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Zhang S, Ma Y, Zang X, Heng H, Liu X, Peng G, Liu R, Liang J, Geng H. A Case of 17q12 Microdeletion Syndrome in a MODY5 Type Diabetes with HNF-1β Gene Mutation Accompanied. Appl Clin Genet 2024; 17:125-130. [PMID: 39050772 PMCID: PMC11268705 DOI: 10.2147/tacg.s465859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 06/22/2024] [Indexed: 07/27/2024] Open
Abstract
Maturity Onset Diabetes of the Young (MODY) is an autosomal dominant inherited disorder prevalent among adolescents. Typically, it manifests with hyperglycemia before the age of 25. MODY5 is attributed to a mutation in the Hepatocyte Nuclear Factor-1β (HNF-1β) gene. A complete absence of HNF-1β is observed in 50% of those with MODY5. The 17q12 microdeletion syndrome closely linked with MODY5. Its incidence in the general population is around 1 in 14,500 and is linked with facial deformities, diabetes, polycystic kidneys, pancreatic hypertrophy, liver anomalies, and neuropsychological impairments. The most primary clinical signs are predominantly associated with the HNF-1β gene deletion. We chronicle the case of a male of 19 years of age diagnosed with diabetes, who, alongside persistent liver damage and polycystic kidneys, was referred from a community hospital to the Xuzhou Central Hospital. His clinical presentation included diabetes, liver dysfunction, polycystic kidneys, lipid irregularities, insulin resistance, and fatty atrophy. Subsequent genetic screening unveiled a 17q12 chromosomal deletion and an absence of the Hepatocyte Nuclear Factor-1β (HNF-1β) gene. Hence, for adolescent patients lacking a familial diabetes history but exhibiting symptoms like polycystic kidneys, liver damage, lipid irregularities, and fatty atrophy, a thorough assessment for the 17q12 microdeletion syndrome becomes imperative.
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Affiliation(s)
- Shuping Zhang
- Graduate School, Bengbu Medical University, Bengbu, Anhui, People’s Republic of China
| | - Yamei Ma
- Graduate School, Bengbu Medical University, Bengbu, Anhui, People’s Republic of China
| | - Xiu Zang
- Department of Endocrinology, Xuzhou Central Hospital, Xuzhou, Jiangsu, People’s Republic of China
| | - Hao Heng
- Department of Endocrinology, Xuzhou Central Hospital, Xuzhou, Jiangsu, People’s Republic of China
| | - Xuekui Liu
- Department of Endocrinology, Xuzhou Central Hospital, Xuzhou, Jiangsu, People’s Republic of China
| | - Gangshan Peng
- The Affiliated Xuzhou Clinical College, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Ran Liu
- The Affiliated Xuzhou Clinical College, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Jun Liang
- Graduate School, Bengbu Medical University, Bengbu, Anhui, People’s Republic of China
- Department of Endocrinology, Xuzhou Central Hospital, Xuzhou, Jiangsu, People’s Republic of China
| | - Houfa Geng
- Graduate School, Bengbu Medical University, Bengbu, Anhui, People’s Republic of China
- Department of Endocrinology, Xuzhou Central Hospital, Xuzhou, Jiangsu, People’s Republic of China
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Jeeyavudeen MS, Murray SR, Strachan MWJ. Management of monogenic diabetes in pregnancy: A narrative review. World J Diabetes 2024; 15:15-23. [PMID: 38313847 PMCID: PMC10835499 DOI: 10.4239/wjd.v15.i1.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/13/2023] [Accepted: 12/08/2023] [Indexed: 01/12/2024] Open
Abstract
Pregnancy in women with monogenic diabetes is potentially complex, with significant implications for both maternal and fetal health. Among these, maturity-onset diabetes of the young (MODY) stands out as a prevalent monogenic diabetes subtype frequently encountered in clinical practice. Each subtype of MODY requires a distinct approach tailored to the pregnancy, diverging from management strategies in non-pregnant individuals. Glucokinase MODY (GCK-MODY) typically does not require treatment outside of pregnancy, but special considerations arise when a woman with GCK-MODY becomes pregnant. The glycemic targets in GCK-MODY pregnancies are not exclusively dictated by the maternal/paternal MODY genotype but are also influenced by the genotype of the developing fetus. During pregnancy, the choice between sulfonylurea or insulin for treating hepatocyte nuclear factor 1-alpha (HNF1A)-MODY and HNF4A-MODY depends on the mother's specific circumstances and the available expertise. Management of other rarer MODY subtypes is individualized, with decisions made on a case-by-case basis. Therefore, a collaborative approach involving expert diabetes and obstetric teams is crucial for the comprehensive management of MODY pregnancies.
