1
|
Tornero C, Navarro-Compán V, Buño A, Heath KE, Díaz-Almirón M, Balsa A, Tenorio JA, Quer J, Aguado P. Biochemical algorithm to identify individuals with ALPL variants among subjects with persistent hypophosphatasaemia. Orphanet J Rare Dis 2022; 17:98. [PMID: 35241128 PMCID: PMC8896389 DOI: 10.1186/s13023-022-02253-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 02/13/2022] [Indexed: 11/11/2022] Open
Abstract
Background Hypophosphatasia (HPP) is a rare and underdiagnosed condition characterized by deficient bone and teeth mineralization. The aim of this study was first, to evaluate the diagnostic utility of employing alkaline phosphatase (ALP) threshold levels to identify adults with variants in ALPL among individuals with persistently low ALP levels and second, to determine the value of also including its substrates (serum pyridoxal-5′-phosphate—PLP—and urinary phosphoetanolamine-PEA) for this purpose in order to create a biochemical algorithm that could facilitate the diagnostic work-up of HPP.
Results The study population comprised 77 subjects with persistent hypophosphatasaemia. They were divided into two groups according to the presence (+GT) or absence (−GT) of pathogenic ALPL variants: 40 +GT and 37 −GT. Diagnostic utility measures were calculated for different ALP thresholds and Receiver Operating Characteristic (ROC) curves were employed to determine PLP and PEA optimal cut-off levels to predict the presence of variants. The optimal threshold for ALP was 25 IU/L; for PLP, 180 nmol/L and for PEA, 30 µmol/g creatinine. Biochemical predictive models were assessed using binary logistic regression analysis and bootstrapping machine learning technique and results were then validated. For ALP < 25 UI/L (model 1), the area under curve (AUC) and the 95% confidence intervals (CI) was 0.68 (95% CI 0.63–0.72) and it improved to 0.87 (95% CI 0.8–0.9), when PEA or PLP threshold levels were added (models 2 and 3), reaching 0.94 (0.91–0.97) when both substrates were included (model 4). The internal validation showed that the addition of serum PLP threshold levels to the model just including ALP improved significantly sensitivity (S) and negative predictive value (NPV) − 100%, respectively- with an accuracy (AC) of 93% in comparison to the inclusion of urinary PEA (S: 71%; NPV 75% and AC: 79%) and similar diagnostic utility measures as those observed in model 3 were detected when both substrates were added. Conclusions In this study, we propose a biochemical predictive model based on the threshold levels of the main biochemical markers of HPP (ALP < 25 IU/L and PLP > 180 nmol/L) that when combined, seem to be very useful to identify individuals with ALPL variants. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02253-5.
Collapse
Affiliation(s)
- C Tornero
- Department of Rheumatology, La Paz University Hospital, IdiPaz, Paseo de La Castellana, 261, 28046, Madrid, Spain. .,Skeletal Dysplasia Multidisciplinary Unit (UMDE) and ERN-BOND, La Paz University Hospital, Madrid, Spain.
