The genomic landscape of balanced cytogenetic abnormalities associated with human congenital anomalies

Journal name:
Nature Genetics
Year published:
Published online


Despite the clinical significance of balanced chromosomal abnormalities (BCAs), their characterization has largely been restricted to cytogenetic resolution. We explored the landscape of BCAs at nucleotide resolution in 273 subjects with a spectrum of congenital anomalies. Whole-genome sequencing revised 93% of karyotypes and demonstrated complexity that was cryptic to karyotyping in 21% of BCAs, highlighting the limitations of conventional cytogenetic approaches. At least 33.9% of BCAs resulted in gene disruption that likely contributed to the developmental phenotype, 5.2% were associated with pathogenic genomic imbalances, and 7.3% disrupted topologically associated domains (TADs) encompassing known syndromic loci. Remarkably, BCA breakpoints in eight subjects altered a single TAD encompassing MEF2C, a known driver of 5q14.3 microdeletion syndrome, resulting in decreased MEF2C expression. We propose that sequence-level resolution dramatically improves prediction of clinical outcomes for balanced rearrangements and provides insight into new pathogenic mechanisms, such as altered regulation due to changes in chromosome topology.

At a glance


  1. Characterization of BCAs detected by karyotyping at nucleotide resolution.
    Figure 1: Characterization of BCAs detected by karyotyping at nucleotide resolution.

    (a) Genome-wide map of all BCA breakpoints identified in the cohort by whole-genome sequencing78. One color is used for each BCA to represent all rearrangement breakpoints in each subject. The scatterplot on the outside ring denotes breakpoint density per 1-Mb bin across the genome, with a blue arrow indicating the largest clustering of breakpoints at 5q14.3. (b) Scatterplot summarizing the overall genomic imbalance associated with fully reconstructed BCAs at varying size thresholds. Curves represent the fraction of cases with final genomic imbalances greater than the corresponding size provided. Solid lines denote the final genomic imbalances for all BCAs and are further delineated as deletions (red) or duplications (blue). The final genomic imbalances among fully mapped BCAs are also split between cases that had been prescreened by CMA (dashed line) and cases without CMA data (dotted line). (c) Sequence signatures of BCA breakpoints. The histogram represents nucleotide signatures at the junction of 662 Sanger-validated breakpoints: inserted nucleotides, blunt ends, microhomology, and longer stretches of homology.

  2. De novo BCAs associated with congenital anomalies disrupt functionally relevant loci.
    Figure 2: De novo BCAs associated with congenital anomalies disrupt functionally relevant loci.

    (a) Box plots illustrate specific gene set enrichments at BCA breakpoints in subjects with congenital anomalies. Each box plot represents the expected distribution (median, first and third quartiles; whiskers extend to maximum values within 1.5 x interquartile range). based on total intersections between 100,000 sets of simulated breakpoints and a particular gene set. Red crosses denote the observed intersection values. Empirical Monte Carlo P values are indicated. SCZ, schizophrenia; T2DM, type 2 diabetes mellitus. (b) Venn diagram showing the detailed overlap of disrupted genes previously associated with three neurodevelopmental phenotypes in amalgamated exome and CNV studies. Black, high-confidence genes (3 or more de novo loss-of-function mutations reported); gray, low-confidence genes (2 de novo loss-of-function mutations). (ce) Diagnostic yields associated with the overall cohort and multiple subgroups of BCAs. (c) Diagnostic yield associated with all 248 mapped BCAs from subjects with congenital or developmental anomalies. (d) Diagnostic yield partitioned by inheritance status. (e) Diagnostic yield associated with BCAs depleted for large pathogenic CNVs detected in CMA prescreening in comparison to BCAs that had not been prescreened by CMA.

  3. Recurrent disruption of long-range regulatory interactions at the 5q14.3 locus.
    Figure 3: Recurrent disruption of long-range regulatory interactions at the 5q14.3 locus.