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Affiliation(s)
| | - Sarah R Murray
- MRC Centre for Reproductive Health, University of Edinburgh Queen’s Medical Research Institute, Edinburgh EH16 4TJ, United Kingdom
| | - Mark W J Strachan
- Metabolic Unit, Western General Hospital, Edinburgh EH4 2XU, United Kingdom
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Severe high-molecular-weight kininogen deficiency: clinical characteristics, deficiency-causing KNG1 variants, and estimated prevalence. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:237-254. [PMID: 36700498 DOI: 10.1016/j.jtha.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Severe high-molecular-weight kininogen (HK) deficiency is a poorly studied autosomal recessive contact system defect caused by pathogenic, biallelic KNG1 variants. AIM We performed the first comprehensive analysis of diagnostic, clinical, genetic, and epidemiological aspects of HK deficiency. METHODS We collected clinical information and blood samples from a newly detected HK-deficient individual and from published cases identified by a systematic literature review. Activity and antigen levels of coagulation factors were determined. Genetic analyses of KNG1 and KLKB1 were performed by Sanger sequencing. The frequency of HK deficiency was estimated considering truncating KNG1 variants from GnomAD. RESULTS We identified 48 cases of severe HK deficiency (41 families), of these 47 have been previously published (n = 19 from gray literature). We genotyped 3 cases and critically appraised 10 studies with genetic data. Ten HK deficiency-causing variants (one new) were identified. All of them were truncating mutations, whereas the only known HK amino acid substitution with a relevant phenotype instead causes hereditary angioedema. Conservative estimates suggest an overall prevalence of severe HK deficiency of approximately one case per 8 million population, slightly higher in Africans. Individuals with HK deficiency appeared asymptomatic and had decreased levels of prekallikrein and factor XI, which could lead to misdiagnosis. CONCLUSION HK deficiency is a rare condition with only few known pathogenic variants. It has an apparently good prognosis but is prone to misdiagnosis. Our understanding of its clinical implications is still limited, and an international prekallikrein and HK deficiency registry is being established to fill this knowledge gap.
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Yau TTL, Yu SCY, Cheng JY, Kwok JSS, Ma RCW. GCK-MODY in pregnancy: A pregnant woman with diabetes and a small-for-gestational-age fetus. Clin Case Rep 2022; 10:e6629. [PMID: 36483860 PMCID: PMC9723257 DOI: 10.1002/ccr3.6629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/23/2022] [Accepted: 11/08/2022] [Indexed: 12/12/2022] Open
Abstract
Glucokinase-maturity-onset diabetes of the young (GCK-MODY) is often misdiagnosed as other forms of diabetes. A 42-year-old pregnant lady with pre-existing diabetes was treated with insulin during first trimester. Fetal growth restriction was noted since mid-second trimester. Genetic testing suggested the diagnosis of GCK-MODY.
