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Al‐Amrani F, Al‐Thihli K, Al‐Ajmi E, Al‐Futaisi A, Al‐Murshedi F. Transient response to high-dose niacin therapy in a patient with NAXE deficiency. JIMD Rep 2024; 65:212-225. [PMID: 38974613 PMCID: PMC11224503 DOI: 10.1002/jmd2.12425] [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: 02/02/2024] [Revised: 04/06/2024] [Accepted: 04/22/2024] [Indexed: 07/09/2024] Open
Abstract
Background NAXE-encephalopathy or early-onset progressive encephalopathy with brain edema and/or leukoencephalopathy-1 (PEBEL-1) and NAXD-encephalopathy (PEBEL-2) have been described recently as mitochondrial disorders causing psychomotor regression, hypotonia, ataxia, quadriparesis, ophthalmoparesis, respiratory insufficiency, encephalopathy, and seizures with the onset being usually within the first three years of life. It usually leads to rapid disease progression and death in early childhood. Anecdotal reports suggest that niacin, through its role in nicotinamide adenine dinucleotinde (NAD) de novo synthesis, corrects biochemical derangement, and slows down disease progression. Reports so far have supported this observation. Methods We describe a patient with a confirmed PEBEL-1 diagnosis and report his clinical response to niacin therapy. Moreover, we systematically searched the literature for PEBEL-1 and PEBEL-2 patients treated with niacin and details about response to treatment and clinical data were reviewed. Furthermore, we are describing off-label use of a COX2 inhibitor to treat niacin-related urticaria in NAXE-encephalopathy. Results So far, seven patients with PEBEL-1 and PEBEL-2 treated with niacin were reported, and all patients showed a good response for therapy or stabilization of symptoms. We report a patient exhibiting PEBEL-1 with an unfavorable outcome despite showing initial stabilization and receiving the highest dose of niacin reported to date. Niacin therapy failed to halt disease progression or attain stabilization of the disease in this patient. Conclusion Despite previous positive results for niacin supplementation in patients with PEBEL-1 and PEBEL-2, this is the first report of a patient with PEBEL-1 who deteriorated to fatal outcome despite being started on the highest dose of niacin therapy reported to date.
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Affiliation(s)
- Fatema Al‐Amrani
- Pediatric Neurology Unit, Department of Child HealthSultan Qaboos University Hospital, Sultan Qaboos UniversityMuscatSultanate of Oman
| | - Khalid Al‐Thihli
- Genetic and Developmental Medicine Clinic, Department of GeneticsSultan Qaboos University Hospital, Sultan Qaboos UniversityMuscatSultanate of Oman
| | - Eiman Al‐Ajmi
- Department of Radiology and Molecular ImagingSultan Qaboos University Hospital, Sultan Qaboos UniversityMuscatSultanate of Oman
| | - Amna Al‐Futaisi
- Department of Child HealthCollege of Medicine and Health Sciences, Sultan Qaboos UniversityMuscatSultanate of Oman
| | - Fathiya Al‐Murshedi
- Genetic and Developmental Medicine Clinic, Department of GeneticsSultan Qaboos University Hospital, Sultan Qaboos UniversityMuscatSultanate of Oman
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Garg D, Sharma S, Mohammad SS, Prasad AN. Editorial: Movement disorders in neurometabolic conditions. Front Neurol 2024; 15:1397998. [PMID: 38585363 PMCID: PMC10995242 DOI: 10.3389/fneur.2024.1397998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/12/2024] [Indexed: 04/09/2024] Open
Affiliation(s)
- Divyani Garg
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Suvasini Sharma
- Department of Pediatrics (Neurology Division), Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
| | - Shekeeb S Mohammad
- Children's Hospital at Westmead, University of Sydney, Sydney, NSW, Australia
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Almudhry M, Prasad C, Rupar CA, Tay KY, Prasad AN. Long-term follow-up of an attenuated presentation of NAXE-related disease, a potentially actionable neurometabolic disease: a case report. Front Neurol 2024; 15:1204848. [PMID: 38419707 PMCID: PMC10899487 DOI: 10.3389/fneur.2024.1204848] [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: 04/12/2023] [Accepted: 01/24/2024] [Indexed: 03/02/2024] Open
Abstract
