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Ithal D, Sukumaran SK, Bhattacharjee D, Vemula A, Nadella R, Mahadevan J, Sud R, Viswanath B, Purushottam M, Jain S. Exome hits demystified: The next frontier. Asian J Psychiatr 2021; 59:102640. [PMID: 33892377 DOI: 10.1016/j.ajp.2021.102640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/26/2021] [Indexed: 12/13/2022]
Abstract
Severe mental illnesses such as schizophrenia and bipolar disorder have complex inheritance patterns, involving both common and rare variants. Whole exome sequencing is a promising approach to find out the rare genetic variants. We had previously reported several rare variants in multiplex families with severe mental illnesses. The current article tries to summarise the biological processes and pattern of expression of genes harbouring the aforementioned variants, linking them to known clinical manifestations through a methodical narrative review. Of the 28 genes considered for this review from 7 families with multiple affected individuals, 6 genes are implicated in various neuropsychiatric manifestations including some variations in the brain morphology assessed by magnetic resonance imaging. Another 15 genes, though associated with neuropsychiatric manifestations, did not have established brain morphological changes whereas the remaining 7 genes did not have any previously recorded neuropsychiatric manifestations at all. Wnt/b-catenin signaling pathway was associated with 6 of these genes and PI3K/AKT, calcium signaling, ERK, RhoA and notch signaling pathways had at least 2 gene associations. We present a comprehensive review of biological and clinical knowledge about the genes previously reported in multiplex families with severe mental illness. A 'disease in dish approach' can be helpful to further explore the fundamental mechanisms.
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Affiliation(s)
- Dhruva Ithal
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Salil K Sukumaran
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Debanjan Bhattacharjee
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Alekhya Vemula
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Ravi Nadella
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Jayant Mahadevan
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Reeteka Sud
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Biju Viswanath
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Meera Purushottam
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India.
| | - Sanjeev Jain
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
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2
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Suzuki T, Inoue I, Yamakawa K. Epilepsy protein Efhc1/myoclonin1 is expressed in cells with motile cilia but not in neurons or mitotic apparatuses in brain. Sci Rep 2020; 10:22076. [PMID: 33328576 PMCID: PMC7744795 DOI: 10.1038/s41598-020-79202-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/04/2020] [Indexed: 11/09/2022] Open
Abstract
EFHC1 gene encodes the myoclonin1 protein, also known as Rib72-1. Pathogenic variants in EFHC1 have been reported in patients with juvenile myoclonic epilepsy (JME). Although several studies of immunohistological investigations reproducibly showed that the myoclonin1 is expressed in cells with flagella and motile cilia such as sperm, trachea and ependymal cells lining the brain ventricles, whether myoclonin1 is also expressed in neurons still remains controversial. Here we investigated myoclonin1 expression using widely-used polyclonal (mRib72-pAb) and self-made monoclonal (6A3-mAb) anti-myoclonin1 antibodies together with Efhc1 homozygous knock-out (Efhc1-/-) mice. All of the western blot, immunocytochemical, and immunohistochemical analyses showed that mRib72-pAb crossreacts with several mouse proteins besides myoclonin1, while 6A3-mAb specifically recognized myoclonin1 and detected it only in cells with motile cilia but not in neurons. In dividing cells, mRib72-pAb signals were observed at the midbody (intercellular bridge) and mitotic spindle, but 6A3-mAb did not show any signals at these apparatuses. We further found that the complete elimination of myoclonin1 in Efhc1-/- mouse did not critically affect cell division and migration of neurons in cerebral cortex. These results indicate that myoclonin1 is not expressed in neurons, not a regulator of cell division or neuronal migration during cortical development, but expressed in choroid plexus and ependymal cells and suggest that EFHC1 mutation-dependent JME is a motile ciliopathy.
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Affiliation(s)
- Toshimitsu Suzuki
- Department of Neurodevelopmental Disorder Genetics, Institute of Brain Science, Nagoya City University Graduate School of Medical Science, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan.,Laboratory for Neurogenetics, RIKEN Center for Brain Science, Wako, Saitama, 351-0198, Japan
| | - Ikuyo Inoue
- Laboratory for Neurogenetics, RIKEN Center for Brain Science, Wako, Saitama, 351-0198, Japan
| | - Kazuhiro Yamakawa
- Department of Neurodevelopmental Disorder Genetics, Institute of Brain Science, Nagoya City University Graduate School of Medical Science, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan. .,Laboratory for Neurogenetics, RIKEN Center for Brain Science, Wako, Saitama, 351-0198, Japan.
