GestaltMatcher Database - A global reference for facial phenotypic variability in rare human diseases
Abstract
The most important factor that complicates the work of dysmorphologists is the significant phenotypic variability of the human face. Next-Generation Phenotyping (NGP) tools that assist clinicians with recognizing characteristic syndromic patterns are particularly challenged when confronted with patients from populations different from their training data. To that end, we systematically analyzed the impact of genetic ancestry on facial dysmorphism. For that purpose, we established the GestaltMatcher Database (GMDB) as a reference dataset for medical images of patients with rare genetic disorders from around the world. We collected 10,980 frontal facial images - more than a quarter previously unpublished - from 8,346 patients, representing 581 rare disorders. Although the predominant ancestry is still European (67%), data from underrepresented populations have been increased considerably via global collaborations (19% Asian and 7% African). This includes previously unpublished reports for more than 40% of the African patients. The NGP analysis on this diverse dataset revealed characteristic performance differences depending on the composition of training and test sets corresponding to genetic relatedness. For clinical use of NGP, incorporating non-European patients resulted in a profound enhancement of GestaltMatcher performance. The top-5 accuracy rate increased by +11.29%. Importantly, this improvement in delineating the correct disorder from a facial portrait was achieved without decreasing the performance on European patients. By design, GMDB complies with the FAIR principles by rendering the curated medical data findable, accessible, interoperable, and reusable. This means GMDB can also serve as data for training and benchmarking. In summary, our study on facial dysmorphism on a global sample revealed a considerable cross ancestral phenotypic variability confounding NGP that should be counteracted by international efforts for increasing data diversity. GMDB will serve as a vital reference database for clinicians and a transparent training set for advancing NGP technology.
Authors 99
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Affiliation as printed
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, NRW, Germany
Institute of Human Genetics, University of Bonn, Bonn, NRW, Germany
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, Germany
Institute of Human Genetics, University of Bonn, Bonn, Germany
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Affiliation as printed
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, NRW, Germany
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, Germany
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Stellenbosch University · Tygerberg Hospital
Affiliation as printed
Division of Molecular Biology and Human Genetics, Stellenbosch University and Medical Genetics, Tygerberg Hospital, Stellenbosch, South Africa
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University of Bonn · Institut für Medizinische Biometrie, Informatik und Epidemiologie
Affiliation as printed
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, NRW, Germany
Institute for Medical Biometry, Informatics and Epidemiology, University of Bonn, Bonn, NRW, Germany
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, Germany
Institute for Medical Biometry, Informatics and Epidemiology, University of Bonn, Bonn, Germany
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Affiliation as printed
New York State Institute for Basic Research in Developmental Disabilities, New York State, Albany, New York, USA
New York State Institute for Basic Research in Developmental Disabilities, New York State, Albany, USA
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Affiliation as printed
Institute of Human Genetics, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
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Affiliation as printed
Department of Human Genetics, Medical Research Institute, Alexandria University, Alexandria, Alexandria, Egypt
Department of Human Genetics, Medical Research Institute, Alexandria University, Alexandria, Egypt
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Jean Tori Pantel Aachen Center for Rare Diseases Aachen (ZSEA) Institute for Digitalization and General Medicine
Universitätsklinikum Aachen · RWTH Aachen University
Affiliation as printed
Centre for Rare Diseases Aachen (ZSEA), University Hospital RWTH Aachen, Aachen, NRW, Germany
Institute for Digitalization and General Medicine, University Hospital RWTH Aachen, Aachen, NRW, Germany
Centre for Rare Diseases Aachen (ZSEA), University Hospital RWTH Aachen, Aachen, Germany
Institute for Digitalization and General Medicine, University Hospital RWTH Aachen, Aachen, Germany
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Affiliation as printed
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, NRW, Germany
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, Germany
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Affiliation as printed
Department of Paediatrics, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
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Affiliation as printed
Department of Paediatrics, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
