More Than a Decade of Rapid Genomic Sequencing: Where Are We Now?

Since the first proof of concept paper describing rapid genome sequencing (rGS) in 2012, this testing has become a commonly used tool in the evaluation of patients in neonatal intensive care units (NICUs). It is estimated that 26% of neonates in this setting have rare genetic diseases. Given the heterogeneity of rare disease, broad testing is the fastest route to early definitive diagnosis. Genome sequencing (GS) allows for the most comprehensive analysis, identifying diagnostic variants in about 30% of cases. This includes those on a clinician's differential diagnosis as well as those not thought of, which may be for many reasons including human fallibility, incomplete or undifferentiated clinical presentation, or new gene-disease associations and phenotypic expansions. In the acute setting, the overall time to diagnosis is important, and rGS has been shown by multiple studies to result in a decreased time to diagnosis. Studies of rGS have also evaluated the impact of a rapid diagnosis by examining changes in medical management and length of NICU stay. Overwhelmingly, it has been demonstrated that running a faster test produces a faster answer, which is beneficial in some cases. Which patients are the most likely to benefit from rGS is ill-defined: for a small number it is undeniably lifesaving. The implementation of rGS requires a careful balance between the desire for rapid molecular diagnosis and limited laboratory and institutional/financial resources, with many scientific and ethical questions concerning the benefits, harms, and costs of this approach. Other testing modalities, such as lower-cost sequencing panels and exome sequencing, are also used for rapid diagnosis of critically ill infants, and other use cases have emerged, such as newborn screening. Though rGS is a great step forward, there are still technical shortcomings in the use of short-read sequencing, and much of the genome remains uninterpretable. Perspectives on the use of rGS were gathered from a virtual roundtable panel of experts regarding the eligibility, benefits, ethics, goals, and future directions of this testing, largely restricting the discussion to the use of rGS for the purpose of diagnosing infants in the NICU. The panel addressing this Q&A has expertise in clinical genetics, neonatology, ethics, genetic counseling, and genomic sequencing/laboratory operations.

Please define what qualifies as rapid genome sequencing (rGS) and who should be eligible?

Zornitza Stark: The answer to this question seems to vary depending on local context and is often measured in relation to the turnaround times of standard testing, so for example 2 to 3 weeks is often considered “rapid” where usual testing takes many months. However, we need to consider this from the perspective of our intensive care colleagues: “rapid” turnaround times in the ICU often mean results available in minutes from point-of-care tests. Striking a balance, for me rGS means results in <3 to 5 days, which places it in the realm of other commonly used but complex to perform and interpret pathology tests. In terms of eligibility, collectively we now have experience of rGS (and rapid exome sequencing) in thousands of critically ill pediatric patients worldwide, and eligibility should be based on the evidence of benefit in specific groups. This needs to be balanced against the relatively high costs associated with rGS, and as these costs decrease, it is likely that eligibility will widen. Particular groups of patients that we know are highly likely to benefit are, for example, those presenting with neonatal seizures (in the absence of trauma or infection) and those with features of underlying neurometabolic disorders.

Luca Brunelli: rGS in the NICU has markedly shortened turnaround times, typically in the order of about 1 week. More recently, ultra-rapid GS (urGS) has become available with turnaround times of about 48 to 72 hours. There remains significant uncertainty about which newborns should be tested with rGS and urGS and when. Given the time requirements of both rGS and urGS, these tests are typically more costly than standard GS. Therefore, it is reasonable to limit eligibility for these tests to clinical situations in which it is essential to achieve a rapid return of results. The acuity of the illness can provide some guidance. One option is to consider that the acuity necessary for a newborn to be eligible for rGS is the persistent failure of at least one organ system. Despite the remaining uncertainties of when to test, if conditions of acuity are met and the clinical team decides to pursue genetic testing, it is reasonable to consider rGS as a first-tier test (unless aberrant methylation or other conditions not picked up by GS are suspected). Clearly, there are situations in which a less acutely ill newborn could be diagnosed with rGS, but in these scenarios clinicians may want to consider GS with standard turn-around times.

