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Velagala VR, Velagala NR, Singh A, Kumar T, Thakre S, Lamture Y. Immunological Nuances and Complications of Pediatric Organ Transplant: A Narrative Review. Cureus 2023; 15:e46309. [PMID: 37916238 PMCID: PMC10616683 DOI: 10.7759/cureus.46309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/01/2023] [Indexed: 11/03/2023] Open
Abstract
Organ transplantation is considered an exaggerated immune state in which the body reacts in an elaborate cascade of reactions against the lifesaving graft transplanted. Unrepairable organ damage is the main indication for a pediatric patient to undergo a transplant. The host and the donor must fulfill the criteria for a successful transplant to have as few side effects as possible. There has been much-needed research in the domain of surgery of organ transplantation, thereby extending into the pediatric age group. This article elaborates on the post-transplant management, the immuno-biochemistry aspect, and its post-surgery treatment. The post-surgery period requires great emphasis as morbidity and mortality are highest. There is much to understand about managing transplant patients to avoid complications such as infections, hypertension, or side effects of immunosuppressive drugs. The treating clinician faces the challenges of managing the dose and frequency of immuno-suppressive medicines to prevent complications in the patients. If the dose is inadequate, there are chances of graft rejection. If the immuno-suppression is prolonged, there may be chances of infections in the patient. This article aims to summarize the mechanism of graft rejection and put forth the need for further research about creating a universal protocol for managing a patient's immune system post-transplant. The authors hope this protocol will help the clinician better understand the patient's current state and help in appropriately using immuno-suppressive drugs. It calls upon the need for a reliable and easily repeatable battery of investigations that will help solve this dilemma.
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Affiliation(s)
- Vivek R Velagala
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Namrata R Velagala
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Arihant Singh
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Tanishq Kumar
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Swedaj Thakre
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Yashwant Lamture
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Gago‐Sánchez AI, Font P, Cárdenas M, Aumente MD, Del Prado JR, Calleja MÁ. Real clinical impact of drug-drug interactions of immunosuppressants in transplant patients. Pharmacol Res Perspect 2021; 9:e00892. [PMID: 34755493 PMCID: PMC8578873 DOI: 10.1002/prp2.892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/23/2021] [Indexed: 11/27/2022] Open
Abstract
The main objective was to determine the prevalence of real drug-drug interactions (DDIs) of immunosuppressants in transplant patients. We conducted a prospective, observational 1-year study at a tertiary hospital, including all transplanted patients. We evaluated data from monitoring blood concentrations of immunosuppressive drugs and adverse drug events (ADEs) caused by DDIs. The DDIs were classified as C, D, or X according to their Lexi-Interact rating (C = monitor therapy, D = consider therapy modification, X = avoid combination). The clinical importance of real DDIs was expressed in terms of patient outcomes. The causality of DDIs was determined using Drug Interaction Probability Scale. The data were analyzed using Statistical Package for Social Sciences v. 25.0. A total of 309 transplant patients were included. Their mean age was 52.0 ± 14.7 years (18-79) and 69.9% were male. The prevalence of real DDIs was 21.7%. Immunosuppressive drugs administered with antifungal azoles and tacrolimus (TAC) with nifedipine have a great clinical impact. Real DDIs caused ADEs in 22 patients. The most common clinical outcome was nephrotoxicity (1.6%; n = 5), followed by hypertension (1.3%; n = 4). Suggestions for avoiding category D and X DDIs included: changing the immunosuppressant dosage, using paracetamol instead of non-steroidal anti-inflammatory drugs, and interrupting atorvastatin. The number of drugs prescribed and having been prescribed TAC was associated with an increased risk of real DDIs. There are many potential DDIs described in the literature but only a small percentage proved to be real DDIs, based on the patients´ outcomes.
