowley TB, Zackai E, McDonald-McGinn DM, Bassett AS. Elucidating the diagnostic odyssey of 22q11.2 deletion syndrome. Am J Med Genet A 2018; 176:936-944. [PMID: 29575622 PMCID: PMC5873609 DOI: 10.1002/ajmg.a.38645] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/23/2018] [Accepted: 01/25/2018] [Indexed: 12/25/2022]
Abstract
Clinical molecular testing has been available for 22q11.2 deletion syndrome (22q11.2DS) for over two decades yet under-recognition and diagnostic delays are common. To characterize the "diagnostic odyssey" in 22q11.2DS we studied 202 well-characterized unrelated adults, none ascertained through an affected relative. We used a regression model to identify clinical and demographic factors associated with length of time to molecular diagnosis. Kaplan-Meier analysis compared time to diagnosis for the molecular testing era (since 1994) and earlier birth cohorts. The results showed that the median time to molecular diagnosis of the 22q11.2 deletion was 4.7 (range 0-20.7) years. Palatal and cardiac anomalies, but not developmental delay/intellectual disability, were associated with a shorter time to molecular diagnosis. Non-European ethnicity was associated with longer time to diagnosis. Inclusion of a cohort from another 22q11.2DS center increased power to observe a significantly earlier diagnosis for patients born in the molecular testing era. Nonetheless, only a minority were diagnosed in the first year of life. On average, patients were seen in seven (range 2-15) different clinical specialty areas prior to molecular diagnosis. The findings indicate that even for those born in the molecular testing era, individuals with 22q11.2DS and their families face a diagnostic odyssey that is often prolonged, particularly in the absence of typical physical congenital features or for those of non-European ancestry. The results support educational efforts to improve clinical recognition and testing, and ultimately newborn screening as a means of maximizing early detection that would provide the best opportunity to optimize outcomes.
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Affiliation(s)
- Lisa Palmer
- The Dalglish Family 22q Clinic for Adults with 22q11.2 Deletion Syndrome, University Health Network, Toronto, Ontario, Canada
| | - Nancy J. Butcher
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- The 22q and You Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Erik Boot
- The Dalglish Family 22q Clinic for Adults with 22q11.2 Deletion Syndrome, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University Health Network, Toronto, Ontario, Canada
| | - Kathleen A. Hodgkinson
- Department of Epidemiology, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Tracy Heung
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Eva WC Chow
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Alina Guna
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - T. Blaine Crowley
- The 22q and You Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elaine Zackai
- The 22q and You Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Clinical Genetics Centre, The Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA
| | - Donna M. McDonald-McGinn
- The 22q and You Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Clinical Genetics Centre, The Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA
- Section of Genetic Counseling, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Anne S. Bassett
- The Dalglish Family 22q Clinic for Adults with 22q11.2 Deletion Syndrome, University Health Network, Toronto, Ontario, Canada
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University Health Network, Toronto, Ontario, Canada
- Division of Cardiology, Department of Medicine, and Toronto General Research Institute, University Health Network, University Health Network, Toronto, Ontario, Canada
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Clinical variability of chromosome 22q11.2 deletion syndrome. Cent Eur J Immunol 2017; 42:412-417. [PMID: 29472823 PMCID: PMC5820982 DOI: 10.5114/ceji.2017.72818] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 06/22/2016] [Indexed: 12/23/2022] Open
Abstract
22q11.2 deletion syndrome (22q11.2 DS) is a disorder that has multiple symptoms and affects various organs and systems. Despite the great variability of clinical manifestations, common 22q11.2 DS includes congenital heart defect, immunodeficiency, characteristic facial features, palatal defects, developmental and/or learning disabilities, and hypocalcaemia. We present the cases of three patients with 22q11.2 DS that we have observed. Heart defects were revealed in all cases, and tetralogy of Fallot in one of them. Immune system disorders in these cases were highly variable and did not correlate with aplasia or hypoplasia of the thymus. Cleft palate was diagnosed only in one case. Characteristic facial features were presented in all cases but they were not significant and varied from subtle to mild. Developmental disability was presented by motor delays in two cases. Hypocalcaemia was revealed in one patient, and seizures were absent. Only one case completely fit CATCH-22 syndrome (cardiac defects, abnormal facies, thymic hypoplasia, cleft palate, and hypocalcaemia caused by22q11.2 deletion). The other cases had three out of the five main features, with some other, less significant signs also presented. In some cases, even just a few signs should be the reason for further examination to exclude 22q11.2 deletion syndrome. Currently, immunological disorders are not a significant determinant in the diagnosis of this syndrome, and timely correction of heart defects can reduce the number of recurrent respiratory infections. A multidisciplinary approach to the management of these patients and providing timely, complex medical care will prevent serious complications.