    (a) Genome-wide distribution of BCA breakpoints in the cohort across each 1-Mb bin. P values correspond to observed cluster sizes versus those expected after 100,000 Monte Carlo randomizations. Corrected P values are reported. One cluster, localized to 5q14.3, achieved genome-wide significance (threshold demarcated by the red line). (b) Hi-C profile and contact domains at the 5q14.3 locus derived from human LCLs. Overlapping Hi-C data suggest that the topology of the MEF2C contact domain is altered in subjects carrying BCAs17. Brain-expressed enhancers located in the region79, loops involving MEF2C (yellow circles)17, and CTCF-binding sites (green, forward; red, reverse) are indicated. Multiple pathogenic mechanisms converge on a similar syndrome: (i) multigenic deletions that encompass MEF2C and one or both TAD boundaries (n = 68), (ii) MEF2C-intragenic deletions (n = 12) or other loss-of-function mutations, (iii) deletions that do not encompass MEF2C but disrupt one TAD boundary (n = 13), and (iv) BCAs with breakpoints distal to MEF2C (n = 7 subjects from this study and 3 previously reported subjects)14, 54, 59. Gray dashed lines indicate reported TADs61. (c) Proposed model of chromatin folding in the region defining a regulatory unit for MEF2C. (d) Significantly decreased expression of MEF2C was observed in subjects harboring BCAs distal to MEF2C in comparison to controls. MEF2C expression was measured by qRT–PCR, with levels normalized against those for three endogenous genes and compared to the average MEF2C expression from 16 age-matched controls (two-sided Wilcoxon rank-sum test: DGAP131, DGAP191, DGAP222, P = 0.0085; DGAP218, P = 0.0160). Individual expression values, medians, and first and third quartiles are shown.

  4. Correlations between phenotypes and genes disrupted in subjects harboring pathogenic BCAs.
    Figure 4: Correlations between phenotypes and genes disrupted in subjects harboring pathogenic BCAs.

    For each gene, the phenotypes reported in the corresponding subject were digitalized using HPO18. One tile represents the normalized count of HPO terms belonging to each organ category reported in the subject(s). Genes clustered together when sharing similarly affected organs, from which five groups can be delineated: (i) genes associated with multiple nervous system and craniofacial abnormalities (dark blue); (ii) genes connected to multiple neurological phenotypes (pink); (iii) genes associated with craniofacial abnormalities and a few neurological symptoms (black); (iv) genes associated with skeletal and limb abnormalities and with limited neurological involvement (green); and (v) genes without neurological involvement (light blue).


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Author information

  1. Present address: Department of Pediatrics, Genetics Division, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee, USA.

    • Chester W Brown
  2. Deceased.

    • Dorothy P Warburton


  1. Molecular Neurogenetics Unit, Center for Human Genetic Research, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA.

    • Claire Redin,
    • Harrison Brand,
    • Ryan L Collins,
    • Carrie Hanscom,
    • Vamsee Pillalamarri,
    • Catarina M Seabra,
    • Rhett Adley,
    • Yu An,
    • Caroline Antolik,
    • Ian Blumenthal,
    • Colby Chiang,
    • Benjamin B Currall,
    • Joseph T Glessner,
    • William Lawless,
    • Diane Lucente,
    • Poornima Manavalan,
    • Matthew R Stone,
    • Matthew J Waterman,
    • Anna Wilson,
    • James F Gusella &
    • Michael E Talkowski
  2. Psychiatric and Neurodevelopmental Genetics Unit, Center for Human Genetic Research, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.

    • Claire Redin,
    • Harrison Brand,
    • Ryan L Collins,
    • Carrie Hanscom,
    • Vamsee Pillalamarri,
    • Catarina M Seabra,
    • Caroline Antolik,
    • Joseph T Glessner,
    • Matthew R Stone &
    • Michael E Talkowski
  3. Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA.