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3
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Gonsales MC, Ribeiro PAO, Betting LE, Alvim MKM, Guerreiro CM, Yasuda CL, Gitaí DLG, Cendes F, Lopes-Cendes I. Revisiting the clinical impact of variants in EFHC1 in patients with different phenotypes of genetic generalized epilepsy. Epilepsy Behav 2020; 112:107469. [PMID: 33181902 DOI: 10.1016/j.yebeh.2020.107469] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/20/2020] [Accepted: 08/30/2020] [Indexed: 01/27/2023]
Abstract
The most common form of genetic generalized epilepsy (GGE) is juvenile myoclonic epilepsy (JME), which accounts for 5 to 10% of all epilepsy cases. The gene EFHC1 has been implicated as a putative cause of JME. However, it remains debatable whether testing for EFHC1 mutations should be included in the diagnostic epilepsy gene panels. To investigate the clinical utility of EFHC1 testing, we studied 125 individuals: 100 with JME and 25 with other GGEs. We amplified and sequenced all EFHC1 coding exons. Then, we predicted the pathogenicity or benign impact of the variants using the analyses proposed by the American College of Medical Genetics and Genomics (ACMG)/Association for Molecular Pathology (AMP). Mutation screening revealed 11 missense variants in 44 probands with JME (44%) and one of the seven individuals with generalized tonic-clonic seizures on awakening (14%). Six of the 11 variants (54%) were classified as 'benign,' and the remaining variants were considered variants of uncertain significance (VUS). There is currently a limitation to test for genes that predispose an individual to complex, nonmonogenic phenotypes. Thus, we show suggestive evidence that EFHC1 testing lacks a scientific foundation based on the disputed nature of the gene-disease relationship and should be currently limited to research purposes.
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Affiliation(s)
- Marina C Gonsales
- Department of Medical Genetics and Genomic Medicine, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil; The Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas, SP, Brazil
| | - Patrícia A O Ribeiro
- Department of Medical Genetics and Genomic Medicine, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil; The Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas, SP, Brazil
| | - Luiz E Betting
- Department of Neurology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil; The Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas, SP, Brazil
| | - Marina K M Alvim
- Department of Neurology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil; The Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas, SP, Brazil
| | - Carlos M Guerreiro
- Department of Neurology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil; The Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas, SP, Brazil
| | - Clarissa L Yasuda
- Department of Neurology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil; The Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas, SP, Brazil
| | - Daniel L G Gitaí
- Institute of Biological Sciences and Health, Federal University of Alagoas (UFAL), Maceió, AL, Brazil
| | - Fernando Cendes
- Department of Neurology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil; The Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas, SP, Brazil
| | - Iscia Lopes-Cendes
- Department of Medical Genetics and Genomic Medicine, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil; The Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas, SP, Brazil.
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4
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Gilsoul M, Grisar T, Delgado-Escueta AV, de Nijs L, Lakaye B. Subtle Brain Developmental Abnormalities in the Pathogenesis of Juvenile Myoclonic Epilepsy. Front Cell Neurosci 2019; 13:433. [PMID: 31611775 PMCID: PMC6776584 DOI: 10.3389/fncel.2019.00433] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/09/2019] [Indexed: 12/17/2022] Open
Abstract
Juvenile myoclonic epilepsy (JME), a lifelong disorder that starts during adolescence, is the most common of genetic generalized epilepsy syndromes. JME is characterized by awakening myoclonic jerks and myoclonic-tonic-clonic (m-t-c) grand mal convulsions. Unfortunately, one third of JME patients have drug refractory m-t-c convulsions and these recur in 70-80% who attempt to stop antiepileptic drugs (AEDs). Behavioral studies documented impulsivity, but also impairment of executive functions relying on organization and feedback, which points to prefrontal lobe dysfunction. Quantitative voxel-based morphometry (VBM) revealed abnormalities of gray matter (GM) volumes in cortical (frontal and parietal) and subcortical structures (thalamus, putamen, and hippocampus). Proton magnetic resonance spectroscopy (MRS) found evidence of dysfunction of thalamic neurons. White matter (WM) integrity was disrupted in corpus callosum and frontal WM tracts. Magnetic resonance imaging (MRI) further unveiled anomalies in both GM and WM structures that were already present at the time of seizure onset. Aberrant growth trajectories of brain development occurred during the first 2 years of JME diagnosis. Because of genetic origin, disease causing variants were sought, first by positional cloning, and most recently, by next generation sequencing. To date, only six genes harboring pathogenic variants (GABRA1, GABRD, EFHC1, BRD2, CASR, and ICK) with Mendelian and complex inheritance and covering a limited proportion of the world population, are considered as major susceptibility alleles for JME. Evidence on the cellular role, developmental and cell-type expression profiles of these six diverse JME genes, point to their pathogenic variants driving the first steps of brain development when cell division, expansion, axial, and tangential migration of progenitor cells (including interneuron cortical progenitors) sculpture subtle alterations in brain networks and microcircuits during development. These alterations may explain "microdysgenesis" neuropathology, impulsivity, executive dysfunctions, EEG polyspike waves, and awakening m-t-c convulsions observed in JME patients.
