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Functional Independence of Taiwanese Children with Osteogenesis Imperfecta. J Pers Med 2022; 12:jpm12081205. [PMID: 35893298 PMCID: PMC9394323 DOI: 10.3390/jpm12081205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 11/17/2022] Open
Abstract
Osteogenesis imperfecta (OI) is a group of rare genetic disorders that affect bone formation. Patients with OI present mainly with increased bone fragility and bone deformities. Twenty-seven Taiwanese children between 2 and 21 years of age with OI and their parents were recruited at MacKay Memorial Hospital from January 2013 to December 2019. We used the Functional Independence Measure for Children (WeeFIM) questionnaire to assess the functional independence of the children and describe any functional limitations or additional burden of daily care. Out of a potential score of 126, the mean total WeeFIM score was 113.7. There was a statistically significant difference between the scores of type I, type III and type IV OI (121.88 [SD 7.01] vs. 80.8 [SD 26.25] vs. 119.17 [SD 10.89]; p < 0.001). There were no statistically significant differences between the scores in different age groups, the male and female participants, and patients with pathogenic variants in COL1A1 and COL1A2. The mean scores for the self-care, mobility, and cognition domains were 48.78 (maximum 56, mean quotient 91.14%), 30.44 (maximum 35, mean quotient 87.12%), and 34.44 (maximum 35, mean quotient 99.05%), respectively. The best performance was in the cognition domain (mean quotient 99.05%), and the worst was in the mobility domain (mean quotient 87.12%). There were no statistically significant correlations between WeeFIM scores and age, or age when symptoms began. The total WeeFIM score and 13 subscores for the self-care and mobility domains were all positively correlated with body height (p < 0.01). The correlation was lowest for bowel and walking/wheelchair tasks, and the highest for bathing and dressing-upper tasks. For tasks in bathing, over 40% of the patients needed help. For tasks in the cognition domain, most patients required no help. For the Taiwanese children with OI, some support and supervision were required for self-care and mobility tasks, and the functional independence in these two domains was correlated with body height and disease types. The WeeFIM questionnaire may be a useful tool to assess the functional strengths and weaknesses of children with OI.
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Lin HY, Chang YH, Lee CL, Tu YR, Lo YT, Hung PW, Niu DM, Liu MY, Liu HY, Chen HJ, Kao SM, Wang LY, Ho HJ, Chuang CK, Lin SP. Newborn Screening Program for Mucopolysaccharidosis Type II and Long-Term Follow-Up of the Screen-Positive Subjects in Taiwan. J Pers Med 2022; 12:jpm12071023. [PMID: 35887520 PMCID: PMC9320252 DOI: 10.3390/jpm12071023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/18/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Mucopolysaccharidosis II (MPS II) is an X-linked disorder resulting from a deficiency in lysosomal enzyme iduronate-2-sulfatase (IDS), which causes the accumulation of glycosaminoglycans (GAGs) in the lysosomes of many tissues and organs, leading to progressive cellular dysfunction. An MPS II newborn screening program has been available in Taiwan since 2015. The aim of the current study was to collect and analyze the long-term follow-up data of the screen-positive subjects in this program. Methods: From August 2015 to April 2022, 548,624 newborns were screened for MPS II by dried blood spots using tandem mass spectrometry, of which 202 suspected infants were referred to our hospital for confirmation. The diagnosis of MPS II was confirmed by IDS enzyme activity assay in leukocytes, quantitative determination of urinary GAGs by mass spectrometry, and identification of the IDS gene variant. Results: Among the 202 referred infants, 10 (5%) with seven IDS gene variants were diagnosed with confirmed MPS II (Group 1), 151 (75%) with nine IDS gene variants were classified as having suspected MPS II or pseudodeficiency (Group 2), and 41 (20%) with five IDS gene variants were classified as not having MPS II (Group 3). Long-term follow-up every 6 months was arranged for the infants in Group 1 and Group 2. Intravenous enzyme replacement therapy (ERT) was started in four patients at 1, 0.5, 0.4, and 0.5 years of age, respectively. Three patients also received hematopoietic stem cell transplantation (HSCT) at 1.5, 0.9, and 0.6 years of age, respectively. After ERT and/or HSCT, IDS enzyme activity and the quantity of urinary GAGs significantly improved in all of these patients compared with the baseline data. Conclusions: Because of the progressive nature of MPS II, early diagnosis via a newborn screening program and timely initiation of ERT and/or HSCT before the occurrence of irreversible organ damage may lead to better clinical outcomes. The findings of the current study could serve as baseline data for the analysis of the long-term effects of ERT and HSCT in these patients.