    • Claire Redin,
    • Harrison Brand,
    • Ryan L Collins,
    • Carrie Hanscom,
    • Vamsee Pillalamarri,
    • Catarina M Seabra,
    • Caroline Antolik,
    • Joseph T Glessner,
    • Matthew R Stone,
    • Cynthia C Morton,
    • James F Gusella &
    • Michael E Talkowski
  4. Program in Bioinformatics and Integrative Genomics, Division of Medical Sciences, Harvard Medical School, Boston, Massachusetts, USA.

    • Ryan L Collins
  5. Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA.

    • Tammy Kammin,
    • Benjamin B Currall,
    • Heather L Ferguson,
    • Pamela Gerrol,
    • Mark A Hayden,
    • Cinthya J Zepeda Mendoza,
    • Zehra Ordulu,
    • Shahrin Pereira &
    • Cynthia C Morton
  6. Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.

    • Elyse Mitchell,
    • Jennelle C Hodge,
    • Troy Gliem &
    • Erik C Thorland
  7. Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.

    • Jennelle C Hodge
  8. Department of Pediatrics, University of California, Los Angeles, Los Angeles, California, USA.

    • Jennelle C Hodge
  9. GABBA Program, University of Porto, Porto, Portugal.

    • Catarina M Seabra
  10. Medical Genetics, Baystate Medical Center, Springfield, Massachusetts, USA.

    • Mary-Alice Abbott
  11. Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA.

    • Omar A Abdul-Rahman
  12. Maritime Medical Genetics Service, IWK Health Centre, Halifax, Nova Scotia, Canada.

    • Erika Aberg &
    • Sandhya Parkash
  13. Medical Genomics Division, Centro Medico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico.

    • Sofia L Alcaraz-Estrada &
    • Raul E Piña Aguilar
  14. Department of Genetics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.

    • Fowzan S Alkuraya &
    • Ranad Shaheen
  15. Institutes of Biomedical Sciences (IBS) of Shanghai Medical School and MOE Key Laboratory of Contemporary Anthropology, Fudan University, Shanghai, China.

    • Yu An
  16. Center for Human Genetic Research DNA and Tissue Culture Resource, Boston, Massachusetts, USA.

    • Mary-Anne Anderson &
    • Jayla Ruliera
  17. Division of Clinical Genetics, Columbia University Medical Center, New York, New York, USA.

    • Kwame Anyane-Yeboa &
    • Dorothy P Warburton
  18. Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA.

    • Joan F Atkin
  19. Division of Molecular and Human Genetics, Nationwide Children's Hospital, Columbus, Ohio, USA.

    • Joan F Atkin
  20. Department of Genetics, Kaiser Permanente, Sacramento, California, USA.

    • Tina Bartell
  21. Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.

    • Jonathan A Bernstein &
    • Andrea Hanson-Kahn
  22. Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.

    • Elizabeth Beyer,
    • Cristin Griffis,
    • Emily Moe,
    • Linda Reis &
    • William Rhead
  23. Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA.

    • Elizabeth Beyer,
    • Cristin Griffis,
    • Emily Moe &
    • William Rhead
  24. Department of Human Genetics, Radboud Institute for Molecular Life Sciences and Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands.

    • Ernie M H F Bongers,
    • Bert B A de Vries,
    • Marjolijn C Jongmans,
    • David A Koolen,
    • Carlo L Marcelis,
    • Bregje W van Bon,
    • Ineke van Der Burgt,
    • Han G Brunner &
    • Nicole de Leeuw
  25. Division of Biomedical Genetics, Department of Genetics, Center for Molecular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands.

    • Eva H Brilstra,
    • Edwin Cuppen,
    • Ron Hochstenbach,
    • Jerome Korzelius,
    • Sjors Middelkamp,
    • Ivo Renkens,
    • Markus J van Roosmalen,
    • Catharina M L Volker-Touw &
    • Wigard P Kloosterman
  26. Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA.

    • Chester W Brown &
    • Brett H Graham
  27. Department of Genetics, Texas Children's Hospital, Houston, Texas, USA.

