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Wijekoon N, Gonawala L, Ratnayake P, Amaratunga D, Hathout Y, Mohan C, Steinbusch HWM, Dalal A, Hoffman EP, de Silva KRD. Duchenne Muscular Dystrophy from Brain to Muscle: The Role of Brain Dystrophin Isoforms in Motor Functions. J Clin Med 2023; 12:5637. [PMID: 37685704 PMCID: PMC10488491 DOI: 10.3390/jcm12175637] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/26/2023] [Accepted: 08/27/2023] [Indexed: 09/10/2023] Open
Abstract
Brain function and its effect on motor performance in Duchenne muscular dystrophy (DMD) is an emerging concept. The present study explored how cumulative dystrophin isoform loss, age, and a corticosteroid treatment affect DMD motor outcomes. A total of 133 genetically confirmed DMD patients from Sri Lanka were divided into two groups based on whether their shorter dystrophin isoforms (Dp140, Dp116, and Dp71) were affected: Group 1, containing patients with Dp140, Dp116, and Dp71 affected (n = 98), and Group 2, containing unaffected patients (n = 35). A subset of 52 patients (Group 1, n = 38; Group 2, n = 14) was followed for up to three follow-ups performed in an average of 28-month intervals. The effect of the cumulative loss of shorter dystrophin isoforms on the natural history of DMD was analyzed. A total of 74/133 (56%) patients encountered developmental delays, with 66/74 (89%) being in Group 1 and 8/74 (11%) being in Group 2 (p < 0.001). Motor developmental delays were predominant. The hip and knee muscular strength, according to the Medical Research Council (MRC) scale and the North Star Ambulatory Assessment (NSAA) activities, "standing on one leg R", "standing on one leg L", and "walk", declined rapidly in Group 1 (p < 0.001 In the follow-up analysis, Group 1 patients became wheelchair-bound at a younger age than those of Group 2 (p = 0.004). DMD motor dysfunction is linked to DMD mutations that affect shorter dystrophin isoforms. When stratifying individuals for clinical trials, considering the DMD mutation site and its impact on a shorter dystrophin isoform is crucial.
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Affiliation(s)
- Nalaka Wijekoon
- Interdisciplinary Center for Innovation in Biotechnology and Neuroscience, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda 10250, Sri Lanka; (N.W.); (L.G.)
- Department of Cellular and Translational Neuroscience, School for Mental Health and Neuroscience, Faculty of Health, Medicine & Life Sciences, Maastricht University, 6200 Maastricht, The Netherlands;
| | - Lakmal Gonawala
- Interdisciplinary Center for Innovation in Biotechnology and Neuroscience, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda 10250, Sri Lanka; (N.W.); (L.G.)
- Department of Cellular and Translational Neuroscience, School for Mental Health and Neuroscience, Faculty of Health, Medicine & Life Sciences, Maastricht University, 6200 Maastricht, The Netherlands;
| | | | | | - Yetrib Hathout
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Binghamton, NY 13902, USA; (Y.H.); (E.P.H.)
| | - Chandra Mohan
- Department of Bioengineering, University of Houston, Houston, TX 77204, USA;
| | - Harry W. M. Steinbusch
- Department of Cellular and Translational Neuroscience, School for Mental Health and Neuroscience, Faculty of Health, Medicine & Life Sciences, Maastricht University, 6200 Maastricht, The Netherlands;
| | - Ashwin Dalal
- Diagnostics Division, Center for DNA Fingerprinting and Diagnostics, Hyderabad 500039, India;
| | - Eric P. Hoffman
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Binghamton, NY 13902, USA; (Y.H.); (E.P.H.)
| | - K. Ranil D. de Silva
- Interdisciplinary Center for Innovation in Biotechnology and Neuroscience, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda 10250, Sri Lanka; (N.W.); (L.G.)