Michael J. Deem: Initial references to rGS occurred around 2012, picking out next generation sequencing tools that could lead to provisional diagnosis in as quickly as 50 hours of sample receipt (considerably faster than the 4- to 6-week turnaround of conventional genetic testing and sequencing tools). By 2016, that time has halved, with provisional diagnosis yielded in roughly 26 hours. Today, there are reports of provisional diagnosis within 8 to 14 hours, with one U.S. medical center boasting an instance of 5 hours to diagnosis. These times, of course, are exceptional; median and mean turnaround times for rGS today is roughly 2 to 3 weeks, with researchers increasingly using the label “ultra-rapid” for next-generation sequencing tools that average turnaround times in days rather than weeks. But who likely benefits from rGS in terms of care? Critically ill patients for whom diagnosis by conventional clinical or phenotypic means is elusive may benefit from the speed with which rGS can yield reliable, provisional molecular diagnosis, leading to appropriate recommendations for care management. This is especially the case for acutely ill neonates presenting with overlapping symptoms, for whom it can be particularly difficult to provide diagnosis through conventional means. However, because some serious and rare monogenic conditions present in early childhood, a case can be made for wider utilization of rGS in pediatric intensive care contexts where diagnosis is uncertain and expeditious care planning is needed.

Emily G. Farrow: rGS has evolved since its inception. The first proof of concept studies returned results at 50 hours. As technology has evolved, laboratories have demonstrated results in as little as 14 hours in a research setting. Currently, in clinical laboratories, rGS is typically translated to results in 7 to 14 days. Despite the decreasing costs of sequencing reagents, rGS does have a significant price differential over standard sequencing. Part of the increased cost can be attributed to lower throughput sequencing configurations, which are more expensive. Another aspect of the increased price, although rarely discussed, can be attributed to personnel considerations. Given these resource considerations, rGS should be reserved for critically ill inpatient newborns.

What are the benefits/goals of rGS?

Zornitza Stark: The main benefit of rGS is the ability to provide accurate and timely diagnosis in critically ill patients with rare diseases. This obviates the need for many other expensive, invasive, and unnecessary tests, improving the overall process of care. The certainty of a molecular diagnosis gives clinicians and families the confidence to make appropriate decisions, particularly about major interventions such as surgery and organ transplant. In a small but increasing proportion of patients, it enables access to precision treatments with major impacts on long-term outcomes.

Luca Brunelli: The potential benefits and goals of rGS are to determine whether genetic variation may be causing or contributing to a medical and/or surgical condition in an acutely ill newborn. Precise diagnosis may inform families’ future reproductive choices and help physicians and parents anticipate evolving clinical problems as well as enable the timely application of therapies, both medical and surgical, hopefully decreasing morbidity and mortality. Negative rGS results may also be beneficial by allowing the likely exclusion of a genetic diagnosis. One of the hopes of applying rGS is that, by identifying a precise diagnosis, the length of hospitalization will be shorter.

Michael J. Deem: Perhaps the clearest benefit of rGS occurs when a molecular diagnosis expeditiously informs appropriate (re)direction of care for undiagnosed patients in critical care settings. This is especially important in the NICU, when the timing of such information may prove lifesaving for acutely ill newborns or move patients whose diagnosis is associated with very poor prognosis quickly to comfort care. There are published studies of patients receiving timely and appropriate (re)direction of care after molecular diagnosis, whether it be care that reduces mortality or morbidity or leads to appropriate use of palliative care. Another potential benefit of faster diagnosis is comfort, closure, or hope to families who have suffered emotionally alongside their undiagnosed child. However, much of the evidence cited to support wider clinical use of rGS comes from retrospective studies involving rGS of samples taken from deceased NICU patients, which posthumously clarified their respective disease etiology. But better care is not a foregone conclusion of a molecular diagnosis, no matter how rapidly it occurs. Appropriate care is the result of a number of additional factors, including clinician communication of diagnostic and prognostic information, receptivity of patients or their surrogate decision-makers to that information, and access to recommended care. A secondary benefit of rGS is potential reduction in cost of care when a diagnosis is yielded. There is evidence that early diagnosis via rGS does not increase care costs or services in the long run. However, we should be cautious against taking this secondary, external goal of care to creep into the space of the primary aim of clinical rGS—the well-being of the patient.

Madhuri Hegde: The goal of rapid whole genome sequencing is to confirm and ascertain clinical diagnosis in a timely manner such that appropriate medical management and treatment such as diet restriction and transplantation can be implemented as early as possible, which may prompt a promising outcome. Based on our current data, rGS provides quick turnaround time, high diagnostic yield, and an overall cost-effective outcome. In particular, individuals with pediatric-onset disorders, metabolic disorders, and other rare early-onset disorders with any treatment options will benefit from early definitive diagnosis using rGS.