Background Early-onset progressive encephalopathy with brain edema and/or leukoencephalopathy (PEBEL-1) is an autosomal recessive disorder whereby a fluctuating clinical course is exacerbated by febrile illnesses. Pathogenic NAD(P)HX epimerase (NAXE) gene mutations underpin this disorder. This mutation damages the metabolite repair system involved in regenerating crucial redox carriers. Longer survival has rarely been reported in this potentially actionable entity. Objectives This case study aims to report a milder phenotype of a patient with NAXE gene mutation and his longitudinal follow-up of more than 20 years. Case report A 24-year-old man first became symptomatic in infancy with frequent initial neurological decompensations in the setting of infections with subsequent clinical improvement followed by stability with residual cerebellar dysfunction. Clinical features noted over the years include chronic ataxia, nystagmus, ptosis, mild spasticity of lower limbs, and neuropsychiatric symptoms. Cerebellar and spinal cord atrophy were noted in cranial and spinal MR imaging. Biallelic homozygous variants in the NAXE gene (c.733 A>C) were identified on whole exome sequencing. Symptom management included the initiation of a mitochondrial cocktail with carnitine, coenzyme Q, and thiamine. Subsequently, niacin (Vitamin B3), which is involved in the cellular biosynthesis of NAD+, was added, given its potentially beneficial therapeutic impact. Conclusion A missense homozygous variant in the NAXE gene is described in this patient with a milder clinical phenotype of the disease. Supplementation with niacin in addition to a mitochondrial cocktail presents a potential supportive therapeutic option to reduce disease progression.
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Affiliation(s)
- Montaha Almudhry
- London Health Sciences Centre and Western University, London, ON, Canada
- Department of Neuroscience, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Chitra Prasad
- London Health Sciences Centre and Western University, London, ON, Canada
- Department of Pediatrics, Section of Genetics and Metabolism, Western University, London, ON, Canada
| | - C Anthony Rupar
- London Health Sciences Centre and Western University, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London, ON, Canada
| | - Keng Yeow Tay
- London Health Sciences Centre and Western University, London, ON, Canada
- Department of Medical Imaging, Western University, London, ON, Canada
| | - Asuri N Prasad
- London Health Sciences Centre and Western University, London, ON, Canada
- Departments of Pediatrics and Pediatric Neurology, Western University, London, ON, Canada
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Choi S, Choi SH, Bastola T, Park Y, Oh J, Kim KY, Hwang S, Miller YI, Ju WK. AIBP: A New Safeguard against Glaucomatous Neuroinflammation. Cells 2024; 13:198. [PMID: 38275823 PMCID: PMC10814024 DOI: 10.3390/cells13020198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/18/2024] [Accepted: 01/20/2024] [Indexed: 01/27/2024] Open
Abstract
Glaucoma is a group of ocular diseases that cause irreversible blindness. It is characterized by multifactorial degeneration of the optic nerve axons and retinal ganglion cells (RGCs), resulting in the loss of vision. Major components of glaucoma pathogenesis include glia-driven neuroinflammation and impairment of mitochondrial dynamics and bioenergetics, leading to retinal neurodegeneration. In this review article, we summarize current evidence for the emerging role of apolipoprotein A-I binding protein (AIBP) as an important anti-inflammatory and neuroprotective factor in the retina. Due to its association with toll-like receptor 4 (TLR4), extracellular AIBP selectively removes excess cholesterol from the plasma membrane of inflammatory and activated cells. This results in the reduced expression of TLR4-associated, cholesterol-rich lipid rafts and the inhibition of downstream inflammatory signaling. Intracellular AIBP is localized to mitochondria and modulates mitophagy through the ubiquitination of mitofusins 1 and 2. Importantly, elevated intraocular pressure induces AIBP deficiency in mouse models and in human glaucomatous retina. AIBP deficiency leads to the activation of TLR4 in Müller glia, triggering mitochondrial dysfunction in both RGCs and Müller glia, and compromising visual function in a mouse model. Conversely, restoring AIBP expression in the retina reduces neuroinflammation, prevents RGCs death, and protects visual function. These results provide new insight into the mechanism of AIBP function in the retina and suggest a therapeutic potential for restoring retinal AIBP expression in the treatment of glaucoma.