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Affiliation(s)
- Hsiang-Yu Lin
- Department of Pediatrics, MacKay Memorial Hospital, Taipei 10449, Taiwan; (H.-Y.L.); (Y.-H.C.); (C.-L.L.)
- Department of Medical Research, MacKay Memorial Hospital, Taipei 10449, Taiwan;
- The Rare Disease Center, MacKay Memorial Hospital, Taipei 10449, Taiwan; (Y.-T.L.); (P.-W.H.)
- Department of Medicine, MacKay Medical College, New Taipei City 25245, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei 11260, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 40402, Taiwan
| | - Ya-Hui Chang
- Department of Pediatrics, MacKay Memorial Hospital, Taipei 10449, Taiwan; (H.-Y.L.); (Y.-H.C.); (C.-L.L.)
- The Rare Disease Center, MacKay Memorial Hospital, Taipei 10449, Taiwan; (Y.-T.L.); (P.-W.H.)
| | - Chung-Lin Lee
- Department of Pediatrics, MacKay Memorial Hospital, Taipei 10449, Taiwan; (H.-Y.L.); (Y.-H.C.); (C.-L.L.)
- Department of Medical Research, MacKay Memorial Hospital, Taipei 10449, Taiwan;
- The Rare Disease Center, MacKay Memorial Hospital, Taipei 10449, Taiwan; (Y.-T.L.); (P.-W.H.)
- Department of Medicine, MacKay Medical College, New Taipei City 25245, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei 11260, Taiwan
| | - Yuan-Rong Tu
- Department of Medical Research, MacKay Memorial Hospital, Taipei 10449, Taiwan;
| | - Yun-Ting Lo
- The Rare Disease Center, MacKay Memorial Hospital, Taipei 10449, Taiwan; (Y.-T.L.); (P.-W.H.)
| | - Pei-Wen Hung
- The Rare Disease Center, MacKay Memorial Hospital, Taipei 10449, Taiwan; (Y.-T.L.); (P.-W.H.)
| | - Dau-Ming Niu
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
| | - Mei-Ying Liu
- The Chinese Foundation of Health, Neonatal Screening Center, Taipei 10699, Taiwan; (M.-Y.L.); (H.-Y.L.); (H.-J.C.); (S.-M.K.)
| | - Hsin-Yun Liu
- The Chinese Foundation of Health, Neonatal Screening Center, Taipei 10699, Taiwan; (M.-Y.L.); (H.-Y.L.); (H.-J.C.); (S.-M.K.)
| | - Hsiao-Jan Chen
- The Chinese Foundation of Health, Neonatal Screening Center, Taipei 10699, Taiwan; (M.-Y.L.); (H.-Y.L.); (H.-J.C.); (S.-M.K.)
| | - Shu-Min Kao
- The Chinese Foundation of Health, Neonatal Screening Center, Taipei 10699, Taiwan; (M.-Y.L.); (H.-Y.L.); (H.-J.C.); (S.-M.K.)
| | - Li-Yun Wang
- Taipei Institute of Pathology, Neonatal Screening Center, Taipei 10374, Taiwan; (L.-Y.W.); (H.-J.H.)
| | - Huey-Jane Ho
- Taipei Institute of Pathology, Neonatal Screening Center, Taipei 10374, Taiwan; (L.-Y.W.); (H.-J.H.)
| | - Chih-Kuang Chuang
- Department of Medical Research, MacKay Memorial Hospital, Taipei 10449, Taiwan;
- College of Medicine, Fu-Jen Catholic University, Taipei 24205, Taiwan
- Correspondence: (C.-K.C.); (S.-P.L.); Tel.: +886-2-2809-4661 (ext. 2348) (C.-K.C.); +886-2-2543-3535 (ext. 3090) (S.-P.L.); Fax: +886-2-2808-5952 (C.-K.C.); +886-2-2543-3642 (S.-P.L.)
| | - Shuan-Pei Lin
- Department of Pediatrics, MacKay Memorial Hospital, Taipei 10449, Taiwan; (H.-Y.L.); (Y.-H.C.); (C.-L.L.)
- Department of Medical Research, MacKay Memorial Hospital, Taipei 10449, Taiwan;
- The Rare Disease Center, MacKay Memorial Hospital, Taipei 10449, Taiwan; (Y.-T.L.); (P.-W.H.)