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Affiliation(s)
- Ana Isabel Gago‐Sánchez
- Pharmacy DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
| | - Pilar Font
- Rheumatology DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
| | - Manuel Cárdenas
- Pharmacy DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
| | - María Dolores Aumente
- Pharmacy DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
| | - José Ramón Del Prado
- Pharmacy DepartmentHospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/University of CórdobaCórdobaSpain
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Katz DT, Torres NS, Chatani B, Gonzalez IA, Chandar J, Miloh T, Rusconi P, Garcia J. Care of Pediatric Solid Organ Transplant Recipients: An Overview for Primary Care Providers. Pediatrics 2020; 146:peds.2020-0696. [PMID: 33208494 DOI: 10.1542/peds.2020-0696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 11/24/2022] Open
Abstract
As the number of living pediatric solid organ transplant (SOT) recipients continues to grow, there is an increased likelihood that primary care providers (PCPs) will encounter pediatric SOT recipients in their practices. In addition, as end-stage organ failure is replaced with chronic medical conditions in transplant recipients, there is a need for a comprehensive approach to their management. PCPs can significantly enhance the care of immunosuppressed hosts by advising parents of safety considerations and avoiding adverse drug interactions. Together with subspecialty providers, PCPs are responsible for ensuring that appropriate vaccinations are given and can play an important role in the diagnosis of infections. Through early recognition of rejection and posttransplant complications, PCPs can minimize morbidity. Growth and development can be optimized through frequent assessments and timely referrals. Adherence to immunosuppressive regimens can be greatly improved through reinforcement at every encounter, particularly among adolescents. PCPs can also improve long-term outcomes by easing the transition of pediatric SOT recipients to adult providers. Although guidelines exist for the primary care management of adult SOT recipients, comprehensive guidance is lacking for pediatric providers. In this evidence-based overview, we outline the main issues affecting pediatric SOT recipients and provide guidance for PCPs regarding their management from the first encounter after the transplant to the main challenges that arise in childhood and adolescence. Overall, PCPs can and should use their expertise and serve as an additional layer of support in conjunction with the transplant center for families that are caring for a pediatric SOT recipient.
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Affiliation(s)
- Daphna T Katz
- Holtz Children's Hospital, Jackson Health System, Miami, Florida.,Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida; and
| | - Nicole S Torres
- Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida; and
| | | | | | - Jayanthi Chandar
- Pediatric Nephrology.,Miami Transplant Institute, Miami, Florida
| | - Tamir Miloh
- Miami Transplant Institute, Miami, Florida.,Pediatric Gastroenterology, and
| | - Paolo Rusconi
- Miami Transplant Institute, Miami, Florida.,Pediatric Cardiology
| | - Jennifer Garcia
- Miami Transplant Institute, Miami, Florida .,Pediatric Gastroenterology, and
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Famure O, Caballero MN, Li A, Tang R, Chen PX, Ashwin M, Adcock L, Schiff J, Kim SJ. A Gap Analysis Assessing the Perceptions of Primary Care Physicians in the Management of Kidney Recipients After Transplantation. Prog Transplant 2019; 29:309-315. [PMID: 31510872 DOI: 10.1177/1526924819873911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To examine the practice patterns and perceptions of primary care physicians in the management of chronic diseases in kidney recipients, assess care provided to recipients, and identify barriers to the optimal delivery of primary care to recipients. METHODS A self-administered questionnaire on the primary care of kidney recipients was developed and implemented. The survey investigated physician comfort and practice patterns in providing preventive and chronic care to recipients, patient self-management support, and physician perceptions on communication with transplant centers and barriers to ideal care. RESULTS A total of 210 physicians completed the survey (response rate of 22%). Among the respondents, 73% indicated they were currently providing care to kidney recipients. The majority of physicians specified that they rarely (57%) or never (20%) communicate with transplant centers. Most physicians felt comfortable providing care to recipients for non-transplant-related issues (92.5%), vaccinations (85%), and periodic health examinations (94%). The majority (75.3%) of physicians felt uncomfortable managing the immunosuppressive medications of recipients. Physicians' most commonly stated barriers to delivering optimal care to recipients were insufficient guidelines provided by the transplant center (68.9%) and lack of knowledge in managing recipients (58.8%). Suggested resources by physicians to improve their comfort level in managing recipients included guidelines and continuing medical educational activities related to transplantation. CONCLUSIONS Our results suggest that there are barriers to delivering optimal primary care to kidney recipients. The approach to providing resources needed to bridge the knowledge gap for physicians in the management of recipients requires further exploration.