Emily G. Farrow: Patients with rare disease often still face diagnostic odysseys. In critically ill newborns the goal of rGS is to provide a genetic diagnosis as quickly as possible to guide care. Ideally, a diagnosis will lead to a therapeutic treatment or intervention. However, even in the absence of a targeted therapy, a genetic diagnosis will help guide management, provide answers to the family, and of course provide recurrence risks.

What results should be returned for newborn rGS?

Zornitza Stark: In critically ill newborns, rGS reporting should be directed towards answering the clinical question. Given the possibility that results can be used to guide irreversible decisions, variants of uncertain significance should be reported judiciously. Although rGS data can be used to screen for a much wider range of health conditions in both the child and parents, decisions about this should be deferred to a time where parents can give these additional analyses due consideration.

Luca Brunelli: Results should be returned when a genomic diagnosis is identified or when a pathogenic or likely pathogenic variant in a gene whose function is plausibly related to the clinical presentation is identified. In some cases, the variant may cause some but not all of the newborn's symptoms. Regarding incidental findings, American College of Medical Genetics recommendations for reporting provide useful guidance.

Michael J. Deem: rGS is appropriate when expeditious care planning is demanded, and this certainly involves acutely ill and undiagnosed newborn patients. The results that should be returned are those that will inform their care. This need not only be results that are diagnostically informative. Indeed, there may be additional findings that are relevant for prognosis after treatment. Are there nondiagnostic genetic factors that will affect the outcomes of certain treatment options otherwise indicated by diagnosis? For example, the continued march of precision medicine could eventually lead to reliable predictions about how newborns would respond to particular medications or interventions (e.g., complex surgery).

Madhuri Hegde: Diagnostic findings related to provided patient phenotype including sequence and copy number pathogenic variants and variants of uncertain significance. Since our rGS includes repeat expansion and SMA screening, positive screening results will also be returned. Secondary findings may be returned according to informed consent.

Emily G. Farrow: Families with critically ill newborns are unquestionably in a high-stress environment. A diagnostic finding related to the patient’s phenotype can help guide parents and the care team in making difficult decisions. In that regard, diagnostic findings related to the patient’s current or immediate future should clearly be included in the clinical report. Relevant variants of unknown significance should also be included. As with all pediatric testing, findings not related to the patient’s phenotype, adult-onset conditions, or carrier status for unrelated disorders should not be reported.

What are the ethical challenges of rGS in newborns?

Zornitza Stark: For me, the biggest ethical challenge at the moment is that of inequitable access. Multiple research studies of rGS/rapid exome sequencing have now been reported worldwide, involving thousands of patients across diverse healthcare systems. All of these studies have demonstrated the high diagnostic and clinical utility of rGS/rapid exome sequencing. Health economic analyses have also demonstrated it to be cost-saving. Yet healthcare systems have been slow to fund and implement this as standard-of-care testing, resulting in considerable inequity of access.

Luca Brunelli: The integration of rGS into neonatal care remains associated with a variety of ethical controversies, including concerns about interpreting and reporting uncertain results, about resource allocation, and whether access to genomic services could exacerbate health disparities. The latter is particularly significant in systems that do not guarantee universal healthcare access to children. In these systems, children who receive a diagnosis might be unable to receive appropriate healthcare services in the long term.

Michael J. Deem: In one sense, there’s nothing new under the genomic sun. rGS is associated with many of the same ethical issues as genome and exome sequencing—for example, whether parents/guardians can provide adequately informed consent, protection of patient and family privacy, management and return of secondary findings, and psychosocial effects on patients or families. However, some of these ethical challenges may be exacerbated with clinical use of rGS. For example, qualitative studies suggest that the recommendation and consent processes for rGS produce considerable anxiety in parents and impact adversely family relationships. This may be due in part to the stress of critical care settings and the experience of having an acutely ill newborn. But the proposal of “rapid” or “ultra-rapid” sequencing may exacerbate the sense that one’s child is imminently at risk of death or permanent disability. Studies also show that, among parents who consent to rGS, those who receive a molecular diagnosis describe adverse impacts on family functioning more often than parents who do not receive a diagnosis. This raises issues that both clinical ethicists and genetic counselors will need to address with clinical use of rGS.

