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Grenier-Chartrand F, Taverne M, James S, Guida L, Paternoster G, Loiselet K, Beccaria K, Dangouloff-Ros V, Levy R, de Saint Denis T, Blauwblomme T, Khonsari RH, Boddaert N, Benichi S. Mobility Assessment Using Multi-Positional MRI in Children with Cranio-Vertebral Junction Anomalies. J Clin Med 2023; 12:6714. [PMID: 37959181 PMCID: PMC10650482 DOI: 10.3390/jcm12216714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 11/15/2023] Open
Abstract
OBJECTIVE This study aimed to assess the relevance of using multi-positional MRI (mMRI) to identify cranio-vertebral junction (CVJ) instability in pediatric patients with CVJ anomalies while determining objective mMRI criteria to detect this condition. MATERIAL AND METHODS Data from children with CVJ anomalies who underwent a mMRI between 2017 and 2021 were retrospectively reviewed. Mobility assessment using mMRI involved: (1) morphometric analysis using hierarchical clustering on principal component analysis (HCPCA) to identify clusters of patients by considering their mobility similarities, assessed through delta (Δ) values of occipito-cervical parameters measured on mMRI; and (2) morphological analysis based on dynamic geometric CVJ models and analysis of displacement vectors between flexion and extension. Receiver operating characteristics (ROC) curves were generated for occipito-cervical parameters to establish instability cut-off values. (3) Additionally, an anatomical qualitative analysis of the CVJ was performed to identify morphological criteria of instability. RESULTS Forty-seven patients with CVJ anomalies were included (26 females, 21 males; mean age: 10.2 years [3-18]). HCPCA identified 2 clusters: cluster №1 (stable patients, n = 39) and cluster №2 (unstable patients, n = 8). ΔpB-C2 (pB-C2 line delta) at ≥2.5 mm (AUC 0.98) and ΔBAI (Basion-axis Interval delta) ≥ 3 mm (AUC 0.97) predicted instability with 88% sensibility and 95% specificity and 88% sensitivity and 85% specificity, respectively. Geometric CVJ shape analysis differentiated patients along a continuum, from a low to a high CVJ motion that was characterized by a subluxation of C1 in the anterior direction. Qualitative analysis found correlations between instability and C2 anomalies, including fusions with C3 (body p = 0.032; posterior arch p = 0.045; inferior articular facets p = 0.012; lateral mass p = 0.029). CONCLUSIONS We identified a cluster of pediatric patients with CVJ instability among a cohort of CVJ anomalies that were characterized by morphometric parameters with corresponding cut-off values that could serve as objective mMRI criteria. These findings warrant further validation through prospective case-control studies.
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Affiliation(s)
- Flavie Grenier-Chartrand
- Department of Pediatric Neurosurgery, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France; (F.G.-C.); (S.J.); (L.G.); (G.P.); (K.B.); (T.d.S.D.); (T.B.)
- School of Medicine, Paris-Cité University, 75006 Paris, France; (K.L.); (R.H.K.); (N.B.)
- Department of Neurosurgery, Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles, CUB Hôpital Erasme, 1070 Bruxelles, Belgium
| | - Maxime Taverne
- Craniofacial Growth and Form, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France;
| | - Syril James
- Department of Pediatric Neurosurgery, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France; (F.G.-C.); (S.J.); (L.G.); (G.P.); (K.B.); (T.d.S.D.); (T.B.)
- Reference Center for Rare Diseases C-MAVEM (Chiari, Spinal Cord and Vertebral Diseases), Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France
| | - Lelio Guida
- Department of Pediatric Neurosurgery, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France; (F.G.-C.); (S.J.); (L.G.); (G.P.); (K.B.); (T.d.S.D.); (T.B.)
| | - Giovanna Paternoster
- Department of Pediatric Neurosurgery, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France; (F.G.-C.); (S.J.); (L.G.); (G.P.); (K.B.); (T.d.S.D.); (T.B.)
| | - Klervie Loiselet
- School of Medicine, Paris-Cité University, 75006 Paris, France; (K.L.); (R.H.K.); (N.B.)
- Department of Pediatric Imaging, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France;
| | - Kevin Beccaria
- Department of Pediatric Neurosurgery, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France; (F.G.-C.); (S.J.); (L.G.); (G.P.); (K.B.); (T.d.S.D.); (T.B.)