- Department of Cellular and Translational Neuroscience, School for Mental Health and Neuroscience, Faculty of Health, Medicine & Life Sciences, Maastricht University, 6200 Maastricht, The Netherlands;
- Institute for Combinatorial Advanced Research and Education (KDU-CARE), General Sir John Kotelawala Defence University, Ratmalana 10390, Sri Lanka
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Sirari T, Suthar R, Singh A, Prinja S, Gupta V, Malviya M, Chauhan AS, Sankhyan N. Development and economic evaluation of a patient-centered care model for children with Duchenne’s Muscular Dystrophy: A quasi-experimental study protocol (Preprint). JMIR Res Protoc 2022; 12:e42491. [PMID: 37115592 PMCID: PMC10182458 DOI: 10.2196/42491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/30/2023] [Accepted: 01/30/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) is a rare progressive muscular disease that primarily affects boys. A lack of comprehensive care for patients living with DMD is directly associated with a compromised quality of life (QoL) for those affected and their caregivers. This disease also has a huge economic impact on families as its treatment requires substantial direct, indirect, and informal care costs. OBJECTIVE This study presents a protocol developed to evaluate the feasibility and efficacy of a patient-centered care (PCC) model for children with DMD. The care model was designed with the aim to empower families, improve QoL, and reduce economic burden on their families. METHODS This study is planned as a quasi-experimental study that will enroll 70 consecutive families with boys (aged 5-15 years) with DMD visiting a tertiary care center. The study is being conducted in 2 phases (preintervention and postintervention phases, referred to as phase 1 and phase 2, respectively). During phase 1, the patients received routine care. The study is now in phase 2, with the intervention currently being administered. The intervention is based on the PCC model individualized by the intervention team. The model has a comprehensive DMD telecare component that includes teleconsultation as one of its key components to reduce in-person physician visits at the health facility. Teleconsultation is especially beneficial for late-ambulatory and nonambulatory patients. Data on economic burden are being collected for out-of-pocket expenses for both phases during in-person visits via telephone or messaging apps on a monthly basis. QoL data for patients and their primary caregivers are being collected at 3 time points (ie, time of enrollment, end of phase 1, and end of phase 2). Outcome measures are being assessed as changes in economic burden on families and changes in QoL scores. RESULTS Participant recruitment began in July 2021. The study is ongoing and expected to be completed by March 2023. The findings based on baseline data are expected to be submitted for publication in 2023. CONCLUSIONS This paper outlines a research proposal developed to study the impact of a PCC model for patients with DMD in low- and middle-income countries (LMICs). This study is expected to provide evidence of whether a multicomponent, patient-centric intervention could reduce economic burdens on families and improve their QoL. The results of this study could guide policy makers and health professionals in India and other LMICs to facilitate a comprehensive care program for patients living with DMD. The economic impact of a rare disease is an important consideration to formulate or evaluate any health policy or intervention related to new treatments and financial support schemes. TRIAL REGISTRATION Clinical Trials Registry India (ICMR-NIMS) CTRI/2021/06/034274; https://www.ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=56650. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/42491.
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Affiliation(s)
- Titiksha Sirari
- Lovely Professional University, Phagwara, India
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Renu Suthar
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amarjeet Singh
- Department of Community Medicine, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
- Community Medicine, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
| | - Shankar Prinja
- Department of Community Medicine, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishwas Gupta
- Lovely Professional University, Phagwara, India
- Symbiosis Centre for Management Studies, Noida, Uttar Pradesh, India
| | - Manisha Malviya
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Naveen Sankhyan
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Yoon JA, Park HE, Kim J, Son J, Shin YB. Cardiac and Pulmonary Management Status of Duchenne Muscular Dystrophy in South Korea Based on Data From the National Health Insurance Database. J Clin Neurol 2022; 18:522-528. [PMID: 36062769 PMCID: PMC9444560 DOI: 10.3988/jcn.2022.18.5.522] [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: 10/26/2021] [Revised: 02/14/2022] [Accepted: 02/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose The purpose of this study was to determine the cardiac and pulmonary management status of patients with Duchenne muscular dystrophy (DMD) in South Korea based on the Korean National Health Insurance database. Methods This study used data of patients with code G71.0 in the National Health Information database, and also those with the special case of code V012. Cardiac function was assessed based on whether echocardiography and 24-h electrocardiography were performed, as well as the frequency of these investigations. Furthermore, information on the use of angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), and beta blockers (BB) in the drug benefit list was checked. Medical charge records were also checked regarding the prescription of respiratory functional assessments and treatments. Results The diagnostic criteria were met by 479 patients, with 41% of these patients receiving a cardiac evaluation, 29.8% being prescribed ACEi at 14.4±3.7 years of age, 59.5% undergoing pulmonary function tests, and 42.1% received pulmonary rehabilitation. The age at receiving ventilator support was 19.4±2.7 years. The frequency of cardiac and respiratory function tests increased with age, but the interval between tests was longer than the recent DMD care recommendations. The trend of taking ACEi, ARB, and BB for cardiac management in South Korea did not change during the study analysis period. Conclusions The findings of this study will contribute to recognizing the current status and the importance of applying an anticipatory approach to cardiopulmonary function in DMD patients.