There are a few reports that discuss secondary findings of genome sequencing impacting decisions against potentially life-extending organ transplantation in infants and young children. In transplantation workups, rGS might be viewed as a quick way to acquire important information about a candidate for transplantation. While secondary findings in some cases can shed light on anticipated outcomes of interventions, clinicians will need to guard against creeping bias towards disability in such judgments. rGS may yield secondary findings that show heightened risk of development of psychiatric conditions, intellectual disability, or even premature mortality. Parsing findings that directly inform care from those that predict conditions against which bias is well documented remains an ethical and scientific challenge.

Madhuri Hegde: The biggest ethical challenge is to return the findings related to adult-onset disease if it is consented. These findings may benefit the parents and other family members such as siblings if they would like to know. On the flip side, they may not be ready or interested in learning their genetic information, at least until adulthood. Therefore, careful design of the rGS, pre-test counseling of test methods and possible results, post-test communication of the results, raw data retention, and the Genetic Information Nondiscrimination Act are important.

Emily G. Farrow: Returning diagnostically relevant results in a critically ill newborn is straightforward. However, incidental or secondary findings should not be immediately returned. Expanded return of results may be coordinated at a later date, when the risks and benefits of the additional findings may be discussed with genetic counseling, outside of the critical inpatient period.

What are the benefits of rGS vs rapid exome sequencing or targeted newborn panel?

Zornitza Stark: rGS is able to assess multiple variant types in a single test, including structural and mitochondrial variants, removing the need for multiple sequential tests. It also has slightly shorter sample preparation times, although these can be offset by longer bioinformatic processing times. Targeted panels can be tempting to use due to lower costs; however, restricting sequencing and analysis has repeatedly been shown to result in missed diagnoses. Overall, the use of rGS increases efficiency and shortens time to definitive diagnosis.

Luca Brunelli: Besides the technical advantages of not requiring a capture step and covering both coding and noncoding regions of the genome, rGS can detect not only DNA sequence variants but also structural variants and indels. Importantly, rGS covers promoters and other regulatory regions and can resolve copy number breakpoints. Exome sequencing has, however, lower costs, and, given the smaller amount of information collected, storage of data is less challenging. Targeted newborn panels typically assess fewer genes than the other 2 tests. However, some large panels (between 1700 and 4900 genes) have been successfully used in the NICU environment. Perhaps in the future the advantages of rGS will increasingly become apparent as more disease-causing variants are being discovered in noncoding regions. For the time being, the choice among these 3 tests depends on several factors including the availability of analytical pipelines, expertise, and the availability of funding.

Madhuri Hegde: Targeted newborn panels only include a certain number of genes related to the most common newborn diseases. Exome sequencing includes only coding exonic regions in the human genome without coverage of introns and regulatory regions. Genome sequencing covers the entire genome including exons, introns, and regulatory regions which ultimately provides uniform coverage across the genome. rGS is able to identify small copy number variations with accurate breakpoints, variants located in deep intronic regions, and regulatory regions that are usually missed by exome. rGS data can be saved and reanalyzed when it is needed.

Emily G. Farrow: The benefits of rGS are primarily based on the technical side. Given sample preparation for next-generation sequencing, a genome can be prepared for sequencing in only a few hours (dependent on the library kit selected). In comparison, a rapid exome or targeted panel will require approximately 2 days and typically requires a pool of samples. In addition, genome sequencing provides more even coverage across the genome. The increased coverage of a genome impacts both single nucleotide and copy number variant detection. Exome and targeted sequencing are limited by the included targets and will often have areas of uneven coverage in difficult regions (high GC content for example). Further, the polymerase chain reaction amplification in targeted sequencing results in the loss of detection of expansion disorders, such as myotonic dystrophy, a relatively common cause of neonatal hypotonia. On the analytical side, targeted sequencing is limited by the genes included. As the full phenotypic spectrum of a disorder is often not evident in a newborn, limiting analysis to a targeted gene panel can result in missed diagnoses and the necessity of additional testing.

What are the limitations of rGS (i.e., what is it missing)?

Zornitza Stark: All technologies have limitations, and this is something we have explored carefully as part of our studies. We know that rGS is less sensitive at detecting mosaic variation due to the lower depth of sequencing. In addition, although it presents the opportunity for analysis for a wide variety of variant types, some of these remain challenging to validate under accredited conditions. We are also limited in our ability to interpret the significance of many variants, and we know that ancillary approaches such as transcriptome sequencing and high-throughput functional assays are needed to optimize diagnostic outcomes.