- Department of Medicine, MacKay Medical College, New Taipei City 25245, Taiwan
- Department of Infant and Child Care, National Taipei University of Nursing and Health Sciences, Taipei 11219, Taiwan
- Correspondence: (C.-K.C.); (S.-P.L.); Tel.: +886-2-2809-4661 (ext. 2348) (C.-K.C.); +886-2-2543-3535 (ext. 3090) (S.-P.L.); Fax: +886-2-2808-5952 (C.-K.C.); +886-2-2543-3642 (S.-P.L.)
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Lin HY, Lee CL, Chang CY, Chiu PC, Chien YH, Niu DM, Tsai FJ, Hwu WL, Lin SJ, Lin JL, Chao MC, Chang TM, Tsai WH, Wang TJ, Chuang CK, Lin SP. Survival and diagnostic age of 175 Taiwanese patients with mucopolysaccharidoses (1985-2019). Orphanet J Rare Dis 2020; 15:314. [PMID: 33160388 PMCID: PMC7648385 DOI: 10.1186/s13023-020-01598-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/26/2020] [Indexed: 01/03/2023] Open
Abstract
Background Mucopolysaccharidoses (MPSs) are a group of inherited metabolic diseases, which are characterized by the accumulation of glycosaminoglycans, and eventually lead to the progressive damage of various tissues and organs. Methods An epidemiological study of MPS in Taiwan was performed using multiple sources. The survival and diagnostic age for different types of MPS between 1985 and 2019 were evaluated.
Results Between 1985 and 2019, there were 175 patients diagnosed with MPS disorders in the Taiwanese population, with a median diagnostic age of 3.9 years. There were 21 (12%), 78 (45%), 33 (19%), 32 (18%) and 11 (6%) patients diagnosed with MPS I, II, III, IV and VI, respectively, with median diagnostic ages of 1.5, 3.8, 4.7, 4.5 and 3.7 years, respectively. Diagnosis of MPS patients was significantly earlier in recent decades (p < 0.01). Pilot newborn screening programs for MPS I, II, VI, IVA, and IIIB were progressively introduced in Taiwan from 2016, and 48% (16/33) of MPS patients diagnosed between 2016 and 2019 were diagnosed by one of these screening programs, with a median diagnostic age at 0.2 years. For patients born between 2016 and 2019, up to 94% (16/17) were diagnosed with MPS via the newborn screening programs. At the time of this study, 81 patients had passed away with a median age at death of 15.6 years. Age at diagnosis was positively correlated with life expectancy (p < 0.01). Life expectancy also significantly increased between 1985 and 2019, however this increase was gradual (p < 0.01). Conclusions The life expectancy of Taiwanese patients with MPS has improved in recent decades and patients are being diagnosed earlier. Because of the progressive nature of the disease, early diagnosis by newborn screening programs and timely implementation of early therapeutic interventions may lead to better clinical outcomes.
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Affiliation(s)
- Hsiang-Yu Lin
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,Department of Pediatrics, MacKay Memorial Hospital, No.92, Sec. 2 Chung-Shan North Road, Taipei, 10449, Taiwan.,Department of Medical Research, MacKay Memorial Hospital, 92 Chung-Shan N. Rd., Sec. 2, Taipei, 10449, Taiwan.,Nursing and Management, MacKay Junior College of Medicine, Taipei, Taiwan.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan.,Institute of Biomedical Sciences, MacKay Medical College, New Taipei City, Taiwan
| | - Chung-Lin Lee
- Nursing and Management, MacKay Junior College of Medicine, Taipei, Taiwan.,Department of Pediatrics, MacKay Memorial Hospital, Hsinchu, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Ying Chang
- Department of Pediatrics, MacKay Memorial Hospital, Hsinchu, Taiwan
| | - Pao Chin Chiu
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yin-Hsiu Chien
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Dau-Ming Niu
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fuu-Jen Tsai
- Department of Pediatrics, China Medical University Hospital, Taichung, Taiwan
| | - Wuh-Liang Hwu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Shio Jean Lin
- Department of Pediatrics, Chi Mei Medical Center, Tainan, Taiwan
| | - Ju-Li Lin
- Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Mei-Chyn Chao
- Department of Pediatrics, Changhua Christian Children's Hospital, Changhua, Taiwan
| | - Tung-Ming Chang
- Department of Pediatric Neurology, Changhua Christian Children's Hospital, Changhua, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Hui Tsai
- Department of Pediatrics, Chi Mei Medical Center, Tainan, Taiwan
| | - Tzu-Jou Wang
- Department of Pediatrics, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chih-Kuang Chuang
- Department of Medical Research, MacKay Memorial Hospital, 92 Chung-Shan N. Rd., Sec. 2, Taipei, 10449, Taiwan. .,College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan.
| | - Shuan-Pei Lin
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan. .,Department of Pediatrics, MacKay Memorial Hospital, No.92, Sec. 2 Chung-Shan North Road, Taipei, 10449, Taiwan. .,Department of Medical Research, MacKay Memorial Hospital, 92 Chung-Shan N. Rd., Sec. 2, Taipei, 10449, Taiwan. .,Department of Infant and Child Care, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.