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Affiliation(s)
- Jin A Yoon
- Department of Rehabilitation Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Ho Eun Park
- Department of Rehabilitation Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jinmi Kim
- Department of Biostatistics, Clinical Trial Center, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jungmin Son
- Department of Biostatistics, Clinical Trial Center, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Yong Beom Shin
- Department of Rehabilitation Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.
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Yoon JA, Park HE, Kim J, Son J, Shin YB. Corticosteroid use and bone health management for Duchenne muscular dystrophy in South Korea. Sci Rep 2022; 12:11300. [PMID: 35788153 PMCID: PMC9253151 DOI: 10.1038/s41598-022-15510-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/24/2022] [Indexed: 11/09/2022] Open
Abstract
This study aimed to determine the current corticosteroid use and bone health management status of patients with Duchenne muscular dystrophy (DMD) in South Korea. This is a national population-based study utilized information from the databased of Korean National Health Insurance Database. Database regarding bone status, spine radiography findings, bone mineral density, and laboratory test results were obtained, as well as the proportion of patients with spine and lower limb prostheses, occurrence of scoliosis, and age at scoliosis surgery. Deflazacort dose in the ambulant group (aged < 15 years) increased by age and year. The maintenance dose of prednisolone and deflazacort for the 15-19 years group decreased by year. Among the patients, 12.47% underwent spine radiography, 23.11% underwent dual-energy X-ray absorptiometry, and 22.7% underwent vitamin D tests. Moreover, 40.9% of the patients were prescribed vitamin D at a mean age of 14.6 ± 6.1 years, while 10.22% were prescribed bisphosphonate at 17.92 ± 3.4 years. Further, 16.1% of the patients underwent posterior spinal instrumentation and fusion at 14.4 ± 2.3 years and 5.3% underwent anterior spinal instrumentation and fusion at 14.4 ± 2.3 years. Ankle-foot orthosis and spine orthosis prescriptions were noted in 4.91% and 1.84% of patients, respectively. In this our study, the current corticosteroid use and bone health management status of DMD in South Korea has been presented. The dose prescription for corticosteroid and bone health monitoring did not reach to current recommendation.
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Affiliation(s)
- Jin A Yoon
- Department of Rehabilitation Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-Ro Seo-Gu, Busan, 602-739, Republic of Korea
| | - Ho Eun Park
- Department of Rehabilitation Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-Ro Seo-Gu, Busan, 602-739, Republic of Korea
| | - Jinmi Kim
- Department of Biostatistics, Clinical Trial Center, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jungmin Son
- Department of Biostatistics, Clinical Trial Center, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Yong Beom Shin
- Department of Rehabilitation Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-Ro Seo-Gu, Busan, 602-739, Republic of Korea.