Luca Brunelli: Perhaps the greatest limitation of rGS relates to the fundamental challenges of short-read sequencing technology and the resulting limitations in analyzing highly repetitive and complex regions, especially if they are >300/400 bp in length. In addition, in some cases it is hard to interpret variants in the absence of information regarding potential downstream variation in RNA expression. Therefore, several research programs are currently testing the combination of rGS with long-read DNA sequencing and RNA sequencing. Finally, current rGS based on short-read technology cannot assess aberrant methylation.

Madhuri Hegde: Due to the complexity of the human genome, short-read-based sequencing of genes with high levels of homology—pseudogenes—is difficult. Regarding duplications, it is difficult to determine the configuration—tandem or insertion into another region in the genome. Balanced chromosome rearrangements such as translocation and inversion without copy number alteration will not be identified by rGS.

Emily G. Farrow: Although genome sequencing implies the entire genome is sequenced, in reality, currently rGS is incomplete with short-read technology, which has technical limitations in variant detection. Multiple laboratories have demonstrated single nucleotide variant detection sensitivity and specificity that is >99% with short-read sequencing. Copy number variant detection from short-read sequencing has also improved dramatically and in many laboratories replaced microarray technology as a first-line test. However, short-read sequencing is not able to detect methylation disorders, fully resolve complex pseudogene regions such as SMN1/2, or sequence expansion disorders to determine the repeat motif and interruptions. Further, while the genome is sequenced, clinical analysis is largely restricted to the exome as the majority of the genome is currently not well understood. Thus, while short-read rGS is a comprehensive test, there are many cases where additional testing may still be required.

What are the operational challenges of rGS?

Zornitza Stark: The delivery of rGS, particularly at scale, poses many operational challenges, both for clinical and for laboratory services. It necessitates changes in working practices both for genetic services and for intensive care teams in order to ensure appropriate patient selection and rapid test initiation. We know that delivery as part of a multidisciplinary team optimizes patient and family outcomes and enhances the quality of rGS data interpretation. However, to be successful and sustainable, such models require additional funding as well as substantial workforce expansion, education, and training.

Luca Brunelli: rGS requires a vast and complex infrastructure for variant analysis and interpretation both in terms of personnel number and expertise and of instrumentation and data analysis/storage availability. Specialists are also necessary for appropriate clinical interpretation once the initial bioinformatics processing and analysis have taken place. Setting up a rGS pipeline from scratch is quite a costly endeavor.

Madhuri Hegde: Collaboration of multiple teams including accessioning the sample, lab processing, bioinformatics, reporting teams (variant analysis, genetic counselors, laboratory directors), and communication from one team to the next is crucial to keep the sample moving from one step to the next without any delay to achieve short turnaround time. If any step does not run well, timely communication with the client is important.

Emily G. Farrow: True rGS poses significant operational considerations. Large laboratories, with high sample throughput, may already be operating 7 days a week, with multiple sample preparations and sequencing runs each week. However, they will still need to dedicate resources to ensure rGS orders are expedited and completed within the promised time frame. Small to medium laboratories are faced with much larger challenges in implementing rGS. These laboratories will more likely follow a traditional 5-day workweek schedule. Smaller sample volumes also mean sample preparation for sequencing is completed in batches, perhaps 1 to 2 times a week, with full sequencing runs also occurring less frequently. In order to meet a rapid turnaround time on the laboratory side, laboratories face the difficult decision to overstaff technicians or maintain staffing levels and prioritize rapid orders. The rGS order will then be completed, while the larger batch of samples is delayed in processing. Sequencing then may be batched or, dependent on the time frame and available samples, be completed with lower throughput flowcells, potentially leading to a significant increase in cost. Analysis and director time are similar. Most often, the rGS samples will be prioritized over standard orders. While the end result is rapid for a few cases, collectively, this approach results in a slower turnaround time for the remaining samples. These may be especially difficult decisions at the laboratory level in the current reimbursement landscape.

What are some future directions for rGS?

Zornitza Stark: I am excited about the use of long-read technologies in this setting, both for the potential to further shorten turnaround times and to improve diagnostic yields, while moving testing closer to point-of-care. Over the next 5 to 10 years, it will also be interesting to see the interplay between rGS and genomic newborn screening. Widespread adoption of genomic newborn screening will shift the paradigm towards rapid indication-based analysis of existing data, but this will require systems to ensure data are appropriately stored and readily accessible.