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Affiliation(s)
- Seunghwan Choi
- Hamilton Glaucoma Center and Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, CA 92093, USA; (S.C.); (T.B.); (Y.P.)
| | - Soo-Ho Choi
- Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Tonking Bastola
- Hamilton Glaucoma Center and Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, CA 92093, USA; (S.C.); (T.B.); (Y.P.)
| | - Younggun Park
- Hamilton Glaucoma Center and Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, CA 92093, USA; (S.C.); (T.B.); (Y.P.)
- Department of Ophthalmology and Visual Science, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Jonghyun Oh
- Hamilton Glaucoma Center and Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, CA 92093, USA; (S.C.); (T.B.); (Y.P.)
- Department of Ophthalmology, Dongguk University Ilsan Hospital, Goyang 10326, Republic of Korea
| | - Keun-Young Kim
- National Center for Microscopy and Imaging Research, Department of Neurosciences, University of California San Diego, La Jolla, CA 92093, USA
| | - Sinwoo Hwang
- Hamilton Glaucoma Center and Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, CA 92093, USA; (S.C.); (T.B.); (Y.P.)
| | - Yury I. Miller
- Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Won-Kyu Ju
- Hamilton Glaucoma Center and Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, CA 92093, USA; (S.C.); (T.B.); (Y.P.)
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Calame DG, Emrick LT. Functional genomics and small molecules in mitochondrial neurodevelopmental disorders. Neurotherapeutics 2024; 21:e00316. [PMID: 38244259 PMCID: PMC10903096 DOI: 10.1016/j.neurot.2024.e00316] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/16/2023] [Accepted: 01/02/2024] [Indexed: 01/22/2024] Open
Abstract
Mitochondria are critical for brain development and homeostasis. Therefore, pathogenic variation in the mitochondrial or nuclear genome which disrupts mitochondrial function frequently results in developmental disorders and neurodegeneration at the organismal level. Large-scale application of genome-wide technologies to individuals with mitochondrial diseases has dramatically accelerated identification of mitochondrial disease-gene associations in humans. Multi-omic and high-throughput studies involving transcriptomics, proteomics, metabolomics, and saturation genome editing are providing deeper insights into the functional consequence of mitochondrial genomic variation. Integration of deep phenotypic and genomic data through allelic series continues to uncover novel mitochondrial functions and permit mitochondrial gene function dissection on an unprecedented scale. Finally, mitochondrial disease-gene associations illuminate disease mechanisms and thereby direct therapeutic strategies involving small molecules and RNA-DNA therapeutics. This review summarizes progress in functional genomics and small molecule therapeutics in mitochondrial neurodevelopmental disorders.
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Affiliation(s)
- Daniel G Calame
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA.
| | - Lisa T Emrick
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
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Van Bergen NJ, Gunanayagam K, Bournazos AM, Walvekar AS, Warmoes MO, Semcesen LN, Lunke S, Bommireddipalli S, Sikora T, Patraskaki M, Jones DL, Garza D, Sebire D, Gooley S, McLean CA, Naidoo P, Rajasekaran M, Stroud DA, Linster CL, Wallis M, Cooper ST, Christodoulou J. Severe NAD(P)HX Dehydratase (NAXD) Neurometabolic Syndrome May Present in Adulthood after Mild Head Trauma. Int J Mol Sci 2023; 24:ijms24043582. [PMID: 36834994 PMCID: PMC9963268 DOI: 10.3390/ijms24043582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 02/12/2023] Open
Abstract
We have previously reported that pathogenic variants in a key metabolite repair enzyme NAXD cause a lethal neurodegenerative condition triggered by episodes of fever in young children. However, the clinical and genetic spectrum of NAXD deficiency is broadening as our understanding of the disease expands and as more cases are identified. Here, we report the oldest known individual succumbing to NAXD-related neurometabolic crisis, at 32 years of age. The clinical deterioration and demise of this individual were likely triggered by mild head trauma. This patient had a novel homozygous NAXD variant [NM_001242882.1:c.441+3A>G:p.?] that induces the mis-splicing of the majority of NAXD transcripts, leaving only trace levels of canonically spliced NAXD mRNA, and protein levels below the detection threshold by proteomic analysis. Accumulation of damaged NADH, the substrate of NAXD, could be detected in the fibroblasts of the patient. In agreement with prior anecdotal reports in paediatric patients, niacin-based treatment also partly alleviated some clinical symptoms in this adult patient. The present study extends our understanding of NAXD deficiency by uncovering shared mitochondrial proteomic signatures between the adult and our previously reported paediatric NAXD cases, with reduced levels of respiratory complexes I and IV as well as the mitoribosome, and the upregulation of mitochondrial apoptotic pathways. Importantly, we highlight that head trauma in adults, in addition to paediatric fever or illness, may precipitate neurometabolic crises associated with pathogenic NAXD variants.