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Kruszka P, Addissie YA, McGinn DE, Porras AR, Biggs E, Share M, Crowley TB, Chung BHY, Mok GTK, Mak CCY, Muthukumarasamy P, Thong MK, Sirisena ND, Dissanayake VHW, Paththinige CS, Prabodha LBL, Mishra R, Shotelersuk V, Ekure EN, Sokunbi OJ, Kalu N, Ferreira CR, Duncan JM, Patil SJ, Jones KL, Kaplan JD, Abdul-Rahman OA, Uwineza A, Mutesa L, Moresco A, Obregon MG, Richieri-Costa A, Gil-da-Silva-Lopes VL, Adeyemo AA, Summar M, Zackai EH, McDonald-McGinn DM, Linguraru MG, Muenke M. 22q11.2 deletion syndrome in diverse populations. Am J Med Genet A 2017; 173:879-888. [PMID: 28328118 PMCID: PMC5363275 DOI: 10.1002/ajmg.a.38199] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/02/2017] [Accepted: 02/02/2017] [Indexed: 11/10/2022]
Abstract
22q11.2 deletion syndrome (22q11.2 DS) is the most common microdeletion syndrome and is underdiagnosed in diverse populations. This syndrome has a variable phenotype and affects multiple systems, making early recognition imperative. In this study, individuals from diverse populations with 22q11.2 DS were evaluated clinically and by facial analysis technology. Clinical information from 106 individuals and images from 101 were collected from individuals with 22q11.2 DS from 11 countries; average age was 11.7 and 47% were male. Individuals were grouped into categories of African descent (African), Asian, and Latin American. We found that the phenotype of 22q11.2 DS varied across population groups. Only two findings, congenital heart disease and learning problems, were found in greater than 50% of participants. When comparing the clinical features of 22q11.2 DS in each population, the proportion of individuals within each clinical category was statistically different except for learning problems and ear anomalies (P < 0.05). However, when Africans were removed from analysis, six additional clinical features were found to be independent of ethnicity (P ≥ 0.05). Using facial analysis technology, we compared 156 Caucasians, Africans, Asians, and Latin American individuals with 22q11.2 DS with 156 age and gender matched controls and found that sensitivity and specificity were greater than 96% for all populations. In summary, we present the varied findings from global populations with 22q11.2 DS and demonstrate how facial analysis technology can assist clinicians in making accurate 22q11.2 DS diagnoses. This work will assist in earlier detection and in increasing recognition of 22q11.2 DS throughout the world.
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MESH Headings
- Adolescent
- Adult
- Asian People
- Biometric Identification/methods
- Black People
- Child
- Child, Preschool
- Chromosomes, Human, Pair 22/chemistry
- DiGeorge Syndrome/diagnosis
- DiGeorge Syndrome/ethnology
- DiGeorge Syndrome/genetics
- DiGeorge Syndrome/pathology
- Facies
- Female
- Heart Defects, Congenital/diagnosis
- Heart Defects, Congenital/ethnology
- Heart Defects, Congenital/genetics
- Heart Defects, Congenital/pathology
- Hispanic or Latino
- Humans
- Image Interpretation, Computer-Assisted/methods
- In Situ Hybridization, Fluorescence
- Infant
- Infant, Newborn
- Learning Disabilities/diagnosis
- Learning Disabilities/ethnology
- Learning Disabilities/genetics
- Learning Disabilities/physiopathology
- Male
- Phenotype
- White People
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Affiliation(s)
- Paul Kruszka
- Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland
| | - Yonit A Addissie
- Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland
| | - Daniel E McGinn
- Division of Human Genetics, 22q and You Center, and Clinical Genetics Center, The Children's Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Antonio R Porras
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, D.C
| | - Elijah Biggs
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, D.C
| | - Matthew Share
- Division of Human Genetics, 22q and You Center, and Clinical Genetics Center, The Children's Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - T Blaine Crowley
- Division of Human Genetics, 22q and You Center, and Clinical Genetics Center, The Children's Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian H Y Chung
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Gary T K Mok
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Christopher C Y Mak
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Premala Muthukumarasamy
- Faculty of Medicine, Department of Paediatrics, University of Malaya, Kuala Lumpur, Malaysia
| | - Meow-Keong Thong
- Faculty of Medicine, Department of Paediatrics, University of Malaya, Kuala Lumpur, Malaysia
| | - Nirmala D Sirisena
- Faculty of Medicine, Human Genetics Unit, University of Colombo, Sri Lanka
| | | | | | | | - Rupesh Mishra
- Faculty of Medicine, Human Genetics Unit, University of Colombo, Sri Lanka
| | - Vorasuk Shotelersuk
- Center of Excellence for Medical Genetics, Faculty of Medicine, Department of Pediatrics, Chulalongkorn University, Bangkok, Thailand
| | - Ekanem Nsikak Ekure
- Department of Paediatrics College of Medicine, University of Lagos, Lagos University Teaching, Lagos, Nigeria
| | | | - Nnenna Kalu
- Department of Paediatrics College of Medicine, University of Lagos, Lagos University Teaching, Lagos, Nigeria
| | - Carlos R Ferreira
- Division of Genetics and Metabolism, Children's National Health System, Washington, D.C
| | - Jordann-Mishael Duncan
- Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland
| | | | - Kelly L Jones
- Division of Medical Genetics, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Julie D Kaplan
- Division of Medical Genetics, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Omar A Abdul-Rahman
- Division of Medical Genetics, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Annette Uwineza
- Center of Human Genetics/School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Leon Mutesa
- Center of Human Genetics/School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Angélica Moresco
- Servicio de Genética, Hospital de Pediatría Garrahan, Buenos Aires, Argentina
| | | | - Antonio Richieri-Costa
- Hospital for the Rehabilitation of Craniofacial Anomalies, São Paulo University, Bauru, Brazil
| | | | - Adebowale A Adeyemo
- Center for Research on Genomics and Global Health, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland
| | - Marshall Summar
- Division of Genetics and Metabolism, Children's National Health System, Washington, D.C
| | - Elaine H Zackai
- Division of Human Genetics, 22q and You Center, and Clinical Genetics Center, The Children's Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna M McDonald-McGinn
- Division of Human Genetics, 22q and You Center, and Clinical Genetics Center, The Children's Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marius George Linguraru
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, D.C
| | - Maximilian Muenke
- Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland
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