Luca Brunelli: Analytical pipelines will continue to improve and be revolutionized by the increasing utilization of models driven by artificial intelligence. Perhaps 5 years from now, bioinformatics analysis will be completely automated. AI will not only streamline interpretation pipelines but can also help select the patients who would benefit from rGS. This might become a moot point if GS becomes integrated into newborn screening programs. Long-read technology is being increasingly utilized and has the potential to bring sequencing closer to the NICU environment for real-time analysis and interpretation. Among other characteristics, it has the additional benefit of assessing methylation abnormalities. Increasingly, rGS is being contemplated as an addition to conventional newborn screening.

Michael J. Deem: As rGS becomes cheaper, more accurate, and widely available, the number of families who receive genetic information about their critically ill children will considerably expand. Some even advocate for rGS as first-tier testing for pediatric patients with neurodevelopmental disorders and congenital heart conditions. Soon, there likely will be market and social pressures to expand rGS beyond these applications. Two such areas might be transplantation medicine, where genome sequencing is already used in workups, and prenatal settings, where rGS would provide far more genetic information about a fetus, and much more quickly, than noninvasive prenatal screening and conventional prenatal genetic testing. But “future directions” in healthcare demand careful ethical deliberation and willingness to pump the brakes on curiosity and ambition. That healthcare can proceed in a particular direction tells us little about whether that direction will lead to virtue and benefit or to injustice and harm.

Madhuri Hegde: Future directions of rGS include incorporation of newborn biochemical screening, cytomegalovirus for hearing and metagenomics testing, repeat expansion, and spinal muscular atrophy screening. Negative rGS cases will be reflexed with RNA sequencing, and combined comprehensive integrated analysis of DNA-level rGS data coupled with RNA-level data will help identify new disease-causing variants including splice defects induced by intronic and silent variants. The negative cases can also be reflexed to untargeted metabolomic analysis. Education of clinicians to fully realize the clinical utility and benefit of rGS is important.

Emily G. Farrow: Genomics remains an exciting field. rGS is evolving, particularly in sequencing technology. Long-read GS is now clinically available, with a turnaround time of 2 to 4 weeks for critically ill inpatients. Long-read GS has multiple advantages over current short-read GS; the long reads provide improved alignment over complex regions such as SMN1/2; improved single nucleotide, copy number, and structural variant detection; sequencing of expansions; and methylation detection in a single test. While long-read GS currently does not match the cost and throughput of short-read GS; it provides the most comprehensive testing available in a single test. As technology continues to advance, the throughput and cost of long-read GS will eventually approach that of short-read GS. Perhaps more importantly, studies investigating the impact of rGS on clinical outcomes are ongoing. As additional data measuring the impact of a rapid diagnosis on health outcomes are completed, clinical algorithms identifying the patients who would most benefit from a rapid diagnosis will evolve, empowering clinicians to appropriately select patients for rapid sequencing.

Nonstandard Abbreviations

rGS, rapid genome sequencing; NICU, neonatal intensive care unit; GS, genome sequencing; urGS, ultra-rapid genome sequencing.

Author Contributions

The corresponding author takes full responsibility that all authors on this publication have met the following required criteria of eligibility for authorship: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting or revising the article for intellectual content; (c) final approval of the published article; and (d) agreement to be accountable for all aspects of the article thus ensuring that questions related to the accuracy or integrity of any part of the article are appropriately investigated and resolved. Nobody who qualifies for authorship has been omitted from the list.

Carol Saunders (Conceptualization-Lead, Project administration-Lead, Writing—original draft-Equal, Writing—review & editing-Equal), Luca Brunelli (Writing—original draft-Equal, Writing—review & editing-Equal), Michael Deem (Writing—original draft-Equal, Writing—review & editing-Equal), Emily Farrow (Writing—original draft-Equal, Writing—review & editing-Equal), Madhuri Hegde (Writing—original draft-Equal, Writing—review & editing-Equal), and Zornitza Stark (Writing—original draft-Equal, Writing—review & editing-Equal)

Authors’ Disclosures or Potential Conflicts of Interest

Upon manuscript submission, all authors completed the author disclosure form.

Research Funding

L. Brunelli, Illumina, National Institutes of Health. Z. Stark, Genomics Health Futures Mission Fund grant GHFM76747, Royal Children's Hospital Foundation Grant 2020-1259.

Disclosures

E.G. Farrow was previously part of the speaker’s bureau for Kyowa Kirin (inactive). Z. Stark received Genomics Health Futures Mission Fund grant APP2008820.