| | - V Navarro-Compán
- Department of Rheumatology, La Paz University Hospital, IdiPaz, Paseo de La Castellana, 261, 28046, Madrid, Spain
| | - A Buño
- Department of Clinical Biochemistry, La Paz University Hospital, Madrid, Spain
| | - K E Heath
- Skeletal Dysplasia Multidisciplinary Unit (UMDE) and ERN-BOND, La Paz University Hospital, Madrid, Spain.,Institute of Medical and Molecular Genetics (INGEMM), La Paz University Hospital, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain.,CIBERER (Centro de Investigación Biomédica en Red de Enfermedades Raras), ISCIII, Madrid, Spain
| | - M Díaz-Almirón
- Department of Biostatistics, La Paz University Hospital, Madrid, Spain
| | - A Balsa
- Department of Rheumatology, La Paz University Hospital, IdiPaz, Paseo de La Castellana, 261, 28046, Madrid, Spain
| | - J A Tenorio
- Institute of Medical and Molecular Genetics (INGEMM), La Paz University Hospital, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain.,CIBERER (Centro de Investigación Biomédica en Red de Enfermedades Raras), ISCIII, Madrid, Spain
| | - J Quer
- Masters in Telecommunications and Big Data, Telecommunications Engineering Degree, ICAI, Madrid, Spain
| | - P Aguado
- Department of Rheumatology, La Paz University Hospital, IdiPaz, Paseo de La Castellana, 261, 28046, Madrid, Spain.,Skeletal Dysplasia Multidisciplinary Unit (UMDE) and ERN-BOND, La Paz University Hospital, Madrid, Spain
| |
Collapse
|
2
|
Santurtún M, Mediavilla-Martinez E, Vega AI, Gallego N, Heath KE, Tenorio JA, Lapunzina P, Riancho-Zarrabeitia L, Riancho JA. Pain and health-related quality of life in patients with hypophosphatasemia with and without ALPL gene mutations. Front Endocrinol (Lausanne) 2022; 13:965476. [PMID: 36072928 PMCID: PMC9442670 DOI: 10.3389/fendo.2022.965476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/26/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Low serum alkaline phosphatase levels are the hallmark of hypophosphatasia, a disorder due to pathogenic variants of the ALPL gene. However, some patients do not carry ALPL variants and the cause of low alkaline phosphatase remains unknown. We aimed to determine health-related quality of life in adults with low alkaline phosphatase and explore the differences between patients with and without ALPL mutations. METHODS We studied 35 adult patients with persistently low alkaline phosphatase unrelated to secondary acquired causes who had ALPL sequenced, and 35 controls of similar age. Three questionnaires about body pain (Brief Pain Inventory, BPI), physical disability (Health Assessment Questionnaire Disability Index, HAQ-DI), and health-related quality of life (36-item Short-Form Health Survey, SF-36) were delivered by telephone interviews. RESULTS The mean BPI intensity and interference scores were higher in the patient group (p=0.04 and 0.004, respectively). All domains of the HAQ instrument tended to score better in the control group, with significant differences in the "reach" score (p=0.037) and the overall mean score (0.23 vs 0.09; p=0.029). Patients scored worse than controls in several SF-36 dimensions (Role physical, p=0.039; Bodily pain p=0.046; Role emotional, p=0.025). Patients with and without pathogenic variants scored similarly across all tests, without between-group significant differences. CONCLUSIONS Patients with persistently low levels of alkaline phosphatase have significantly worse scores in body pain and other health-related quality of life dimensions, without differences between patients with and without pathogenic variants identified in ALPL gene. This is consistent with the latter ones carrying mutations in regulatory regions.
Collapse
Affiliation(s)
- Maite Santurtún
- Departamento de Enfermería, Hospital Padre Meni, Universidad de Cantabria, Santander, Spain
| | | | - Ana I. Vega
- Servicio de Genética, Hospital UM Valdecila, Santander, Spain
| | - Natalia Gallego