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Affiliation(s)
- Maxime Gilsoul
- GIGA-Stem Cells, University of Liège, Liège, Belgium
- GIGA-Neurosciences, University of Liège, Liège, Belgium
- GENESS International Consortium, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Thierry Grisar
- GENESS International Consortium, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Antonio V. Delgado-Escueta
- GENESS International Consortium, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Epilepsy Genetics/Genomics Lab, Neurology and Research Services, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Laurence de Nijs
- GENESS International Consortium, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- School for Mental Health and Neuroscience, Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, Netherlands
| | - Bernard Lakaye
- GIGA-Stem Cells, University of Liège, Liège, Belgium
- GIGA-Neurosciences, University of Liège, Liège, Belgium
- GENESS International Consortium, Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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Ganapathy A, Mishra A, Soni MR, Kumar P, Sadagopan M, Kanthi AV, Patric IRP, George S, Sridharan A, Thyagarajan TC, Aswathy SL, Vidya HK, Chinnappa SM, Nayanala S, Prakash MB, Raghavendrachar VG, Parulekar M, Gowda VK, Nampoothiri S, Menon RN, Pachat D, Udani V, Naik N, Kamate M, Devi ARR, Mohammed Kunju PA, Nair M, Hegde AU, Kumar MP, Sundaram S, Tilak P, Puri RD, Shah K, Sheth J, Hasan Q, Sheth F, Agrawal P, Katragadda S, Veeramachaneni V, Chandru V, Hariharan R, Mannan AU. Multi-gene testing in neurological disorders showed an improved diagnostic yield: data from over 1000 Indian patients. J Neurol 2019; 266:1919-1926. [PMID: 31069529 DOI: 10.1007/s00415-019-09358-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/25/2019] [Accepted: 05/03/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Neurological disorders are clinically heterogeneous group of disorders and are major causes of disability and death. Several of these disorders are caused due to genetic aberration. A precise and confirmatory diagnosis in the patients in a timely manner is essential for appropriate therapeutic and management strategies. Due to the complexity of the clinical presentations across various neurological disorders, arriving at an accurate diagnosis remains a challenge. METHODS We sequenced 1012 unrelated patients from India with suspected neurological disorders, using TruSight One panel. Genetic variations were identified using the Strand NGS software and interpreted using the StrandOmics platform. RESULTS We were able to detect mutations in 197 genes in 405 (40%) cases and 178 mutations were novel. The highest diagnostic rate was observed among patients with muscular dystrophy (64%) followed by leukodystrophy and ataxia (43%, each). In our cohort, 26% of the patients who received definitive diagnosis were primarily referred with complex neurological phenotypes with no suggestive diagnosis. In terms of mutations types, 62.8% were truncating and in addition, 13.4% were structural variants, which are also likely to cause loss of function. CONCLUSION In our study, we observed an improved performance of multi-gene panel testing, with an overall diagnostic yield of 40%. Furthermore, we show that NGS (next-generation sequencing)-based testing is comprehensive and can detect all types of variants including structural variants. It can be considered as a single-platform genetic test for neurological disorders that can provide a swift and definitive diagnosis in a cost-effective manner.