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Schiava M, Amos R, VanRuiten H, McDermott MP, Martens WB, Gregory S, Mayhew A, McColl E, Tawil R, Willis T, Bushby K, Griggs RC, Guglieri M. Clinical and Genetic Characteristics in Young, Glucocorticoid-Naive Boys With Duchenne Muscular Dystrophy. Neurology 2022; 98:e390-e401. [PMID: 34857536 PMCID: PMC8793104 DOI: 10.1212/wnl.0000000000013122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 11/16/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Duchenne muscular dystrophy (DMD) is a pediatric neuromuscular disorder caused by mutations in the dystrophin gene. Genotype-phenotype associations have been examined in glucocorticoid-treated boys, but there are few data on the young glucocorticoid-naive DMD population. A sample of young glucocorticoid-naive DMD boys is described, and genotype-phenotype associations are investigated. METHODS Screening and baseline data were collected for all the participants in the Finding the Optimum Corticosteroid Regime for Duchenne Muscular Dystrophy (FOR-DMD) study, an international, multicenter, randomized, double-blind, clinical trial comparing 3 glucocorticoid regimens in glucocorticoid-naive, genetically confirmed boys with DMD between 4 and <8 years of age. RESULTS One hundred ninety-six boys were recruited. The mean ± SD age at randomization was 5.8 ± 1.0 years. The predominant mutation type was out-of-frame deletions (67.4%, 130 of 193), of which 68.5% (89 of 130) were amenable to exon skipping. The most frequent mutations were deletions amenable to exon 51 skipping (13.0%, 25 of 193). Stop codon mutations accounted for 10.4% (20 of 193). The mean age at first parental concerns was 29.8 ± 18.7 months; the mean age at genetic diagnosis was 53.9 ± 21.9 months; and the mean diagnostic delay was 25.9 ± 18.2 months. The mean diagnostic delay for boys diagnosed after an incidental finding of isolated hyperCKemia (n = 19) was 6.4 ± 7.4 months. The mean ages at independent walking and talking in sentences were 17.1 ± 4.2 and 29.0 ± 10.7 months, respectively. Median height percentiles were below the 25th percentile regardless of age group. No genotype-phenotype associations were identified expect for boys with exon 8 skippable deletions, who had better performance on time to walk/run 10 m (p = 0.02) compared to boys with deletions not amenable to skipping. DISCUSSION This study describes clinical and genetic characteristics of a sample of young glucocorticoid-naive boys with DMD. A low threshold for creatine kinase testing can lead to an earlier diagnosis. Motor and speech delays were common presenting symptoms. The effects of low pretreatment height on growth and adult height require further study. These findings may promote earlier recognition of DMD and inform study design for future clinical trials. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov Identifier: NCT01603407.
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Affiliation(s)
- Marianela Schiava
- From the John Walton Muscular Dystrophy Research Centre (M.S., A.M., K.B., M.G.), Clinical and Translational Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trusts; Great North Children Hospital (R.A., H.V.R.), Newcastle Hospitals NHS Foundation Trusts, UK; Department of Biostatistics and Computational Biology (M.P.M.) and Department of Neurology (M.P.M., W.B.M., S.G., R.T., R.C.G.), University of Rochester Medical Centre, NY; Newcastle University (E.M.); and The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (T.W.), Oswestry, UK
| | - Rachel Amos
- From the John Walton Muscular Dystrophy Research Centre (M.S., A.M., K.B., M.G.), Clinical and Translational Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trusts; Great North Children Hospital (R.A., H.V.R.), Newcastle Hospitals NHS Foundation Trusts, UK; Department of Biostatistics and Computational Biology (M.P.M.) and Department of Neurology (M.P.M., W.B.M., S.G., R.T., R.C.G.), University of Rochester Medical Centre, NY; Newcastle University (E.M.); and The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (T.W.), Oswestry, UK
| | - Henriette VanRuiten
- From the John Walton Muscular Dystrophy Research Centre (M.S., A.M., K.B., M.G.), Clinical and Translational Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trusts; Great North Children Hospital (R.A., H.V.R.), Newcastle Hospitals NHS Foundation Trusts, UK; Department of Biostatistics and Computational Biology (M.P.M.) and Department of Neurology (M.P.M., W.B.M., S.G., R.T., R.C.G.), University of Rochester Medical Centre, NY; Newcastle University (E.M.); and The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (T.W.), Oswestry, UK
| | - Michael P McDermott
- From the John Walton Muscular Dystrophy Research Centre (M.S., A.M., K.B., M.G.), Clinical and Translational Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trusts; Great North Children Hospital (R.A., H.V.R.), Newcastle Hospitals NHS Foundation Trusts, UK; Department of Biostatistics and Computational Biology (M.P.M.) and Department of Neurology (M.P.M., W.B.M., S.G., R.T., R.C.G.), University of Rochester Medical Centre, NY; Newcastle University (E.M.); and The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (T.W.), Oswestry, UK