    • Chester W Brown &
    • Brett H Graham
  28. Department of Clinical Genetics, Erasmus University Medical Centre, Rotterdam, the Netherlands.

    • Hennie T Brüggenwirth
  29. Center for Medical Genetics, Ghent University, Ghent, Belgium.

    • Bert Callewaert,
    • Annelies Dheedene,
    • Sandra Janssens,
    • Björn Menten &
    • Sarah Vergult
  30. Greenwood Genetic Center, Columbia, South Carolina, USA.

    • Ken Corning
  31. West Midlands Regional Clinical Genetics Unit, Birmingham Women's Hospital, Edgbaston, Birmingham, UK.

    • Helen Cox
  32. Department of Genetics, Harvard Medical School, Boston, Massachusetts, USA.

    • Benjamin B Currall,
    • Samantha L P Schilit &
    • James F Gusella
  33. Division of Pediatric Genetics, Department of Pediatrics, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA.

    • Tom Cushing
  34. Department of Human Genetics, National Health Institute Doutor Ricardo Jorge, Lisbon, Portugal.

    • Dezso David
  35. Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

    • Matthew A Deardorff
  36. Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

    • Matthew A Deardorff
  37. Department of Neurology and Child Neurology, Algemeen Ziekenhuis Sint-Jan, Brugge, Belgium.

    • Marc D'Hooghe
  38. Seattle Children's, Seattle, Washington, USA.

    • Dawn L Earl
  39. Mount Sinai West Hospital, New York, New York, USA.

    • Heather Fisher
  40. MRC Human Genetics Unit, Institute of Genetic and Molecular Medicine, University of Edinburgh, Western General Hospital, Edinburgh, UK.

    • David R FitzPatrick
  41. Medical Genetics Unit, Department of Clinical and Biological Sciences, University of Torino, Turin, Italy.

    • Daniela Giachino,
    • Giorgia Mandrile &
    • Giulia Pregno
  42. UW Cancer Center at ProHealth Care, Waukesha, Wisconsin, USA.

    • Margo Grady
  43. Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

    • Karen W Gripp
  44. Division of Neurogenetics and Developmental Pediatrics, Children's National Medical Center, Washington, DC, USA.

    • Andrea L Gropman
  45. Department of Genetics, Stanford University School of Medicine, Stanford, California, USA.

    • Andrea Hanson-Kahn
  46. Division of Genetics, Boston Children's Hospital, Boston, Massachusetts, USA.

    • David J Harris
  47. Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.

    • David J Harris
  48. Department of Neurology, Auckland City Hospital, Auckland, New Zealand.

    • Rosamund Hill
  49. Division of Genetics, Department of Pediatrics, Boston Medical Center, Boston, Massachusetts, USA.

    • Jodi D Hoffman
  50. Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.

    • Robert J Hopkin
  51. Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.

    • Robert J Hopkin
  52. Pediatric Genetics Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

    • Monika W Hubshman
  53. Raphael Recanati Genetic Institute, Rabin Medical Center, Petach Tikva, Israel.

    • Monika W Hubshman
  54. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

    • Monika W Hubshman
  55. Department of Medical Genetics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

    • A Micheil Innes &
    • Rebecca Sparkes
  56. Academic Affairs, American Board of Medical Specialties, Chicago, Illinois, USA.

    • Mira Irons
  57. Department of Clinical Genetics, Guy's and St Thomas' NHS Foundation Trust, London, UK.

    • Melita Irving &
    • Shehla Mohammed
  58. Division of Medical and Molecular Genetics, King's College London, London, UK.

    • Melita Irving
  59. Centre for Brain Research and School of Biological Sciences, University of Auckland, Auckland, New Zealand.

    • Jessie C Jacobsen
  60. Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.

    • Tamison Jewett &
    • Megan E Mortenson
  61. Department of Molecular Genetics, Shodair Children's Hospital, Helena, Montana, USA.