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Instituto de Genética Médica y Molecular, Hospital U Lapaz, Instituto de Investigación Sanitaria La Paz (IDIPAZ), Madrid, Spain
- ERN-ITHACA, Brussels, Belgium
| | - Karen E. Heath
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Instituto de Genética Médica y Molecular, Hospital U Lapaz, Instituto de Investigación Sanitaria La Paz (IDIPAZ), Madrid, Spain
- ERN-ITHACA, Brussels, Belgium
| | - Jair A. Tenorio
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Instituto de Genética Médica y Molecular, Hospital U Lapaz, Instituto de Investigación Sanitaria La Paz (IDIPAZ), Madrid, Spain
- ERN-ITHACA, Brussels, Belgium
| | - Pablo Lapunzina
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Instituto de Genética Médica y Molecular, Hospital U Lapaz, Instituto de Investigación Sanitaria La Paz (IDIPAZ), Madrid, Spain
- ERN-ITHACA, Brussels, Belgium
| | - Leyre Riancho-Zarrabeitia
- Servicio de Reumatología, Hospital U Sierrallana Torrelavega, Instituto de Investigación Sanitaria Valdecilla (IDIVAL), Santander, Spain
| | - José A. Riancho
- Departamento de Medicina y Psiquiatría, Servicio de Medicina Interna, Hospital Valdecilla, Instituto de Investigación Sanitaria Valdecilla (IDIVAL), Universidad de Cantabria, Santander, Spain
- *Correspondence: José A. Riancho,
| |
Collapse
|
3
|
Tornero C, Navarro-Compán V, Tenorio JA, García-Carazo S, Buño A, Monjo I, Plasencia-Rodriguez C, Iturzaeta JM, Lapunzina P, Heath KE, Balsa A, Aguado P. Can we identify individuals with an ALPL variant in adults with persistent hypophosphatasaemia? Orphanet J Rare Dis 2020; 15:51. [PMID: 32066479 PMCID: PMC7026995 DOI: 10.1186/s13023-020-1315-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 01/24/2020] [Indexed: 12/19/2022] Open
Abstract
Background Hypophosphatasia (HPP) is an inborn error of metabolism characterized by low levels of serum alkaline phosphatase (ALP). Scarce evidence exists about features that should signal the potential association between hypophosphatasaemia and HPP in adults. The aim of this study is to estimate the prevalence of ALPL variants in subjects with persistent hypophosphatasaemia and determine the associated clinical and laboratory features. For this cross-sectional study, laboratory records of 386,353 subjects were screened by measurement of ALP activity. A total of 85 (0.18%) subjects with persistent hypophosphatasaemia (≥2 serum alkaline phosphatase–ALP–measurements ≤35 IU/L and none > 45 IU/L) were included (secondary causes previously discarded). ALPL genetic testing and a systematized questionnaire to retrieve demographic, clinical and laboratory data were performed. Descriptive analysis and logistic regression models were employed to identify the clinical and laboratory characteristics associated with ALPL variants. Results Forty subjects (47%) had a variant(s) in ALPL. With regard to clinical characteristics, the presence of an ALPL variant was significantly associated only with musculoskeletal pain (OR: 7.6; 95% IC: 1.9–30.9). Nevertheless, a trend to present more dental abnormalities (OR: 3.6; 95% IC: 0.9–13.4) was observed. Metatarsal stress fractures were also more frequent (4 vs 0; p < 0.05) in this group. Regarding laboratory features, median ALP levels were lower in subjects with ALPL variants (26 vs 29 IU/L; p < 0.005). Interestingly, the threshold of ALP levels < 25 IU/L showed a specificity, positive predictive value and positive likelihood ratio of 97.8, 94.4% and 19.8 to detect a positive ALPL test, respectively. Conclusions In subjects with persistent hypophosphatasaemia –secondary causes excluded– one out of two presented ALPL variants. Musculoskeletal pain and ALP levels < 25 IU/L are associated with this variant(s). In this scenario, ALP levels < 25 IU/L seem to be very useful to identify individuals with the presence of an ALPL variant.
Collapse
Affiliation(s)
- C Tornero
- Department of Rheumatology, La Paz University Hospital, IdiPAZ, Paseo de la Castellana, 261, 28046, Madrid, Spain.