| | - Williams B Martens
- From the John Walton Muscular Dystrophy Research Centre (M.S., A.M., K.B., M.G.), Clinical and Translational Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trusts; Great North Children Hospital (R.A., H.V.R.), Newcastle Hospitals NHS Foundation Trusts, UK; Department of Biostatistics and Computational Biology (M.P.M.) and Department of Neurology (M.P.M., W.B.M., S.G., R.T., R.C.G.), University of Rochester Medical Centre, NY; Newcastle University (E.M.); and The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (T.W.), Oswestry, UK
| | - Stephanie Gregory
- From the John Walton Muscular Dystrophy Research Centre (M.S., A.M., K.B., M.G.), Clinical and Translational Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trusts; Great North Children Hospital (R.A., H.V.R.), Newcastle Hospitals NHS Foundation Trusts, UK; Department of Biostatistics and Computational Biology (M.P.M.) and Department of Neurology (M.P.M., W.B.M., S.G., R.T., R.C.G.), University of Rochester Medical Centre, NY; Newcastle University (E.M.); and The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (T.W.), Oswestry, UK
| | - Anna Mayhew
- From the John Walton Muscular Dystrophy Research Centre (M.S., A.M., K.B., M.G.), Clinical and Translational Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trusts; Great North Children Hospital (R.A., H.V.R.), Newcastle Hospitals NHS Foundation Trusts, UK; Department of Biostatistics and Computational Biology (M.P.M.) and Department of Neurology (M.P.M., W.B.M., S.G., R.T., R.C.G.), University of Rochester Medical Centre, NY; Newcastle University (E.M.); and The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (T.W.), Oswestry, UK
| | - Elaine McColl
- From the John Walton Muscular Dystrophy Research Centre (M.S., A.M., K.B., M.G.), Clinical and Translational Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trusts; Great North Children Hospital (R.A., H.V.R.), Newcastle Hospitals NHS Foundation Trusts, UK; Department of Biostatistics and Computational Biology (M.P.M.) and Department of Neurology (M.P.M., W.B.M., S.G., R.T., R.C.G.), University of Rochester Medical Centre, NY; Newcastle University (E.M.); and The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (T.W.), Oswestry, UK
| | - Rabi Tawil
- From the John Walton Muscular Dystrophy Research Centre (M.S., A.M., K.B., M.G.), Clinical and Translational Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trusts; Great North Children Hospital (R.A., H.V.R.), Newcastle Hospitals NHS Foundation Trusts, UK; Department of Biostatistics and Computational Biology (M.P.M.) and Department of Neurology (M.P.M., W.B.M., S.G., R.T., R.C.G.), University of Rochester Medical Centre, NY; Newcastle University (E.M.); and The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (T.W.), Oswestry, UK
| | - Tracey Willis
- From the John Walton Muscular Dystrophy Research Centre (M.S., A.M., K.B., M.G.), Clinical and Translational Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trusts; Great North Children Hospital (R.A., H.V.R.), Newcastle Hospitals NHS Foundation Trusts, UK; Department of Biostatistics and Computational Biology (M.P.M.) and Department of Neurology (M.P.M., W.B.M., S.G., R.T., R.C.G.), University of Rochester Medical Centre, NY; Newcastle University (E.M.); and The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (T.W.), Oswestry, UK
| | - Kate Bushby
- From the John Walton Muscular Dystrophy Research Centre (M.S., A.M., K.B., M.G.), Clinical and Translational Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trusts; Great North Children Hospital (R.A., H.V.R.), Newcastle Hospitals NHS Foundation Trusts, UK; Department of Biostatistics and Computational Biology (M.P.M.) and Department of Neurology (M.P.M., W.B.M., S.G., R.T., R.C.G.), University of Rochester Medical Centre, NY; Newcastle University (E.M.); and The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (T.W.), Oswestry, UK
| | - Robert C Griggs
- From the John Walton Muscular Dystrophy Research Centre (M.S., A.M., K.B., M.G.), Clinical and Translational Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trusts; Great North Children Hospital (R.A., H.V.R.), Newcastle Hospitals NHS Foundation Trusts, UK; Department of Biostatistics and Computational Biology (M.P.M.) and Department of Neurology (M.P.M., W.B.M., S.G., R.T., R.C.G.), University of Rochester Medical Centre, NY; Newcastle University (E.M.); and The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (T.W.), Oswestry, UK
| | - Michela Guglieri
- From the John Walton Muscular Dystrophy Research Centre (M.S., A.M., K.B., M.G.), Clinical and Translational Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trusts; Great North Children Hospital (R.A., H.V.R.), Newcastle Hospitals NHS Foundation Trusts, UK; Department of Biostatistics and Computational Biology (M.P.M.) and Department of Neurology (M.P.M., W.B.M., S.G., R.T., R.C.G.), University of Rochester Medical Centre, NY; Newcastle University (E.M.); and The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (T.W.), Oswestry, UK.
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