- School of Medicine, Paris-Cité University, 75006 Paris, France; (K.L.); (R.H.K.); (N.B.)
| | - Volodia Dangouloff-Ros
- School of Medicine, Paris-Cité University, 75006 Paris, France; (K.L.); (R.H.K.); (N.B.)
- Department of Pediatric Imaging, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France;
| | - Raphaël Levy
- Department of Pediatric Imaging, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France;
| | - Timothée de Saint Denis
- Department of Pediatric Neurosurgery, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France; (F.G.-C.); (S.J.); (L.G.); (G.P.); (K.B.); (T.d.S.D.); (T.B.)
- Reference Center for Rare Diseases C-MAVEM (Chiari, Spinal Cord and Vertebral Diseases), Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France
| | - Thomas Blauwblomme
- Department of Pediatric Neurosurgery, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France; (F.G.-C.); (S.J.); (L.G.); (G.P.); (K.B.); (T.d.S.D.); (T.B.)
- School of Medicine, Paris-Cité University, 75006 Paris, France; (K.L.); (R.H.K.); (N.B.)
| | - Roman Hossein Khonsari
- School of Medicine, Paris-Cité University, 75006 Paris, France; (K.L.); (R.H.K.); (N.B.)
- Craniofacial Growth and Form, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France;
- Department of Maxillofacial Surgery and Plastic Surgery, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France
| | - Nathalie Boddaert
- School of Medicine, Paris-Cité University, 75006 Paris, France; (K.L.); (R.H.K.); (N.B.)
- Department of Pediatric Imaging, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France;
| | - Sandro Benichi
- Department of Pediatric Neurosurgery, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France; (F.G.-C.); (S.J.); (L.G.); (G.P.); (K.B.); (T.d.S.D.); (T.B.)
- School of Medicine, Paris-Cité University, 75006 Paris, France; (K.L.); (R.H.K.); (N.B.)
- Reference Center for Rare Diseases C-MAVEM (Chiari, Spinal Cord and Vertebral Diseases), Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France
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Vazquez S, Dominguez JF, Das A, Soldozy S, Kinon MD, Ragheb J, Hanft SJ, Komotar RJ, Morcos JJ. Treatment of Chiari malformations with craniovertebral junction anomalies: Where do we stand today? World Neurosurg X 2023; 20:100221. [PMID: 37456684 PMCID: PMC10338356 DOI: 10.1016/j.wnsx.2023.100221] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/14/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background Chiari malformation type 1 (CM-1) is characterized by cerebellar tonsil herniation through the foramen magnum and can be associated with additional craniovertebral junction anomalies (CVJA). The pathophysiology and treatment for CM-1 with CVJA (CM-CVJA) is debated. Objective To evaluate the trends and outcomes of surgical interventions for patients with CM-CVJA. Methods A systematic review of the literature was performed to obtain articles describing surgical interventions for patients with CM-CVJA. Articles included were case series describing surgical approach; reviews were excluded. Variables evaluated included patient characteristics, approach, and postoperative outcomes. Results The initial query yielded 403 articles. Twelve articles, published between 1998-2020, met inclusion criteria. From these included articles, 449 patients underwent surgical interventions for CM-CVJA. The most common CVJAs included basilar invagination (BI) (338, 75.3%), atlantoaxial dislocation (68, 15.1%) odontoid process retroflexion (43, 9.6%), and medullary kink (36, 8.0%). Operations described included posterior fossa decompression (PFD), transoral (TO) decompression, and posterior arthrodesis with either occipitocervical fusion (OCF) or atlantoaxial fusion. Early studies described good results using combined ventral and posterior decompression. More recent articles described positive outcomes with PFD or posterior arthrodesis in combination or alone. Treatment failure was described in patients with PFD alone that later required posterior arthrodesis. Additionally, reports of treatment success with posterior arthrodesis without PFD was seen. Conclusion Patients with CM-CVJA appear to benefit from posterior arthrodesis with or without decompressive procedures. Further definition of the pathophysiology of craniocervical anomalies is warranted to identify patient selection criteria and ideal level of fixation.