| | - V Navarro-Compán
- Department of Rheumatology, La Paz University Hospital, IdiPAZ, Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - J A Tenorio
- Institute of Medical and Molecular Genetics (INGEMM), La Paz University Hospital, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain.,CIBERER (Centro de Investigación Biomédica en Red de Enfermedades Raras), ISCIII, Madrid, Spain
| | - S García-Carazo
- Department of Rheumatology, La Paz University Hospital, IdiPAZ, Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - A Buño
- Department of Clinical Biochemistry, La Paz University Hospital, Madrid, Spain
| | - I Monjo
- Department of Rheumatology, La Paz University Hospital, IdiPAZ, Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - C Plasencia-Rodriguez
- Department of Rheumatology, La Paz University Hospital, IdiPAZ, Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - J M Iturzaeta
- Department of Clinical Biochemistry, La Paz University Hospital, Madrid, Spain
| | - P Lapunzina
- Institute of Medical and Molecular Genetics (INGEMM), La Paz University Hospital, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain.,CIBERER (Centro de Investigación Biomédica en Red de Enfermedades Raras), ISCIII, Madrid, Spain
| | - K E Heath
- Institute of Medical and Molecular Genetics (INGEMM), La Paz University Hospital, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain.,CIBERER (Centro de Investigación Biomédica en Red de Enfermedades Raras), ISCIII, Madrid, Spain.,Skeletal dysplasia multidisciplinary Unit (UMDE), La Paz University Hospital, Madrid, Spain
| | - A Balsa
- Department of Rheumatology, La Paz University Hospital, IdiPAZ, Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - P Aguado
- Department of Rheumatology, La Paz University Hospital, IdiPAZ, Paseo de la Castellana, 261, 28046, Madrid, Spain
| |
Collapse
|
4
|
López-Delgado L, Riancho-Zarrabeitia L, García-Unzueta MT, Tenorio JA, García-Hoyos M, Lapunzina P, Valero C, Riancho JA. Abnormal bone turnover in individuals with low serum alkaline phosphatase. Osteoporos Int 2018; 29:2147-2150. [PMID: 29947871 DOI: 10.1007/s00198-018-4571-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/08/2018] [Indexed: 10/14/2022]
Abstract
The clinical spectrum of hypophosphatasia (HPP) is broad and variable within families. Along severe infantile forms, adult forms with mild manifestations may be incidentally discovered by the presence of low alkaline phosphatase (ALP) activity in serum. However, it is still unclear whether individuals with persistently low levels of ALP, in the absence of overt manifestations of HPP, have subclinical abnormalities of bone remodeling or bone mass. The aim of this study was to obtain a better understanding of the skeletal phenotype of adults with low ALP by analyzing bone mineral density (BMD), bone microarchitecture (trabecular bone score, TBS), and bone turnover markers (P1NP and ß-crosslaps). We studied 42 individuals with persistently low serum ALP. They showed lower levels of P1NP (31.4 ± 13.7 versus 48.9 ± 24.4 ng/ml; p = 0.0002) and ß-crosslaps (0.21 ± 0.17 versus 0.34 ± 0.22 ng/ml, p = 0.0015) than individuals in the control group. There were no significant differences in BMD, bone mineral content, or TBS. These data suggest that individuals with hypophosphatasemia have an overall reduction of bone turnover, even in the absence of overt manifestations of HPP or low BMD. We evaluated bone mineral density (BMD), bone microarchitecture, and bone turnover markers in patients with low serum levels of alkaline phosphatase. Our results show that these patients have low bone remodeling even in the absence of BMD abnormalities, thus supporting the recommendation of avoiding antiresorptives such as bisphosphonates in these subjects.
Collapse
Affiliation(s)
- L López-Delgado
- Service of Internal Medicine, Hospital U.M. Valdecilla, University of Cantabria, IDIVAL, Av Valdecilla SN, 39008, Santander, Spain
| | | | - M T García-Unzueta
- Service of Clinical Biochemistry, Hospital U.M. Valdecilla, University of Cantabria, IDIVAL, Santander, Spain
| | - J A Tenorio
- Institute of Medical and Molecular Genetics (INGEMM), Hospital Universitario La Paz. IdiPAZ, Universidad Autónoma de Madrid and CIBERER, ISCIII, Madrid, Spain
| | - M García-Hoyos
- Service of Internal Medicine, Hospital U.M. Valdecilla, University of Cantabria, IDIVAL, Av Valdecilla SN, 39008, Santander, Spain
| | - P Lapunzina
- Institute of Medical and Molecular Genetics (INGEMM), Hospital Universitario La Paz. IdiPAZ, Universidad Autónoma de Madrid and CIBERER, ISCIII, Madrid, Spain
| | - C Valero
- Service of Internal Medicine, Hospital U.M. Valdecilla, University of Cantabria, IDIVAL, Av Valdecilla SN, 39008, Santander, Spain
| | - J A Riancho
- Service of Internal Medicine, Hospital U.M. Valdecilla, University of Cantabria, IDIVAL, Av Valdecilla SN, 39008, Santander, Spain.