    • John P Johnson
  62. Division of Genetics and Metabolism, Arkansas Children's Hospital, Little Rock, Arkansas, USA.

    • Stephen G Kahler &
    • Cynthia Lim
  63. Institute of Human Genetics, Medical University of Graz, Graz, Austria.

    • Peter M Kroisel
  64. Department of Pediatrics, Louisiana State University Health Sciences Center (LSUHSC) and Children's Hospital, New Orleans, Louisiana, USA.

    • Yves Lacassie
  65. Department of Pediatrics, University of Montreal, CHU Sainte-Justine, Montreal, Quebec, Canada.

    • Emmanuelle Lemyre
  66. Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington, USA.

    • Kathleen Leppig
  67. Clinical Genetics, Group Health Cooperative, Seattle, Washington, USA.

    • Kathleen Leppig
  68. Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

    • Alex V Levin
  69. Center for Reproduction and Genetics, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China.

    • Haibo Li &
    • Hong Li
  70. Center for Regenerative Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.

    • Eric C Liao
  71. Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.

    • Eric C Liao
  72. Harvard Stem Cell Institute, Cambridge, Massachusetts, USA.

    • Eric C Liao
  73. Virginia G. Piper Cancer Center at HonorHealth, Scottsdale, Arizona, USA.

    • Cynthia Lim
  74. Department of Genetics, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA.

    • Edward J Lose
  75. Clinical Cytogenetics Laboratory, New York–Presbyterian Hospital, Columbia University Medical Center, New York, New York, USA.

    • Michael J Macera
  76. Genomics Platform, Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA.

    • Lauren Margolin,
    • Tamara Mason &
    • Danielle Perrin
  77. Department of Genetics, Rady Children's Hospital, San Diego, California, USA.

    • Diane Masser-Frye
  78. Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, Washington, USA.

    • Michael W McClellan
  79. Harvard Medical School, Boston, Massachusetts, USA.

    • Cinthya J Zepeda Mendoza,
    • Zehra Ordulu,
    • Susan P Pauker,
    • Samantha L P Schilit,
    • Joseph V Thakuria &
    • Cynthia C Morton
  80. Group for Advanced Molecular Investigation, Graduate Program in Health Sciences, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil.

    • Liya R Mikami &
    • Salmo Raskin
  81. Centro Universitário Autônomo do Brasil (Unibrasil), Curitiba, Brazil.

    • Liya R Mikami
  82. Department of Clinical Genetics, Kuopio University Hospital, Kuopio, Finland.

    • Tarja Mononen
  83. Novant Health Derrick L. Davis Cancer Center, Winston-Salem, North Carolina, USA.

    • Megan E Mortenson
  84. GENOS Laboratory, Buenos Aires, Argentina.

    • Graciela Moya
  85. Department of Clinical Genetics, VU University Medical Center, Amsterdam, the Netherlands.

    • Aggie W Nieuwint,
    • Pino J Poddighe &
    • Jiddeke van de Kamp
  86. Department of Pediatrics, Maritime Medical Genetics Service, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada.

    • Sandhya Parkash
  87. Medical Genetics, Harvard Vanguard Medical Associates, Watertown, Massachusetts, USA.

    • Susan P Pauker
  88. Hayward Genetics Program, Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana, USA.

    • Katy Phelan
  89. School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK.

    • Raul E Piña Aguilar
  90. Children's Research Institute, Milwaukee, Wisconsin, USA.

    • Linda Reis
  91. Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.

    • William Rhead
  92. Midwest Diagnostic Pathology, Aurora Clinical Labs, Rosemont, Illinois, USA.

    • Debra Rita
  93. Algemeen Ziekenhuis Delta, Roeselare, Belgium.

    • Filip Roelens
  94. University of Groningen, University Medical Center Groningen, Department of Genetics, Groningen, the Netherlands.

    • Patrick Rump,
    • Ton van Essen &
    • Conny M van Ravenswaaij-Arts
  95. Division of Maternal Fetal Medicine, Columbia University Medical Center, New York, New York, USA.