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Affiliation(s)
- Tiffany Tse Ling Yau
- Department of Medicine and TherapeuticsThe Chinese University of Hong Kong, Prince of Wales HospitalShatinHong Kong
| | - Stephanie Cheuk Yin Yu
- Department of Chemical PathologyThe Chinese University of Hong Kong, Prince of Wales HospitalShatinHong Kong
| | - Jenny Yeuk‐Ki Cheng
- Department of Chemical PathologyThe Chinese University of Hong Kong, Prince of Wales HospitalShatinHong Kong
| | - Jeffrey Sung Shing Kwok
- Department of Chemical PathologyThe Chinese University of Hong Kong, Prince of Wales HospitalShatinHong Kong
| | - Ronald Ching Wan Ma
- Department of Medicine and TherapeuticsThe Chinese University of Hong Kong, Prince of Wales HospitalShatinHong Kong
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health SciencesThe Chinese University of Hong KongShatinHong Kong
- Chinese University of Hong Kong‐Shanghai Jiao Tong University Joint Research Centre in Diabetes Genomics and Precision MedicineThe Chinese University of Hong KongShatinHong Kong
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The Challenges of Treating Glucokinase MODY during Pregnancy: A Review of Maternal and Fetal Outcomes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19105980. [PMID: 35627517 PMCID: PMC9141824 DOI: 10.3390/ijerph19105980] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 02/01/2023]
Abstract
Background: The optimal treatment strategy for the follow-up and management of women with glucokinase maturity-onset diabetes of the young (GCK−MODY)during pregnancy remains unknown. Data regarding maternal and fetal outcomes are lacking. Aim: This paper summarizes the existing literature regarding the maternal and fetal outcomes of women with glucokinase MODY to guide future treatment strategy. Methods: A literature search was conducted in Pubmed, Embace, and Cochrane library with citation follow-up using the terms: glucokinase, MODY, diabetes, pregnancy, gestation, and outcomes. We searched for articles with known fetal mutational status. Relevant outcomes included: birthweight, large for gestational age (LGA), small for gestational age (SGA), macrosomia, cesarean delivery (CD), shoulder dystocia, congenital anomalies, miscarriages, preterm births, and long-term outcomes. Results: Fourteen relevant manuscripts were identified describing maternal and fetal outcomes. The percentage of LGA and macrosomia in 102 glucokinase -unaffected offspring (GCK−) was significantly higher than in the glucokinase -affected offspring (GCK+) (44% vs. 10%, p < 0.001 and 22% vs. 2%, p < 0.001, respectively). Among the 173 GCK(+) offspring, only 5% were SGA, which can be expected according to the normal distribution. We observed higher rates of CD and shoulder dystocia in the GCK(−) offspring. Conclusions: GCK(−) offspring have significantly higher birthweights and more birth complications. The optimal treatment strategy to guide management should take into consideration multiple variables other than fetal mutational status.
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Jiang Y, Jiang F, Li M, Wu Q, Xu C, Zhang R, Song M, Wang Y, Wang Y, Chen Y, Zhang J, Ge X, Zhu Q, Zhuang L, Yang D, Lu M, Wang F, Jiang M, Liu X, Liu Y, Liu L. Identification and management of GCK-MODY complicating pregnancy in Chinese patients with gestational diabetes. Mol Cell Biochem 2022; 477:1629-1643. [PMID: 35229243 DOI: 10.1007/s11010-022-04374-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 01/27/2022] [Indexed: 10/19/2022]
Abstract
Precise differentiation of glucokinase (GCK) monogenic diabetes from gestational diabetes mellitus (GDM) is critical for accurate management of the pregnancy outcome. We screened GCK-MODY complicating pregnancies in Chinese GDM patients, explored the pathogenesis of novel GCK mutations, and evaluated the patients' pregnancy outcome and management. The GCK gene from 411 GDM patients was screened with PCR-direct sequencing and multiplex ligation-dependent probe amplification (MLPA) and 15 GCK mutations were identified. We also retrospectively analyzed a total of 65 pregnancies from 21 GCK-MODY families, wherein 41 were from 15 maternal families and 24 were from six paternal families. Bioinformatic analysis and biochemical functional study were conducted to identify novel GCK mutations. In total, we identified 21 GCK mutations: 15 from the 411 GDM patients and six from 24 fathers. Of th Asp78Asn (GAC → AAC), Met87Arg (ATG → AGG), Leu451Val (CTT → GTT), Leu451Pro (CTG → CCG) and 1019 + 20G > A e mutations, five, i.e., were novel and deleterious, with markedly decreased enzyme activity and thermal stability. The unaffected offspring of GCK mutation-affected mothers were heavier than affected offspring (p < 0.001). Of 21 insulin-treated affected mothers, 10 had maternal hypoglycemia (47.6%) and seven had perinatal complications (33.3%), and the affected offspring of the insulin-treated affected mothers had significantly lower birth weights than that of the 20 diet-control affected mothers (p = 0.031). In this study, the prevalence of GCK-MODY complicating pregnancy in Chinese GDM patients was 3.6% (15/411). The defective GCK may contribute to the hyperglycemia in GCK-MODY. Insulin therapy is not beneficial for GCK-MODY complicating pregnancy and therefore should not be recommended.