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Affiliation as printed
Department of Paediatrics, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
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Affiliation as printed
GeneTalk GmbH, Bonn, NRW, Germany
GeneTalk, Bonn, Germany
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Affiliation as printed
GeneTalk GmbH, Bonn, NRW, Germany
GeneTalk, Bonn, Germany
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Affiliation as printed
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, NRW, Germany
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, Germany
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Affiliation as printed
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, NRW, Germany
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, Germany
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Affiliation as printed
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, NRW, Germany
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, Germany
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University of Rwanda · Centre Hospitalier Universitaire de Kigali
Affiliation as printed
College of Medicine and Health Sciences, University of Rwanda, and University Teaching Hospital of Kigali, Kigali, Rwanda
Department of Clinical Biology, University of Rwanda, Kigali, Rwanda
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Affiliation as printed
Institute for Human Genetics and Genomic Medicine, Medical Faculty, RWTH Aachen University, Aachen, NRW, Germany
Institute for Human Genetics and Genomic Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
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Tbilisi State Medical University
Affiliation as printed
Department of Molecular and Medical Genetics, Tbilisi State Medical University, Tbilisi, Georgia
Givi Zhvania Pediatric Academic Clinic, Tbilisi State Medical University, Georgia
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Affiliation as printed
Institute for Human Genetics and Genomic Medicine, Medical Faculty, RWTH Aachen University, Aachen, NRW, Germany
Institute for Human Genetics and Genomic Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
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Affiliation as printed
Institute for Human Genetics and Genomic Medicine, Medical Faculty, RWTH Aachen University, Aachen, NRW, Germany
Institute for Human Genetics and Genomic Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
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University Hospital Leipzig · Leipzig University
Affiliation as printed
Institute of Human Genetics, University of Leipzig Medical Center, Leipzig, Germany
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University of Cologne · University Hospital Cologne
Affiliation as printed
Institute of Human Genetics, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, NRW, Germany
Institute of Human Genetics, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
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University Hospital Leipzig · Leipzig University
Affiliation as printed
Institute of Human Genetics, University of Leipzig Medical Center, Leipzig, Germany
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TUM Klinikum · Institut für Humangenetik · Technical University of Munich
Affiliation as printed
Institute of Human Genetics, Klinikum rechts der Isar, Technical University of Munich, School of Medicine and Health, Munich, Germany
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Meyer Children's Hospital · University of Florence
Affiliation as printed
Department of Experimental and Clinical Biomedical Sciences "Mario Serio", Università degli Studi di Firenze, Italy
Medical Genetics, Meyer Children's Hospital IRCCS, Firenze, Italy
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Guy's Hospital · King's College London · Guy's and St Thomas' NHS Foundation Trust · Great Ormond Street Hospital · The Francis Crick Institute
Affiliation as printed
Department of Medical & Molecular Genetics, School of Basic and Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, UK
Department of Medical Genetics, Guy's and St. Thomas' NHS Foundation Trust, London, UK
Neural Stem Cell Biology Laboratory, The Francis Crick Institute, UK
North East Thames Regional Genetics Service, Great Ormond Street Hospital for Children, Great Ormond Street, London, UK
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Universidade Federal de São Paulo
Affiliation as printed
Genetics Division, Department of Morphology and Genetics, Universidade Federal de São Paulo, São Paulo, Brazil
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Universidade Federal de São Paulo
Affiliation as printed
Genetics Division, Department of Morphology and Genetics, Universidade Federal de São Paulo, São Paulo, Brazil
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Affiliation as printed
Genetics Unit, Instituto da Criança, Universidade de São Paulo, São Paulo, Brazil
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Affiliation as printed
Genetics Unit, Instituto da Criança, Universidade de São Paulo, São Paulo, Brazil
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Universidade Federal de São Paulo
Affiliation as printed
Genetics Division, Department of Morphology and Genetics, Universidade Federal de São Paulo, São Paulo, Brazil