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Affiliation(s)
- Sima Vazquez
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Jose F. Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Ankita Das
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Sauson Soldozy
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Merritt D. Kinon
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - John Ragheb
- Department of Neurosurgery, Brian Institute, Nicklaus Children's Hospital, Miami, FL, USA
| | - Simon J. Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Ricardo J. Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jacques J. Morcos
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Mascioli I, Iapadre G, Ingrosso D, Donato GD, Giannini C, Salpietro V, Chiarelli F, Farello G. Brain and eye involvement in McCune-Albright Syndrome: clinical and translational insights. Front Endocrinol (Lausanne) 2023; 14:1092252. [PMID: 37274327 PMCID: PMC10235602 DOI: 10.3389/fendo.2023.1092252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/10/2023] [Indexed: 06/06/2023] Open
Abstract
McCune-Albright Syndrome (MAS) is a rare mosaic (post-zygotic) genetic disorder presenting with a broad continuum clinical spectrum. MAS arises from somatic, activating mutations in the GNAS gene, which induces a dysregulated Gsα-protein signaling in several tissues and an increased production of intracellular cyclic adenosine monophosphate (cAMP). Overall, MAS is a rare disorder affecting less than 1/100,000 children and, for this reason, data establishing genotype-phenotype correlations remain limited. Affected individuals clinically present with a variable combination of fibrous dysplasia of bone (FD), extra-skeletal manifestations (including cafeí-au-lait spots) and precocious puberty which might also be associated to broad hyperfunctioning endocrinopathies, and also gastrointestinal and cardiological involvement. Central nervous system (CNS) and eye involvement in MAS are among the less frequently described complications and remain largely uncharacterized. These rare complications mainly include neurodevelopmental abnormalities (e.g., delayed motor development, cognitive and language impairment), CNS anomalies (e.g., Chiari malformation type I) and a wide array of ophthalmological abnormalities often associated with vision loss. The pathophysiological mechanisms underlying abnormal neurological development have not been yet fully elucidated. The proposed mechanisms include a deleterious impact of chronically dysregulated Gsα-protein signaling on neurological function, or a secondary (damaging) effect of (antenatal and/or early postnatal) hypercortisolism on early pre- and post-natal CNS development. In this Review, we summarize the main neurological and ophthalmological features eventually associated with the MAS spectrum, also providing a detailed overview of the potential pathophysiological mechanisms underlying these clinical complications.
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Affiliation(s)
- Ilaria Mascioli
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Giulia Iapadre
- Department of Pediatrics, University of L’Aquila, L’Aquila, Italy
| | | | - Giulio Di Donato
- Department of Pediatrics, University of L’Aquila, L’Aquila, Italy
| | - Cosimo Giannini
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | | | | | - Giovanni Farello
- Department of Pediatrics, University of L’Aquila, L’Aquila, Italy
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Sunshine KS, Elder TA, Tomei KL. Noninvasive evaluation of craniovertebral junction instability in 2 patients following Chiari decompression with rigid C-collar immobilization: illustrative cases. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE20114. [PMID: 36045931 PMCID: PMC9394172 DOI: 10.3171/case20114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The complex Chiari malformation has been identified in a subset of Chiari patients at higher risk for worsening symptoms following Chiari decompression. Although parameters such as the clivoaxial angle and the perpendicular distance of the dens to the line from the basion to the inferoposterior part of the C2 body (pBC2) have been evaluated to help with the prediction of risk, the decision to pursue an occipitocervical fusion in lower-risk patients does not come without inherent risk. OBSERVATIONS The authors present 2 patients who had symptoms of worsening ventral brainstem compression following Chiari decompression, neither of whom was categorized in the highest risk category for occipitocervical instability. In addition, neither patient had gross instability on radiographic imaging. A trial with rigid C-collar immobilization provided relief of symptoms in both patients and allowed reassurance of the likelihood of success of occipitocervical fusion. LESSONS In patients without clear radiographic instability following Chiari decompression, a C-collar trial may provide a noninvasive option for assessing the potential success of occipitocervical fusion.