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Affiliation(s)
- Yanyan Jiang
- Shanghai Diabetes Institute, Department of Endocrinology & Metabolism, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiaotong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Fusong Jiang
- Shanghai Diabetes Institute, Department of Endocrinology & Metabolism, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiaotong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Ming Li
- Shanghai Diabetes Institute, Department of Endocrinology & Metabolism, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiaotong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Qingkai Wu
- Department of Obstetrics and Gynecology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No.600 Yishan Road, Shanghai, 200233, China
| | - Chenming Xu
- The Obstetrics & Gynecology Hospital of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Rong Zhang
- Shanghai Diabetes Institute, Department of Endocrinology & Metabolism, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiaotong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Mingqiang Song
- Department of Endocrinology, Weihai Municipal Hospital, No. 70, Heping Road, Weihai, 264200, China
| | - Yanzhong Wang
- School of Population Health and Environmental Science, King's College London, London, UK
| | - Ying Wang
- Department of Pediatrics, Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, 90502, USA
| | - Yating Chen
- Shanghai Diabetes Institute, Department of Endocrinology & Metabolism, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiaotong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Juan Zhang
- Shanghai Diabetes Institute, Department of Endocrinology & Metabolism, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiaotong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
- School of Medicine, Huanghuai University, Zhumadian, 463000, Henan, China
| | - Xiaoxu Ge
- Department of Endocrinology, School of Medicine, Shanghai Tongren Hospital, Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Qihan Zhu
- Department of Endocrinology, The first affiliated hospital of Wenzhou Medical University, The South of Shangcai Village, Nanbaixiang Town, Ouhai District, Wenzhou, 325000, Zhejiang, China
| | - Langen Zhuang
- Department of Endocrinology, the First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, 233004, China
| | - Di Yang
- Department of Nutritional Sciences and Toxicology, University of California at Berkeley, Berkeley, USA
| | - Ming Lu
- Department of Endocrinology & Metabolism, Putuo Hospital Attached to Shanghai University of Traditional Chinese Medicine, 164 Lanxi Road, Shanghai, 200000, China
| | - Feng Wang
- Department of Nephrology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Meisheng Jiang
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA
| | - Xipeng Liu
- State Key Laboratory of Microbial Metabolism, School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, 800 Dong-Chuan Road, Shanghai, 200240, China
| | - Yanjun Liu
- Department of Internal Medicine, Charles R. Drew University, Los Angeles, USA
- David Geffen School of Medicine at University of California, Los Angeles, USA
| | - Limei Liu
- Shanghai Diabetes Institute, Department of Endocrinology & Metabolism, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiaotong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
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Fu J, Ping F, Wang T, Liu Y, Wang X, Yu J, Deng M, Liu J, Zhang Q, Yu M, Li M, Li Y, Xiao X. A Clinical Prediction Model to Distinguish Maturity-Onset Diabetes of the Young From Type 1 and Type 2 Diabetes in the Chinese Population. Endocr Pract 2021; 27:776-782. [PMID: 33991656 DOI: 10.1016/j.eprac.2021.