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Affiliation as printed
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, NRW, Germany
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, Germany
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Affiliation as printed
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, NRW, Germany
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, Germany
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Medical University of Białystok
Affiliation as printed
Centre for Bioinformatics and Data Analysis, Medical University of Bialystok, Bialystok, Poland
IMAGENE.ME SA, Bialystok, Poland
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Medical University of Białystok
Affiliation as printed
Centre for Bioinformatics and Data Analysis, Medical University of Bialystok, Bialystok, Poland
IMAGENE.ME SA, Bialystok, Poland
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Great Ormond Street Hospital · University College London
Affiliation as printed
Department of Genetics and Genomic Medicine, UCL Institute of Child Health, London UK
North East Thames Regional Genetics Service, Great Ormond Street Hospital for Children, Great Ormond Street, London, UK
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University of Münster · University Hospital Münster
Affiliation as printed
Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, NRW, Germany
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University of Newcastle Australia
Affiliation as printed
School of Medicine and Public Health, University of Newcastle, Callaghan NSW, Australia
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University of Cologne · University Hospital Cologne
Affiliation as printed
Kabuki Syndrome Foundation, Northbrook, IL, USA
Institute of Human Genetics, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
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University of Bonn · Hunter Genetics · Hunter New England Local Health District
Affiliation as printed
Hunter Genetics, Hunter New England Health Service, Newcastle, Australia
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, Germany
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Affiliation as printed
Department of Clinical Genetics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Affiliation as printed
Department of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
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Affiliation as printed
Department of Human Genetics, Medical Research Institute, Alexandria University, Alexandria, Alexandria, Egypt
Department of Human Genetics, Medical Research Institute, Alexandria University, Alexandria, Egypt
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Affiliation as printed
Institute for Human Genetics and Genomic Medicine, Medical Faculty, RWTH Aachen University, Aachen, NRW, Germany
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Essen University Hospital · University of Duisburg-Essen
Affiliation as printed
Institute of Human Genetics, University Hospital Essen, University Duisburg-Essen, Essen, NRW, Germany
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Affiliation as printed
Department of Genetics, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Sao Paulo, Brazil
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Düsseldorf University Hospital · Heinrich Heine University Düsseldorf
Affiliation as printed
Department of General Pediatrics and Neonatology, University Children's Hospital, Heinrich-Heine-University, Medical Faculty, Düsseldorf, Germany
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Affiliation as printed
Department of Paediatrics, College of Medicine, University of Lagos, Lagos, Nigeria
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Ljubljana University Medical Centre
Affiliation as printed
Clinical Institute of Genomic Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Ljubljana University Medical Centre
Affiliation as printed
Clinical Institute of Genomic Medicine, University Medical Centre Ljubljana
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IRCCS Azienda Ospedliero-Universitaria di Bologna Policlinico di Sant'Orsola
Affiliation as printed
Medical Genetics Unit, Ausl Romagna, Cesena, Italy
Medical Genetics Unit, Policlinico S. Orsola-Malpighi, Bologna, Italy
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Ain Shams University · Armed Forces College of Medicine
Affiliation as printed
Medical Genetics Center, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Medical Genetics Department, Armed Forces College of Medicine, Cairo, Egypt
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Instituto Nacional de Pediatria · Universidad Nacional Autónoma de México
Affiliation as printed
Laboratorio de Citogenética, Instituto Nacional de Pediatría, México City, Mexico
Programa de Maestría y Doctorado en Ciencias Médicas, Odontológicas y de la Salud, Universidad Nacional Autónoma de México, México City, Mexico
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IRCCS Materno Infantile Burlo Garofolo
Affiliation as printed
Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
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Humboldt-Universität zu Berlin · Berlin Institute of Health at Charité - Universitätsmedizin Berlin · NeuroCure Cluster of Excellence · Freie Universität Berlin · Charité - Universitätsmedizin Berlin