    • Erica Spiegel
  96. McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA.

    • Blair Stevens
  97. Genetic Services, Alberta Health Services, Lethbridge, Alberta, Canada.

    • Julia Tagoe
  98. Division of Medical Genetics, Massachusetts General Hospital, Boston, Massachusetts, USA.

    • Joseph V Thakuria
  99. Department of Biology, Eastern Nazarene College, Quincy, Massachusetts, USA.

    • Matthew J Waterman
  100. Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinatti, Ohio, USA.

    • Susan Wiley
  101. Laboratory of Genetics, Centro Medico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico.

    • Maria de la Concepcion A Yerena-de Vega
  102. Division of Pediatric Genetics and Metabolism, University of Florida, Gainesville, Florida, USA.

    • Roberto T Zori
  103. Department of Pathology, Columbia University, New York, New York, USA.

    • Brynn Levy
  104. Department of Clinical Genetics, and Grow School of Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands.

    • Han G Brunner
  105. Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA.

    • Cynthia C Morton
  106. Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Center, Manchester, UK.

    • Cynthia C Morton


M.E.T., J.F.G., C.C.M., E.C.T., J.C.H., W.P.K., N.d.L., and H.G.B. designed the study. C.R., H.B., R.L.C., V.P., I.B., C.C., J.T.G., M.R.S., M.J.v.R., and W.P.K. performed computational analyses. C.H., C.M.S., R.A., M.-A. Anderson, C.A., E.C., B.B.C., J.K., W.L., P.M., L.M., T. Mason, D.P., J.R., M.J.W., and A.W. performed cellular, molecular, or genomic experiments. T.K., E. Mitchell, J.C.H., M.-A. Abbott, O.A.A.-R., E.A., S.L.A.-E., F.S.A., Y.A., K.A.-Y., J.F.A., T.B., J.A.B., E.B., E.M.H.F.B., E.H.B., C.W.B., H.T.B., B.C., K.C., H.C., T.C., D.D., M.A.D., A.D., M.D'H., B.B.A.d.V., D.L.E., H.L.F., H.F., D.R.F., P.G., D.G., T.G., M.G., B.H.G., C.G., K.W.G., A.L.G., A.H.-K., D.J.H., M.A.H., R. Hill, R. Hochstenbach, J.D.H., R.J.H., M.W.H., A.M.I., M. Irons, M. Irving, J.C.J., S.J., T.J., J.P.J., M.C.J., S.G.K., D.A.K., P.M.K., Y.L., E.L., K.L., A.V.L., Haibo Li, Hong Li, E.C.L., C.L., E.J.L., D.L., M.J.M., G. Mandrile, C.L.M., D.M.-F., M.W.M., C.J.Z.M., B.M., S. Middelkamp, L.R.M., E. Moe, S. Mohammed, T. Mononen, M.E.M., G. Moya, A.W.N., Z.O., S. Parkash, S.P.P., S. Pereira, K.P., R.E.P.A., P.J.P., G.P., S.R., L.R., W.R., D.R., I.R., F.R., P.R., S.L.P.S., R. Shaheen, R. Sparkes, E.S., B.S., J.T., J.V.T., B.W.v.B., J.v.d.K., I.v.D.B., T.v.E., C.M.v.R.-A., S.V., C.M.L.V.-T., D.P.W., S.W., M.d.l.C.A.Y.-d.V., R.T.Z., B.L., H.G.B., N.d.L., W.P.K., E.C.T., C.C.M., and J.F.G. ascertained and enrolled subjects and provided phenotypic information. C.R. and M.E.T. wrote the manuscript, which was approved by all authors.

Competing financial interests

The authors declare no competing financial interests.

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Supplementary information

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  1. Supplementary Text and Figures (40,805 KB)

    Supplementary Figures 1–77 and Supplementary Note.

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  1. Supplementary Tables 1–12 (788 KB)

    Supplementary Tables 1–12.

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