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Affiliation(s)
- Nicole J. Van Bergen
- Brain and Mitochondrial Research Group, Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, VIC 3002, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC 3002, Australia
- Correspondence: (N.J.V.B.); (J.C.)
| | - Karen Gunanayagam
- Department of Neurology, Royal Hobart Hospital, Hobart, TAS 7000, Australia
| | - Adam M. Bournazos
- Kids Neuroscience Centre, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
- The Children’s Medical Research Institute, 214 Hawkesbury Road, Westmead, Sydney, NSW 2145, Australia
| | - Adhish S. Walvekar
- Enzymology and Metabolism Group, Luxembourg Centre for Systems Biomedicine, University of Luxembourg, L-4367 Belvaux, Luxembourg
| | - Marc O. Warmoes
- Enzymology and Metabolism Group, Luxembourg Centre for Systems Biomedicine, University of Luxembourg, L-4367 Belvaux, Luxembourg
| | - Liana N. Semcesen
- Department of Biochemistry & Pharmacology, Bio21 Molecular Science & Biotechnology Institute, University of Melbourne, Melbourne, VIC 3002, Australia
| | - Sebastian Lunke
- Department of Paediatrics, University of Melbourne, Melbourne, VIC 3002, Australia
- Victorian Clinical Genetics Services, Royal Children’s Hospital, Melbourne, VIC 3002, Australia
| | - Shobhana Bommireddipalli
- Kids Neuroscience Centre, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
- The Children’s Medical Research Institute, 214 Hawkesbury Road, Westmead, Sydney, NSW 2145, Australia
| | - Tim Sikora
- Brain and Mitochondrial Research Group, Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, VIC 3002, Australia
| | - Myrto Patraskaki
- Enzymology and Metabolism Group, Luxembourg Centre for Systems Biomedicine, University of Luxembourg, L-4367 Belvaux, Luxembourg
| | - Dean L. Jones
- Department of Neurology, Royal Hobart Hospital, Hobart, TAS 7000, Australia
- School of Medicine, University of Tasmania, Hobart, TAS 7000, Australia
| | - Denisse Garza
- Tasmanian Clinical Genetics Service, Royal Hobart Hospital, Hobart, TAS 7000, Australia
| | - Dale Sebire
- Department of Neurology, Royal Hobart Hospital, Hobart, TAS 7000, Australia
| | - Samuel Gooley
- Department of Neurology, Royal Hobart Hospital, Hobart, TAS 7000, Australia
| | - Catriona A. McLean
- Department of Anatomical Pathology, Alfred Hospital, Melbourne, VIC 3002, Australia
| | - Parm Naidoo
- Department of Medical Imaging, Royal Hobart Hospital, Hobart, TAS 7000, Australia
| | - Mugil Rajasekaran
- Department of Medical Imaging, Royal Hobart Hospital, Hobart, TAS 7000, Australia
| | - David A. Stroud
- Brain and Mitochondrial Research Group, Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, VIC 3002, Australia
- Department of Biochemistry & Pharmacology, Bio21 Molecular Science & Biotechnology Institute, University of Melbourne, Melbourne, VIC 3002, Australia
| | - Carole L. Linster
- Enzymology and Metabolism Group, Luxembourg Centre for Systems Biomedicine, University of Luxembourg, L-4367 Belvaux, Luxembourg
| | - Mathew Wallis
- School of Medicine, University of Tasmania, Hobart, TAS 7000, Australia
- Tasmanian Clinical Genetics Service, Royal Hobart Hospital, Hobart, TAS 7000, Australia
| | - Sandra T. Cooper
- Kids Neuroscience Centre, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
- The Children’s Medical Research Institute, 214 Hawkesbury Road, Westmead, Sydney, NSW 2145, Australia
- Discipline of Child and Adolescent Health, Faculty of Health and Medicine, University of Sydney, Sydney, NSW 2006, Australia
| | - John Christodoulou
- Brain and Mitochondrial Research Group, Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, VIC 3002, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC 3002, Australia
- Victorian Clinical Genetics Services, Royal Children’s Hospital, Melbourne, VIC 3002, Australia
- Discipline of Child and Adolescent Health, Faculty of Health and Medicine, University of Sydney, Sydney, NSW 2006, Australia
- Correspondence: (N.J.V.B.); (J.C.)