Affiliation as printed
Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, D-10117 Berlin, German
Department of Neuropediatrics, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, D-13353 Berlin, Germany
NeuroCure Cluster of Excellence; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, D-10117 Berlin, Germany
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Thai Red Cross Society · Chulalongkorn University · King Chulalongkorn Memorial Hospital
Affiliation as printed
Division of Medical Genetics and Genomics, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
Excellence Center for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
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Affiliation as printed
Institute for Human Genetics and Genomic Medicine, Medical Faculty, RWTH Aachen University, Aachen, NRW, Germany
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Affiliation as printed
Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany
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Khalifa University of Science and Technology · Shaikh Khalifa Medical City · Alexandria University
Affiliation as printed
Khalifa University, Abu Dhabi, United Arab Emirates
Pediatric Gastroenterology Department, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
Department of Human Genetics, Medical Research Institute, Alexandria University, Alexandria, Egypt
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University of Freiburg · University Medical Center Freiburg
Affiliation as printed
Institute of Human Genetics, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Universitat Autònoma de Barcelona · Hospital Universitari Germans Trias i Pujol
Affiliation as printed
Paediatric Neurology Unit, Department of Pediatrics, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
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TUM Klinikum · Institut für Humangenetik · Technical University of Munich
Affiliation as printed
Institute of Human Genetics, Klinikum rechts der Isar, Technical University of Munich, School of Medicine and Health, Munich, Germany
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Affiliation as printed
Institute of Human Genetics, Medical University Innsbruck, Innsbruck, Austria
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Autonomous University of Yucatán
Affiliation as printed
Universidad Autonoma de Yucatan (University Autonomus of Yucatan), Merida, Yucatan, Mexico
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University of Bonn · TUM Klinikum · Institut für Humangenetik · Technical University of Munich
Affiliation as printed
Institute of Human Genetics, Klinikum rechts der Isar, Technical University of Munich, School of Medicine and Health, Munich, Germany
Institute for Genomic Statistics and Bioinformatics, University of Bonn, Bonn, Germany
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George Washington University · Florida International University
Affiliation as printed
Department of Human and Molecular Genetics, Florida International University, 11200 SW 8th Street, AHC2 Miami, Florida 22199
Department of Pediatrics, George Washington University, 2121 I St. NW, Washington D.C. 2005
Department of Research, The Focus Foundation, 820 W. Central Ave. #190, Davidsonville, MD 21035
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Affiliation as printed
Department of Research, The Focus Foundation, 2772 Rutland Road P.O. Box 190, Davidsonville, MD 21035
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Affiliation as printed
Department of Research, The Focus Foundation, 2772 Rutland Road P.O. Box 190, Davidsonville, MD 21035
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University Hospital Leipzig · Leipzig University
Affiliation as printed
Institute of Human Genetics, University of Leipzig Medical Center, Leipzig, Germany
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Research Centre for Medical Genetics
Affiliation as printed
Research Centre for Medical Genetics (RCMG), Moscow, Russia
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University Hospital Leipzig · Leipzig University
Affiliation as printed
Institute of Human Genetics, University of Leipzig Medical Center, Leipzig, Germany
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University Hospital Leipzig · Leipzig University
Affiliation as printed
Institute of Human Genetics, University of Leipzig Medical Center, Leipzig, Germany
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University Hospital Leipzig · Leipzig University
Affiliation as printed
Institute of Human Genetics, University of Leipzig Medical Center, Leipzig, Germany
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Utrecht University · University Medical Center Utrecht
Affiliation as printed
Department of Genetics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Cambridge University Hospitals NHS Foundation Trust
Affiliation as printed
Department of Clinical Genetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Affiliation as printed
Institute of Human Genetics, University of Bonn, Bonn, NRW, Germany
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University of Freiburg · University Medical Center Freiburg
Affiliation as printed
Institute of Human Genetics, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Affiliation as printed