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Lin HY, Lee CL, Lo YT, Tu RY, Chang YH, Chang CY, Chiu PC, Chang TM, Tsai WH, Niu DM, Chuang CK, Lin SP. An At-Risk Population Screening Program for Mucopolysaccharidoses by Measuring Urinary Glycosaminoglycans in Taiwan. Diagnostics (Basel) 2019; 9:diagnostics9040140. [PMID: 31590383 PMCID: PMC6963841 DOI: 10.3390/diagnostics9040140] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/02/2019] [Accepted: 10/02/2019] [Indexed: 01/13/2023] Open
Abstract
Background: The mucopolysaccharidoses (MPSs) are a group of rare lysosomal storage disorders characterized by the accumulation of glycosaminoglycans (GAGs) and which eventually cause progressive damage to various tissues and organs. We developed a feasible MPS screening algorithm and established a cross-specialty collaboration platform between medical geneticists and other medical specialists based on at-risk criteria to allow for an earlier confirmative diagnosis of MPS. Methods: Children (<19 years of age) with clinical signs and symptoms compatible with MPS were prospectively enrolled from pediatric clinics between July 2013 and June 2018. Urine samples were collected for a non-specific total GAG analysis using the dimethylmethylene blue (DMB) spectrophotometric method, and the quantitation of three urinary GAGs (dermatan sulfate (DS), heparan sulfate (HS), and keratan sulfate (KS)) was performed by liquid chromatography/tandem mass spectrometry (LC-MS/MS). The subjects with elevated urinary GAG levels were recalled for leukocyte enzyme activity assay and genetic testing for confirmation. Results: Among 153 subjects enrolled in this study, 13 had a confirmative diagnosis of MPS (age range, 0.6 to 10.9 years—three with MPS I, four with MPS II, five with MPS IIIB, and one with MPS IVA). The major signs and symptoms with regards to different systems recorded by pediatricians at the time of the decision to test for MPS were the musculoskeletal system (55%), followed by the neurological system (45%) and coarse facial features (39%). For these 13 patients, the median age at the diagnosis of MPS was 2.9 years. The false negative rate of urinary DMB ratio using the dye-based method for these 13 patients was 31%, including one MPS I, two MPS IIIB, and one MPS IVA. However, there were no false negative results with urinary DS, HS and KS using the MS/MS-based method. Conclusions: We established an at-risk population screening program for MPS by measuring urinary GAG fractionation biomarkers using the LC-MS/MS method. The program included medical geneticists and other medical specialists to increase awareness and enable an early diagnosis by detecting MPS at the initial onset of clinical symptoms.
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Affiliation(s)
- Hsiang-Yu Lin
- Department of Medicine, MacKay Medical College, New Taipei City 252, Taiwan.
- Department of Pediatrics, MacKay Memorial Hospital, Taipei 100, Taiwan.
- Department of Medical Research, MacKay Memorial Hospital, Taipei 100, Taiwan.
- MacKay Junior College of Medicine, Nursing and Management, Taipei 100, Taiwan.
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 400, Taiwan.
- Institute of Biomedical Sciences, MacKay Medical College, New Taipei City 252, Taiwan.
| | - Chung-Lin Lee
- Department of Pediatrics, MacKay Memorial Hospital, Hsinchu 300, Taiwan.
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 100, Taiwan.
| | - Yun-Ting Lo
- Department of Laboratory Medicine, MacKay Memorial Hospital, Taipei 100, Taiwan.
| | - Ru-Yi Tu
- Department of Medical Research, MacKay Memorial Hospital, Taipei 100, Taiwan.
| | - Ya-Hui Chang
- Department of Pediatrics, MacKay Memorial Hospital, Taipei 100, Taiwan.
| | - Chia-Ying Chang
- Department of Pediatrics, MacKay Memorial Hospital, Hsinchu 300, Taiwan.
| | - Pao Chin Chiu
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung 800, Taiwan.
| | - Tung-Ming Chang
- Department of Pediatric Neurology, Changhua Christian Children's Hospital, Changhua 500, Taiwan.