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Affiliation(s)
- Olusegun Famure
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Myra N Caballero
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Anna Li
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada.,Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Rosalind Tang
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Pei Xuan Chen
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Monika Ashwin
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Leslie Adcock
- Family Health Team, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey Schiff
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - S Joseph Kim
- Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada.,Division of Nephrology and the Renal Transplant Program, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Rotshild V, Azoulay L, Zarifeh M, Masarwa R, Hirsh-Raccah B, Perlman A, Muszkat M, Matok I. The Risk for Lung Cancer Incidence with Calcium Channel Blockers: A Systematic Review and Meta-Analysis of Observational Studies. Drug Saf 2018; 41:555-564. [PMID: 29484611 DOI: 10.1007/s40264-018-0644-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION There are conflicting findings regarding the association between the use of calcium channel blockers (CCBs) and the risk of lung cancer. Considering the public health importance of lung cancer prevention, and emerging evidence of a significant biologic role of calcium channel regulation in the development of lung cancer, we conducted a meta-analysis to assess the risk of lung cancer in CCB users compared with non-CCB users. MATERIALS AND METHODS We conducted a comprehensive systematic search of leading medical databases for observational studies published up to December 2017 that examined CCB use and the risk of lung cancer. We used random-effects models to pool results. The impact of duration of CCB use on the estimated effect size was explored using random effects meta-regression. RESULTS Ten studies (six cohort and four case-control studies) that evaluated the overall cancer risk among 38,758 CCB users were included in the analysis. Overall risk ratio (RR) for CCB use and lung cancer was 1.15 (95% confidence interval [CI] 1.01-1.32). Subgroup analysis by duration of CCB use suggested that the observed increase in lung cancer risk was driven by the results of five studies with prolonged (≥ 4 years) exposure (RR 1.18; 95% CI 1.08-1.30). CONCLUSIONS Our analysis suggests exposure to CCBs is associated with an increased risk of lung cancer. Considering their widespread use, and the paucity of data on the long-term effects of chronic exposure to CCBs, these results are reason for concern and warrant further investigation. SYSTEMATIC REVIEW REGISTRATION The protocol for this study was registered at the PROSPERO registry of systematic reviews (registry number: CRD42017056362).
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Affiliation(s)
- Victoria Rotshild
- Pharmacoepidemiology Research Lab, Division of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Institute for Drug Research, the Hebrew University of Jerusalem, P.O.B 12065, 9112001, Jerusalem, Israel
| | - Laurent Azoulay
- Department of Epidemiology, Biostatistics, and Occupational Health, Centre for Clinical Epidemiology, Jewish General Hospital, Lady Davis Institute, Montreal, Canada.,Gerald Bronfman Department of Oncology, McGill University, Montreal, Canada
| | - Majd Zarifeh
- Hadassah Braun School of Public and Community Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Reem Masarwa
- Pharmacoepidemiology Research Lab, Division of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Institute for Drug Research, the Hebrew University of Jerusalem, P.O.B 12065, 9112001, Jerusalem, Israel
| | - Bruria Hirsh-Raccah
- Pharmacoepidemiology Research Lab, Division of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Institute for Drug Research, the Hebrew University of Jerusalem, P.O.B 12065, 9112001, Jerusalem, Israel
| | - Amichai Perlman
- Pharmacoepidemiology Research Lab, Division of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Institute for Drug Research, the Hebrew University of Jerusalem, P.O.B 12065, 9112001, Jerusalem, Israel
| | - Mordechai Muszkat
- Department of Medicine, Hadassah University Hospital Mt. Scopus, Jerusalem, Israel
| | - Ilan Matok
- Pharmacoepidemiology Research Lab, Division of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Institute for Drug Research, the Hebrew University of Jerusalem, P.O.B 12065, 9112001, Jerusalem, Israel.
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Wlodarczyk E, Wlodarczyk Z, Paczek L, Szymanska A, Glyda M, Adamowicz A, Baczyk G, Ulatowska A. Holistic Long-Term Care Over Elderly Kidney Transplant Recipients. Transplant Proc 2018; 50:1900-1903. [PMID: 30056925 DOI: 10.1016/j.transproceed.2018.04.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 04/10/2018] [Accepted: 04/24/2018] [Indexed: 10/17/2022]
Abstract
Kidney transplantation is an optimal method of renal replacement therapy in patients with phase V chronic kidney disease. Elderly patients (older than 60 years) with a kidney transplant create a significant and constantly growing pool of patients with this type of organ transplantation. In this group of patients, long-term care should be particularly stringent and vigilant. Apart from typical conditions associated with chronic kidney disease and possible post-transplant complications as well as side effects of immunosuppressive treatment, the patient also experiences changes and limitations associated with the progress of age and diseases typical for old age, characterized by a higher risk of infection, and changed pharmacokinetics/pharmacodynamics. Undoubtedly, patients should remain under the medical care of qualified transplantologists, but constant cooperation with a general practitioner and geriatrician would be of added value. Study results show that although most of the elderly kidney recipients have constant contact with their general practitioners, and almost half of them use private care, contribution of the geriatrician to the transplant care system is unsatisfactory, and elderly kidney recipients would expect more extensive outpatient care.