| |
Collapse
|
5
|
Riancho-Zarrabeitia L, García-Unzueta M, Tenorio JA, Gómez-Gerique JA, Ruiz Pérez VL, Heath KE, Lapunzina P, Riancho JA. Clinical, biochemical and genetic spectrum of low alkaline phosphatase levels in adults. Eur J Intern Med 2016; 29:40-5. [PMID: 26783040 DOI: 10.1016/j.ejim.2015.12.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 09/21/2015] [Accepted: 12/15/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Low serum levels of alkaline phosphatase (ALP) are a hallmark of hypophosphatasia. However, the clinical significance and the underlying genetics of low ALP in unselected populations are unclear. METHODS In order to clarify this issue, we performed a clinical, biochemical and genetic study of 42 individuals (age range 20-77yr) with unexplained low ALP levels. RESULTS Nine had mild hyperphosphatemia and three had mild hypercalcemia. ALP levels were inversely correlated with serum calcium (r=-0.38, p=0.012), pyridoxal phosphate (PLP; r=-0.51, p=0.001) and urine phosphoethanolamine (PEA; r=-0.49, p=0.001). Although many subjects experienced minor complaints, such as mild musculoskeletal pain, none had major health problems. Mutations in ALPL were found in 21 subjects (50%), including six novel mutations. All but one, were heterozygous mutations. Missense mutations were the most common (present in 18 subjects; 86%) and the majority were predicted to have a damaging effect on protein activity. The presence of a mutated allele was associated with tooth loss (48% versus 12%; p=0.04), slightly lower levels of serum ALP (p=0.002), higher levels of PLP (p<0.0001) and PEA (p<0.0001), as well as mildly increased serum phosphate (p=0.03). Ten individuals (24%) had PLP levels above the reference range; all carried a mutated allele. CONCLUSION One-half of adult individuals with unexplained low serum ALP carried an ALPL mutation. Although the associated clinical manifestations are usually mild, in approximately 50% of the cases, enzyme activity is low enough to cause substrate accumulation and may predispose to defects in calcified tissues.
Collapse
Affiliation(s)
| | - Mayte García-Unzueta
- Dept. of Clinical Biochemistry, Hospital Universitario Marqués Valdecilla, IDIVAL, Santander, Spain.
| | - Jair A Tenorio
- Institute of Medical and Molecular Genetics (INGEMM), Hospital Universitario La Paz, IdiPAZ, Universidad Autónoma de Madrid, Spain; CIBERER, ISCIII, Madrid, Spain.
| | - Juan A Gómez-Gerique
- Dept. of Clinical Biochemistry, Hospital Universitario Marqués Valdecilla, IDIVAL, Santander, Spain.
| | - Víctor L Ruiz Pérez
- Instituto de Investigaciones Biomédicas "Alberto Sols", IdiPAZ, UAM-CIBERER - ISCIII, Madrid, Spain.
| | - Karen E Heath
- Institute of Medical and Molecular Genetics (INGEMM), Hospital Universitario La Paz, IdiPAZ, Universidad Autónoma de Madrid, Spain; Skeletal Dysplasia Multidisciplinary Unit, Hospital Universitario La Paz, Madrid, Spain.
| | - Pablo Lapunzina
- Institute of Medical and Molecular Genetics (INGEMM), Hospital Universitario La Paz, IdiPAZ, Universidad Autónoma de Madrid, Spain; Skeletal Dysplasia Multidisciplinary Unit, Hospital Universitario La Paz, Madrid, Spain.
| | - José A Riancho
- Dept. of Internal Medicine, Hospital Universitario Marqués Valdecilla, IDIVAL, University of Cantabria, RETICEF, Santander, Spain.