- Department of Biological Science and Technology, College of Biological Science and Technology, National Chiao Tung University, Hsinchu 300, Taiwan.
| | - Wen-Hui Tsai
- Department of Pediatrics, Chi Mei Medical Center, Tainan 700, Taiwan.
| | - Dau-Ming Niu
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 100, Taiwan.
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei 100, Taiwan.
| | - Chih-Kuang Chuang
- Department of Medical Research, MacKay Memorial Hospital, Taipei 100, Taiwan.
- College of Medicine, Fu-Jen Catholic University, Taipei 100, Taiwan.
| | - Shuan-Pei Lin
- Department of Medicine, MacKay Medical College, New Taipei City 252, Taiwan.
- Department of Pediatrics, MacKay Memorial Hospital, Taipei 100, Taiwan.
- Department of Medical Research, MacKay Memorial Hospital, Taipei 100, Taiwan.
- Department of Infant and Child Care, National Taipei University of Nursing and Health Sciences, Taipei 100, Taiwan.
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Lee CL, Lin HY, Chuang CK, Chiu HC, Tu RY, Huang YH, Hwu WL, Tsai FJ, Chiu PC, Niu DM, Chen YJ, Chao MC, Chang TM, Lin JL, Chang CY, Kao YC, Lin SP. Functional independence of Taiwanese patients with mucopolysaccharidoses. Mol Genet Genomic Med 2019; 7:e790. [PMID: 31215158 PMCID: PMC6687640 DOI: 10.1002/mgg3.790] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 05/05/2019] [Accepted: 05/17/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Information on functional strengths and weaknesses of mucopolysaccharidosis (MPS) patients is important for early intervention programs and enzyme replacement therapy (ERT). METHODS We used the Functional Independence Measure for Children (WeeFIM) questionnaire to assess the functional skills of 63 Taiwanese MPS patients (median age, 13 years 3 months; range, 3-20 years) from January 2012 to December 2018. RESULTS Mean total WeeFIM score was 75.4 of a potential score of 126. Mean total WeeFIM scores of each type (MPS I, MPS II, MPS IIIB, MPS IVA, and MPS VI) were 103.8, 76.2, 41.6, 92.2, and 113.6, respectively. Mean scores for self-care, mobility, and cognition domains were 30 (maximum 56), 23 (maximum 35), and 22 (maximum 35), respectively. MPS type IIIB patients had the lowest scores in self-care, mobility, cognition, and total domains compared to other types of MPS. All patients with ERT in MPS I, II, and IVA had higher scores in self-care and mobility domains than patients without ERT. Most patients required assistance for self-care skills, especially in grooming and bathing. CONCLUSION MPS patients require support and supervision in self-care tasks. For cognition tasks, MPS IIIB patients also require help. This questionnaire is useful to identify the strengths and limitations of MPS patients.
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Affiliation(s)
- Chung-Lin Lee
- Department of Pediatrics, Mackay Memorial Hospital, Hsinchu, Taiwan
| | - Hsiang-Yu Lin
- Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei City, Taiwan.,Division of Genetics and Metabolism, Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan.,Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chih-Kuang Chuang
- Division of Genetics and Metabolism, Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan.,College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
| | - Huei-Ching Chiu
- Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan
| | - Ru-Yi Tu
- Division of Genetics and Metabolism, Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan
| | - You-Hsin Huang
- Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan
| | - Wuh-Liang Hwu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Fuu-Jen Tsai
- Department of Medical Research, Genetics Center, China Medical University Hospital, Taichung, Taiwan
| | - Pao-Chin Chiu
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Dau-Ming Niu
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yann-Jang Chen
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Pediatrics, Renai Branch, Taipei City Hospital, Taipei, Taiwan
| | - Mei-Chyn Chao
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Pediatric Neurology, Changhua Christian Children's Hospital, Changhua, Taiwan
| | - Tung-Ming Chang
- Department of Pediatric Neurology, Changhua Christian Children's Hospital, Changhua, Taiwan.,Department of Biological Science and Technology, College of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Ju-Li Lin
- Department of Pediatrics, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chia-Ying Chang
- Department of Pediatrics, Mackay Memorial Hospital, Hsinchu, Taiwan
| | - Yu-Chia Kao
- Department of Pediatrics, E-DA Hospital, Kaohsiung, Taiwan
| | - Shuan-Pei Lin
- Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei City, Taiwan.,Division of Genetics and Metabolism, Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Infant and Child Care, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
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