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Kim JD, Zhou T, Zhang A, Li S, Gupte AA, Hamilton DJ, Fang L. AIBP Regulates Metabolism of Ketone and Lipids but Not Mitochondrial Respiration. Cells 2022; 11:cells11223643. [PMID: 36429071 PMCID: PMC9688289 DOI: 10.3390/cells11223643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022] Open
Abstract
Accumulating evidence indicates that the APOA1 binding protein (AIBP)-a secreted protein-plays a profound role in lipid metabolism. Interestingly, AIBP also functions as an NAD(P)H-hydrate epimerase to catalyze the interconversion of NAD(P)H hydrate [NAD(P)HX] epimers and is renamed as NAXE. Thus, we call it NAXE hereafter. We investigated its role in NAD(P)H-involved metabolism in murine cardiomyocytes, focusing on the metabolism of hexose, lipids, and amino acids as well as mitochondrial redox function. Unbiased metabolite profiling of cardiac tissue shows that NAXE knockout markedly upregulates the ketone body 3-hydroxybutyric acid (3-HB) and increases or trends increasing lipid-associated metabolites cholesterol, α-linolenic acid and deoxycholic acid. Paralleling greater ketone levels, ChemRICH analysis of the NAXE-regulated metabolites shows reduced abundance of hexose despite similar glucose levels in control and NAXE-deficient blood. NAXE knockout reduces cardiac lactic acid but has no effect on the content of other NAD(P)H-regulated metabolites, including those associated with glucose metabolism, the pentose phosphate pathway, or Krebs cycle flux. Although NAXE is present in mitochondria, it has no apparent effect on mitochondrial oxidative phosphorylation. Instead, we detected more metabolites that can potentially improve cardiac function (3-HB, adenosine, and α-linolenic acid) in the Naxe-/- heart; these mice also perform better in aerobic exercise. Our data reveal a new role of NAXE in cardiac ketone and lipid metabolism.
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Affiliation(s)
- Jun-dae Kim
- Center for Cardiovascular Regeneration, Department of Cardiovascular Sciences, Houston Methodist Research Institute, 6550 Fannin St., Houston, TX 77030, USA
| | - Teng Zhou
- Center for Cardiovascular Regeneration, Department of Cardiovascular Sciences, Houston Methodist Research Institute, 6550 Fannin St., Houston, TX 77030, USA
| | - Aijun Zhang
- Center for Bioenergetics, Houston Methodist Research Institute, 6550 Fannin St., Houston, TX 77030, USA
- Department of Medicine, Houston Methodist, Weill Cornell Medicine Affiliate, 6550 Fannin St., Houston, TX 77030, USA
| | - Shumin Li
- Center for Bioenergetics, Houston Methodist Research Institute, 6550 Fannin St., Houston, TX 77030, USA
| | - Anisha A. Gupte
- Center for Bioenergetics, Houston Methodist Research Institute, 6550 Fannin St., Houston, TX 77030, USA
- Department of Medicine, Houston Methodist, Weill Cornell Medicine Affiliate, 6550 Fannin St., Houston, TX 77030, USA
| | - Dale J. Hamilton
- Center for Bioenergetics, Houston Methodist Research Institute, 6550 Fannin St., Houston, TX 77030, USA
- Department of Medicine, Houston Methodist, Weill Cornell Medicine Affiliate, 6550 Fannin St., Houston, TX 77030, USA
- Weill Cornell Medical College, Cornell University, 407 E 61st St., New York, NY 10065, USA
| | - Longhou Fang
- Center for Cardiovascular Regeneration, Department of Cardiovascular Sciences, Houston Methodist Research Institute, 6550 Fannin St., Houston, TX 77030, USA
- Department of Medicine, Houston Methodist, Weill Cornell Medicine Affiliate, 6550 Fannin St., Houston, TX 77030, USA
- Weill Cornell Medical College, Cornell University, 407 E 61st St., New York, NY 10065, USA
- Correspondence: ; Tel.: +713-363-9012; Fax: +713-363-9782
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