Department of Human Genetics, Medical Research Institute, Alexandria University, Alexandria, Alexandria, Egypt
Department of Human Genetics, Medical Research Institute, Alexandria University, Alexandria, Egypt
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Affiliation as printed
Department of Molecular Medicine, University of Pavia, Pavia, Italy
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Affiliation as printed
Department of Molecular Medicine, University of Pavia, Pavia, Italy
Medical Genetics Unit, IRCCS San Matteo Foundation, Pavia, Italy
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Affiliation as printed
Department of Clinical Genetics, SJD Barcelona Children's Hospital, Esplugues del Llobregat (Barcelona), Spain
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University of Freiburg · University Medical Center Freiburg
Affiliation as printed
Institute of Human Genetics, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Affiliation as printed
Department of Human Genetics, Medical Research Institute, Alexandria University, Alexandria, Alexandria, Egypt
Department of Human Genetics, Medical Research Institute, Alexandria University, Alexandria, Egypt
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Vall d'Hebron Institut de Recerca · Vall d'Hebron Hospital Universitari
Affiliation as printed
Department of Clinical and Molecular Genetics, Vall d'Hebron Barcelona Hospital Campus, Vall d'Hebron Hospital Universitari, Barcelona, Catalunya, Spain
Medicine Genetics Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Vall d'Hebron Hospital Universitari, Barcelona, Catalunya, Spain
Department of Clinical and Molecular Genetics, Vall d'Hebron Barcelona Hospital Campus, Vall d'Hebron Hospital Universitari, Barcelona, Spain
Medicine Genetics Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Vall d'Hebron Hospital Universitari, Barcelona, Spain
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Newcastle upon Tyne Hospitals NHS Foundation Trust · Newcastle University
Affiliation as printed
Biosciences Institute, Newcastle University, Central Parkway, Newcastle upon Tyne, UK
Renal Services, The Newcastle Upon Tyne NHS Hospitals Foundation Trust, Freeman Road, Newcastle Upon Tyne, UK
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Humboldt-Universität zu Berlin · Berlin Institute of Health at Charité - Universitätsmedizin Berlin · Charité - Universitätsmedizin Berlin
Affiliation as printed
Institute of Medical Genetics and Human Genetics, Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Humboldt-Universität zu Berlin · Berlin Institute of Health at Charité - Universitätsmedizin Berlin · Charité - Universitätsmedizin Berlin
Affiliation as printed
Institute of Medical Genetics and Human Genetics, Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Humboldt-Universität zu Berlin · Berlin Institute of Health at Charité - Universitätsmedizin Berlin · Charité - Universitätsmedizin Berlin
Affiliation as printed
Institute of Medical Genetics and Human Genetics, Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Humboldt-Universität zu Berlin · Berlin Institute of Health at Charité - Universitätsmedizin Berlin · Charité - Universitätsmedizin Berlin
Affiliation as printed
Institute of Medical Genetics and Human Genetics, Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Heidelberg University · Humboldt-Universität zu Berlin · Berlin Institute of Health at Charité - Universitätsmedizin Berlin · Charité - Universitätsmedizin Berlin
Affiliation as printed
Institute of Medical Genetics and Human Genetics, Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
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Humboldt-Universität zu Berlin · Berlin Institute of Health at Charité - Universitätsmedizin Berlin · Charité - Universitätsmedizin Berlin
Affiliation as printed
Institute of Medical Genetics and Human Genetics, Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Humboldt-Universität zu Berlin · Berlin Institute of Health at Charité - Universitätsmedizin Berlin · Charité - Universitätsmedizin Berlin
Affiliation as printed
Institute of Medical Genetics and Human Genetics, Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Humboldt-Universität zu Berlin · University Hospital Leipzig · Berlin Institute of Health at Charité - Universitätsmedizin Berlin · Charité - Universitätsmedizin Berlin · Leipzig University
Affiliation as printed
Institute of Medical Genetics and Human Genetics, Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
Institute of Human Genetics, University of Leipzig Medical Center, Leipzig, Germany
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Humboldt-Universität zu Berlin · Berlin Institute of Health at Charité - Universitätsmedizin Berlin · Charité - Universitätsmedizin Berlin
Affiliation as printed
Institute of Medical Genetics and Human Genetics, Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Affiliation as printed
Department of Paediatrics, Faculty of Medicine, University Malaya, 59100 Kuala Lumpur, Malaysia
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Affiliation as printed
GeneTalk, Bonn, Germany
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Affiliation as printed
Ege University, Faculty of Medicine, Department of Pediatric Gastroenterology Hepatology and Nutrition, Izmir, Turkey
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