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Affiliation(s)
| | - Theresa A. Elder
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Krystal L. Tomei
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
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Alexander H, Tsering D, Myseros JS, Magge SN, Oluigbo C, Sanchez CE, Keating RF. Management of Chiari I malformations: a paradigm in evolution. Childs Nerv Syst 2019; 35:1809-1826. [PMID: 31352576 DOI: 10.1007/s00381-019-04265-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/17/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE Despite decades of experience and research, the etiology and management of Chiari I malformations (CM-I) continue to raise more questions than answers. Controversy abounds in every aspect of management, including the indications, timing, and type of surgery, as well as clinical and radiographic outcomes. This review aims to outline past experiences, consolidate current evidence, and recommend directions for the future management of the Chiari I malformation. METHODS A review of recent literature on the management of CM-I in pediatric patients is presented, along with our experience in managing 1073 patients who were diagnosed with CM-I over the past two decades (1998-2018) at Children's National Medical Center (CNMC) in Washington DC. RESULTS The general trend reveals an increase in the diagnosis of CM-I at younger ages with a significant proportion of these being incidental findings (0.5-3.6%) in asymptomatic patients as well as a rise in the number of patients undergoing Chiari posterior fossa decompression surgery (PFD). The type of surgical intervention varies widely. At our institution, 104 (37%) Chiari surgeries were bone-only PFD with/without outer leaf durectomy, whereas 177 (63%) were PFD with duraplasty. We did not find a significant difference in outcomes between the PFD and PFDD groups (p = 0.59). An analysis of failures revealed a significant difference between patients who underwent tonsillar coagulation versus those whose tonsils were not manipulated (p = 0.02). CONCLUSION While the optimal surgical intervention continues to remain elusive, there is a shift away from intradural techniques in favor of a simple, extradural approach (including dural delamination) in pediatric patients due to high rates of clinical and radiographic success, along with a lower complication rate. The efficacy, safety, and necessity of tonsillar manipulation continue to be heavily contested, as evidence increasingly supports the efficacy and safety of less tonsillar manipulation, including our own experience.
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Affiliation(s)
- H Alexander
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Georgetown University School of Medicine, Washington, DC, USA
| | - D Tsering
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA
| | - J S Myseros
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - S N Magge
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - C Oluigbo
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - C E Sanchez
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA. .,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA.
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The Relationship Between Basilar Invagination and Chiari Malformation Type I: A Narrative Review. ACTA NEUROCHIRURGICA SUPPLEMENT 2019; 125:111-118. [DOI: 10.1007/978-3-319-62515-7_16] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Pan KS, Heiss JD, Brown SM, Collins MT, Boyce AM. Chiari I Malformation and Basilar Invagination in Fibrous Dysplasia: Prevalence, Mechanisms, and Clinical Implications. J Bone Miner Res 2018; 33:1990-1998. [PMID: 29924878 PMCID: PMC6218312 DOI: 10.1002/jbmr.3531] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 06/08/2018] [Accepted: 06/17/2018] [Indexed: 01/22/2023]
Abstract
Fibrous dysplasia (FD) is a mosaic disorder of benign fibro-osseous lesions, which may be associated with extraskeletal features as part of McCune-Albright syndrome (MAS). Cranial base abnormalities, including Chiari I malformation (CM1), in which the cerebellum extends below the foramen magnum, and secondary basilar invagination (BI), in which the odontoid prolapses into the posterior cranial fossa, are potentially serious complications of metabolic bone disorders. The purpose of this study was to determine the prevalence, natural history, and risk factors for CM1 and BI in patients with FD/MAS, and to determine mechanisms of cranial base deformities. Clinical and radiographic data from subjects in an FD/MAS natural history study were evaluated and compared to normal controls. In 158 patients with craniofacial FD, 10 (6.3%) cases of CM1 and 12 (7.6%) cases of BI were diagnosed. No cranial base abnormalities were identified in 10 control subjects. Craniomorphometric and volumetric analyses identified cranial constriction and cranial settling as the primary mechanisms of cranial base abnormalities, whereas intracranial hypertension was a contributing factor in a minority of subjects. Longitudinal analyses found progression of odontoid position with age, but no progression of tonsillar position. No endocrinopathies were associated with CM1. MAS endocrinopathies associated with BI included hyperthyroidism (odds ratio [OR] 12.0; 95% confidence interval [CI], 2.9 to 55.6; p < 0.01), precocious puberty (OR 5.6; 95% CI, 1.2 to 26.0; p < 0.05), and hypophosphatemia (OR 7.7; 95% CI, 1.9 to 27.0; p < 0.01). Scoliosis was associated with both CM1 (OR 4.8; 95% CI, 1.1 to 22.8; p < 0.05) and BI (OR = infinity; 95% CI, 4.7 to infinity; p < 0.01). This study successfully characterized cranial base abnormalities in FD/MAS and the pathophysiological connection between them. These findings support routine screening for cranial base abnormalities in patients with craniofacial FD, as well as aggressive management of contributory risk factors. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Kristen S Pan
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - John D Heiss
- Surgical Neurology Branch, National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Sydney M Brown
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Alison M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
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