| |
Collapse
|
6
|
Nevado J, Rosenfeld JA, Mena R, Palomares-Bralo M, Vallespín E, Ángeles Mori M, Tenorio JA, Gripp KW, Denenberg E, Del Campo M, Plaja A, Martín-Arenas R, Santos-Simarro F, Armengol L, Gowans G, Orera M, Sanchez-Hombre MC, Corbacho-Fernández E, Fernández-Jaén A, Haldeman-Englert C, Saitta S, Dubbs H, Bénédicte DB, Li X, Devaney L, Dinulos MB, Vallee S, Crespo MC, Fernández B, Fernández-Montaño VE, Rueda-Arenas I, de Torres ML, Ellison JW, Raskin S, Venegas-Vega CA, Fernández-Ramírez F, Delicado A, García-Miñaúr S, Lapunzina P. PIAS4 is associated with macro/microcephaly in the novel interstitial 19p13.3 microdeletion/microduplication syndrome. Eur J Hum Genet 2015; 23:1615-26. [PMID: 25853300 DOI: 10.1038/ejhg.2015.51] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 12/23/2014] [Accepted: 02/17/2015] [Indexed: 12/24/2022] Open
Abstract
Array comparative genomic hybridization (aCGH) is a powerful genetic tool that has enabled the identification of novel imbalances in individuals with intellectual disability (ID), autistic disorders and congenital malformations. Here we report a 'genotype first' approach using aCGH on 13 unrelated patients with 19p13.3 submicroscopic rearrangement (11 deletions and 2 duplications) and review cases in the literature and in public databases. Shared phenotypic features suggest that these patients represent an interstitial microdeletion/microduplication syndrome at 19p13.3. Common features consist of abnormal head circumference in most patients (macrocephaly with the deletions and microcephaly with the duplications), ID with developmental delay (DD), hypotonia, speech delay and common dysmorphic features. The phenotype is associated with at least a ~0.113 Mb critical region harboring three strong candidate genes probably associated with DD, ID, speech delay and other dysmorphic features: MAP2K2, ZBTB7A and PIAS4, an E3 ubiquitin ligase involved in the ubiquitin signaling pathways, which we hypothesize for the first time to be associated with head size in humans.
Collapse
Affiliation(s)
- Julián Nevado
- Section of Functional and Structural Genomics Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain.,CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII, Madrid, Spain
| | - Jill A Rosenfeld
- Signature Genomic Laboratories, PerkinElmer Inc., Spokane, WA, USA
| | - Rocío Mena
- Section of Functional and Structural Genomics Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | - María Palomares-Bralo
- Section of Functional and Structural Genomics Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain.,CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII, Madrid, Spain
| | - Elena Vallespín
- Section of Functional and Structural Genomics Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain.,CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII, Madrid, Spain
| | - María Ángeles Mori
- Section of Functional and Structural Genomics Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain.,CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII, Madrid, Spain
| | - Jair A Tenorio
- Section of Functional and Structural Genomics Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | - Karen W Gripp
- AI DuPont Hospital for Children, Wilmington, DE, USA
| | | | | | | | - Rubén Martín-Arenas
- Section of Functional and Structural Genomics Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | | | | | | | | | | | | | | | | | - Sulagna Saitta
- Medical Genetics Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Holly Dubbs
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Xia Li
- Ameripath Northeast, Shelton, CT, USA
| | - Lani Devaney
- Henry Ford Health System, Sterling Heights, Michigan, USA
| | | | | | - M Carmen Crespo
- Section of Functional and Structural Genomics Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | - Blanca Fernández
- Section Cytogenetics, INGEMM-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | - Victoria E Fernández-Montaño
- Section of Functional and Structural Genomics Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | - Inmaculada Rueda-Arenas
- Section of Functional and Structural Genomics Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | - María Luisa de Torres
- CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII, Madrid, Spain.,Section Cytogenetics, INGEMM-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | | | - Salmo Raskin
- Center for Health and Biological Sciences, Pontifícia Universidade Católica do Paraná (PUC-PR), Curitiba, Brazil
| | - Carlos A Venegas-Vega
- Genetic Unit Hospital General de México, México, México.,School of Medicine. Universidad Autónoma de México, México, México
| | | | - Alicia Delicado
- CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII, Madrid, Spain.,Section Cytogenetics, INGEMM-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | - Sixto García-Miñaúr
- CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII, Madrid, Spain.,Section of Clinical Genetics, INGEMM-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | - Pablo Lapunzina
- CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII, Madrid, Spain.,Section of Clinical Genetics, INGEMM-IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| |
Collapse
|