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/03/2021] [Accepted: 05/04/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Genetic detection for the diagnosis of maturity-onset diabetes of the young (MODY) in China has low sensitivity and specificity. Better gene detection is urgently needed to distinguish testing subjects. We proposed to use numerous and weighted clinical traits as key indicators for reasonable genetic testing to predict the probability of MODY in the Chinese population. METHODS We created a prediction model based on data from 306 patients, including 140 patients with MODY, 84 patients with type 1 diabetes (T1D), and 82 patients with type 2 diabetes (T2D). This model was evaluated using receiver operating characteristic curves. RESULTS Compared with patients with T1D, patients with MODY had higher C-peptide levels and negative antibodies, and most patients with MODY had a family history of diabetes. Different from T2D, MODY was characterized by lower body mass index and younger diagnostic age. A clinical prediction model was established to define the comprehensive probability of MODY by a weighted consolidation of the most distinguishing features, and the model showed excellent discrimination (areas under the curve of 0.916 in MODY vs T1D and 0.942 in MODY vs T2D). Further, high-sensitivity C-reactive protein, glycated hemoglobin A1c, 2-h postprandial glucose, and triglyceride were used as indicators for glucokinase-MODY, while triglyceride, high-sensitivity C-reactive protein, and hepatocellular adenoma were used as indicators for hepatocyte nuclear factor 1-α MODY. CONCLUSION We developed a practical prediction model that could predict the probability of MODY and provide information to identify glucokinase-MODY and hepatocyte nuclear factor 1-α MODY. These results provide an advanced and more reasonable process to identify the most appropriate patients for genetic testing.
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Affiliation(s)
- Junling Fu
- Department of Endocrinology, Key Laboratory of Endocrinology of the Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China; Department of Endocrinology, Beijing Institute of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Fan Ping
- Department of Endocrinology, Key Laboratory of Endocrinology of the Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Tong Wang
- Department of Endocrinology, Key Laboratory of Endocrinology of the Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Yiwen Liu
- Department of Endocrinology, Key Laboratory of Endocrinology of the Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Xiaojing Wang
- Department of Endocrinology, Key Laboratory of Endocrinology of the Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Jie Yu
- Department of Endocrinology, Key Laboratory of Endocrinology of the Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Mingqun Deng
- Department of Endocrinology, Key Laboratory of Endocrinology of the Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Jieying Liu
- Department of Endocrinology, Key Laboratory of Endocrinology of the Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Qian Zhang
- Department of Endocrinology, Key Laboratory of Endocrinology of the Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Miao Yu
- Department of Endocrinology, Key Laboratory of Endocrinology of the Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Ming Li
- Department of Endocrinology, Key Laboratory of Endocrinology of the Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Yuxiu Li
- Department of Endocrinology, Key Laboratory of Endocrinology of the Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Xinhua Xiao
- Department of Endocrinology, Key Laboratory of Endocrinology of the Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China.
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Affiliation(s)
- Miriam S Udler
- From the Departments of Medicine (M.S.U., C.E.P.) and Pathology (C.A.A.-T.), Massachusetts General Hospital, and the Departments of Medicine (M.S.U., C.E.P.) and Pathology (C.A.A.-T.), Harvard Medical School - both in Boston
| | - Camille E Powe
- From the Departments of Medicine (M.S.U., C.E.P.) and Pathology (C.A.A.-T.), Massachusetts General Hospital, and the Departments of Medicine (M.S.U., C.E.P.) and Pathology (C.A.A.-T.), Harvard Medical School - both in Boston
| | - Christina A Austin-Tse
- From the Departments of Medicine (M.S.U., C.E.P.) and Pathology (C.A.A.-T.), Massachusetts General Hospital, and the Departments of Medicine (M.S.U., C.E.P.) and Pathology (C.A.A.-T.), Harvard Medical School - both in Boston
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