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Affiliation(s)
- Aparna Ganapathy
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Avshesh Mishra
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Megha Rani Soni
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Priyanka Kumar
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Mukunth Sadagopan
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Anil Vittal Kanthi
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Irene Rosetta Pia Patric
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Sobha George
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Aparajit Sridharan
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - T C Thyagarajan
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - S L Aswathy
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - H K Vidya
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Swathi M Chinnappa
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Swetha Nayanala
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Manasa B Prakash
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Vijayashree G Raghavendrachar
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Minothi Parulekar
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | | | | | - Ramshekhar N Menon
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | - Vrajesh Udani
- P. D. Hinduja Hospital and Medical Research Centre, Mumbai, India
| | - Neeta Naik
- EN1 Neuro Services Pvt. Ltd., Mumbai, India
| | | | | | | | | | | | | | - Soumya Sundaram
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Preetha Tilak
- St. Johns Medical College Hospital, Bangalore, India
| | | | - Krati Shah
- ONE-Centre for Rheumatology and Genetics, Vadodara, India
| | - Jayesh Sheth
- FRIGE'S Institute of Human Genetics, Ahmedabad, India
| | | | - Frenny Sheth
- FRIGE'S Institute of Human Genetics, Ahmedabad, India
| | - Pooja Agrawal
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Shanmukh Katragadda
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Vamsi Veeramachaneni
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India
| | - Vijay Chandru
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India.,Indian Institute of Science, Bangalore, India
| | - Ramesh Hariharan
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India.,Indian Institute of Science, Bangalore, India
| | - Ashraf U Mannan
- Strand Center for Genomics and Personalized Medicine, Strand Life Sciences, Bellary Road, Hebbal, Bangalore, 560024, India.
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6
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Wu SZ, Ye H, Yang XG, Lu ZL, Qu Q, Qu J. Case-control pharmacogenetic study of HCN1/HCN2 variants and genetic generalized epilepsies. Clin Exp Pharmacol Physiol 2017; 45:226-233. [PMID: 29047147 DOI: 10.1111/1440-1681.12877] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 10/06/2017] [Accepted: 10/12/2017] [Indexed: 11/27/2022]
Abstract
Epilepsy is a common complex neurological disorder, and some forms are resistant to drug treatment. The HCN1/HCN2 genes encode hyperpolarization-activated cyclic nucleotide-gated channels, which play important roles in the electrophysiology of neurons. We investigated the association between HCN1/HCN2 variants and drug resistance or the risk of genetic generalized epilepsies (GGEs). We used matrix-assisted laser desorption/ionization time-of-flight mass spectrometry to assess nine variants of HCN1/HCN2 in 284 healthy participants and 483 GGEs (279 drug-responsive, 204 drug-resistant). Frequencies of HCN2 rs7255568 and rs3752158 G alleles differed in GGEs and in controls (P = .039, P = .027, respectively). The frequency of HCN2 haplotype (CAC) was higher in patients than controls (P = .046). The frequency of the HCN1 rs10462087 CC+CT genotype was lower in patients with childhood absence epilepsy (CAE) than controls (P = .047). Rs7255568 was associated with the risk of CAE (P = .028) and juvenile myoclonic epilepsy (JME) (P = .02). Rs3752158 was associated with the risk of generalized tonic-clonic seizures, JME, and febrile seizures (all P < .05). The frequency of the HCN2 haplotype (CAC) was higher in patients with JME (P = .015) and in those with febrile seizures (P = .024) than in controls. No significant association was found between HCN1/HCN2 alleles, genotypes or haplotypes, and drug resistance in patients. After Bonferroni's multiple comparisons correction, only the HCN2 rs3752158 C allele and GC+CC genotype frequencies in patients with JME were higher than those in controls (19.2% vs 11.6%, odds ratio (OR) = 1.71, 95% CI = 1.18-2.32), P = .004 < 0.05/9; 36% vs 22.2%, OR = 1.62(1.18-2.23), P = .003 < 0.05/9). Our study suggests that HCN2 rs3752158 is involved in the susceptibility to JME.
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Affiliation(s)
- Shu-Zhi Wu
- Department of Neurology, The Third Clinical Institute Affiliated to Wenzhou Medical University & Wenzhou People's Hospital, Wenzhou, China
| | - Hua Ye
- Department of Neurology, The Third Clinical Institute Affiliated to Wenzhou Medical University & Wenzhou People's Hospital, Wenzhou, China
| | - Xiao-Guo Yang
- Department of Neurology, The Third Clinical Institute Affiliated to Wenzhou Medical University & Wenzhou People's Hospital, Wenzhou, China
| | - Zhi-Li Lu
- Department of Pathology, Hunan Cancer Hospital, Central South University, Changsha, China
| | - Qiang Qu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
| | - Jian Qu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
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