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Affiliation(s)
- E Wlodarczyk
- Department of Geriatrics, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Z Wlodarczyk
- Department of Transplantology and General Surgery, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland.
| | - L Paczek
- Department of Immunology, Transplantology and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - A Szymanska
- Department of Immunology, Transplantology and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - M Glyda
- Department of Transplantology and General Surgery, Poznan District Hospital, Poznan, Poland
| | - A Adamowicz
- Department of Transplantology and General Surgery, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - G Baczyk
- Faculty of Nursing, Poznan Medical University, Poznan, Poland
| | - A Ulatowska
- Faculty of Nursing, Poznan Medical University, Poznan, Poland
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Parikh S, Karaa A, Goldstein A, Ng YS, Gorman G, Feigenbaum A, Christodoulou J, Haas R, Tarnopolsky M, Cohen BK, Dimmock D, Feyma T, Koenig MK, Mundy H, Niyazov D, Saneto RP, Wainwright MS, Wusthoff C, McFarland R, Scaglia F. Solid organ transplantation in primary mitochondrial disease: Proceed with caution. Mol Genet Metab 2016; 118:178-184. [PMID: 27312126 DOI: 10.1016/j.ymgme.2016.04.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 04/18/2016] [Accepted: 04/18/2016] [Indexed: 01/02/2023]
Abstract
Solid organ transplants are rarely performed in both adult and pediatric patients with primary mitochondrial disease. Poor outcomes have been described in case reports and small case series. It is unclear whether the underlying genetic disease has a significant impact on post-transplant morbidity and mortality. Data were obtained for 35 patients from 17 Mitochondrial Disease Centers across North America, the United Kingdom and Australia. Patient outcomes were noted after liver, kidney or heart transplantation. Excluding patients with POLG-related disease, post-transplant survival approached or met outcomes seen in non-mitochondrial disease transplant patients. The majority of mitochondrial disease patients did not have worsening of their mitochondrial disease within 90-days post-transplant. Post-transplant complications, including organ rejection, were not a common occurrence and were generally treatable. Many patients did not have a mitochondrial disease considered or diagnosed prior to transplantation. In conclusion, patients with mitochondrial disease in this cohort generally tolerated solid-organ transplantation. Such patients may not need to be excluded from transplant solely for their mitochondrial diagnosis; additional caution may be needed for patients with POLG-related disease. Transplant teams should be aware of mitochondrial disease as an etiology for organ-failure and consider appropriate consultation in patients without a known cause of their symptoms.
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Affiliation(s)
- Sumit Parikh
- Neurogenetics & Mitochondrial Disease, Center for Pediatric Neurology, Cleveland Clinic, Cleveland, OH, United States.
| | - Amel Karaa
- Department of Medical Genetics, Massachusetts General Hospital, Boston, MA, United States
| | - Amy Goldstein
- Center for Pediatric Neurology, Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Yi S Ng
- Wellcome Trust Centre for Mitochondrial Research, Newcastle University, Newcastle upon Tyne, UK
| | - Grainne Gorman
- Wellcome Trust Centre for Mitochondrial Research, Newcastle University, Newcastle upon Tyne, UK
| | - Annette Feigenbaum
- Department of Medical Genetics, Rady Children's Hospital, San Diego, CA, United States
| | - John Christodoulou
- Western Sydney Genetics Program, Children's Hospital at Westmead, Sydney and Disciplines of Paediatrics and Child Health and Genetic Medicine, University of Sydney, Sydney, Australia
| | - Richard Haas
- Department of Pediatric Neurology, Rady Children's Hospital, San Diego, CA, United States
| | - Mark Tarnopolsky
- Department of Pediatrics, Division of Neuromuscular and Neurometabolic Disease, McMaster University, Hamilton, ON, Canada
| | - Bruce K Cohen
- Department of Pediatric Neurology, Akron Children's Hospital, Akron, OH, United States
| | - David Dimmock
- Department of Medical Genetics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Tim Feyma
- Department of Pediatric Neurology, Gillette Children's Specialty Healthcare, St. Paul, MN, United States
| | - Mary K Koenig
- Department of Pediatrics, Division of Child & Adolescent Neurology, The University of Texas Medical School at Houston, Houston, TX, United States
| | - Helen Mundy
- Pediatric Metabolism, Evelina London Children's Healthcare, London, UK
| | - Dmitriy Niyazov
- Division of Medical Genetics, Department of Pediatrics, Ochsner Clinic Foundation, New Orleans, LA, United States
| | - Russell P Saneto
- Department of Pediatric Neurology, Seattle Children's Hospital, Seattle, WA, United States
| | - Mark S Wainwright
- Department of Pediatrics, Division of Neurology, Lurie Children's Hospital, Chicago, IL, United States
| | - Courtney Wusthoff
- Department of Pediatric Neurology, Lucile Packard Children's Hospital, Palo Alto, CA, United States
| | - Robert McFarland
- Wellcome Trust Centre for Mitochondrial Research, Newcastle University, Newcastle upon Tyne, UK
| | - Fernando Scaglia
- Department of Molecular and Human Genetics, Baylor College of Medicine, Baylor, TX, United States
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