1
|
Spoto G, Ceraolo G, Butera A, Di Rosa G, Nicotera AG. Exploring the Genetic Landscape of Chorea in Infancy and Early Childhood: Implications for Diagnosis and Treatment. Curr Issues Mol Biol 2024; 46:5632-5654. [PMID: 38921008 PMCID: PMC11202702 DOI: 10.3390/cimb46060337] [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: 04/21/2024] [Revised: 06/01/2024] [Accepted: 06/02/2024] [Indexed: 06/27/2024] Open
Abstract
Chorea is a hyperkinetic movement disorder frequently observed in the pediatric population, and, due to advancements in genetic techniques, an increasing number of genes have been associated with this disorder. In genetic conditions, chorea may be the primary feature of the disorder, or be part of a more complex phenotype characterized by epileptic encephalopathy or a multisystemic syndrome. Moreover, it can appear as a persistent disorder (chronic chorea) or have an episodic course (paroxysmal chorea). Managing chorea in childhood presents challenges due to its varied clinical presentation, often involving a spectrum of hyperkinetic movement disorders alongside neuropsychiatric and multisystemic manifestations. Furthermore, during infancy and early childhood, transient motor phenomena resembling chorea occurring due to the rapid nervous system development during this period can complicate the diagnosis. This review aims to provide an overview of the main genetic causes of pediatric chorea that may manifest during infancy and early childhood, focusing on peculiarities that can aid in differential diagnosis among different phenotypes and discussing possible treatment options.
Collapse
Affiliation(s)
- Giulia Spoto
- Unit of Child Neurology and Psychiatry, Department of Biomedical Sciences, Dental Sciences & Morpho-Functional Imaging, University of Messina, 98125 Messina, Italy;
| | - Graziana Ceraolo
- Unit of Child Neurology and Psychiatry, Department of Human Pathology of the Adult and Developmental Age “Gaetano Barresi”, University of Messina, 98125 Messina, Italy;
| | - Ambra Butera
- Unit of Child Neurology and Psychiatry, Department of Chemical, Biological, Farmaceutical & Environmental Science, University of Messina, 98125 Messina, Italy;
| | - Gabriella Di Rosa
- Unit of Child Neurology and Psychiatry, Department of Biomedical Sciences, Dental Sciences & Morpho-Functional Imaging, University of Messina, 98125 Messina, Italy;
| | - Antonio Gennaro Nicotera
- Unit of Child Neurology and Psychiatry, Maternal-Infantile Department, University of Messina, 98125 Messina, Italy;
| |
Collapse
|
2
|
Garcia Ruiz PJ, Feliz LD, Feliz CE, Sanchez IL, Fernandez AA, Kelly FB, Tiebas MJT, del Val J, Vinagre IN. The enduring enigma of sporadic chorea: A single center case series. Tremor Other Hyperkinet Mov (N Y) 2023; 13:33. [PMID: 37692071 PMCID: PMC10487123 DOI: 10.5334/tohm.800] [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: 07/12/2023] [Accepted: 08/24/2023] [Indexed: 09/12/2023] Open
Abstract
Chorea can have a wide variety of causes including neurodegenerative, pharmacological, structural, metabolic, infectious, immunologic and paraneoplastic processes. We reviewed the clinical records of patients with apparently sporadic choreic movements and no relevant family history, who presented to our neurology department (Hospital Fundación Jimenez Diaz) between 1991 and 2022. We detected 38 cases of apparent sporadic chorea (ASC); Our analysis revealed 5 cases of genetic chorea (including 3 cases with Huntington's disease) while 6 cases were autoimmune/hematological; 6 drug-related chorea, 5 metabolic-vascular, 5 due to miscellaneous conditions and 4 were of mixed etiology. No clear etiology was identified in 8 cases. The differential diagnosis of ASC is extensive and challenging. Highlights Chorea can have a wide variety of genetic and sporadic causesWe reviewed the clinical records of patients with apparently sporadic chorea (ASC), who presented to our neurology department over the last 30 yearsWe detected 38 cases of apparent ASC; Our analysis revealed a wide array of different sporadic conditions and 5 cases of genetic choreaThe differential diagnosis of ASC is extensive and challenging.
Collapse
Affiliation(s)
| | - Lola Diaz Feliz
- Department of Neurology, Fundacion Jimenez Diaz, Madrid, Spain
| | - Cici E. Feliz
- Department of Neurology, Fundacion Jimenez Diaz, Madrid, Spain
| | | | | | | | | | - Javier del Val
- Department of Neurology, Fundacion Jimenez Diaz, Madrid, Spain
| | | |
Collapse
|
3
|
Menon PJ, Nilles C, Silveira‐Moriyama L, Yuan R, de Gusmao CM, Münchau A, Carecchio M, Grossman S, Grossman G, Méneret A, Roze E, Pringsheim T. Scoping Review on ADCY5-Related Movement Disorders. Mov Disord Clin Pract 2023; 10:1048-1059. [PMID: 37476318 PMCID: PMC10354615 DOI: 10.1002/mdc3.13796] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/29/2023] [Accepted: 05/04/2023] [Indexed: 07/22/2023] Open
Abstract
Background Adenylyl cyclase 5 (ADCY5)-related movement disorder (ADCY5-RMD) is a rare, childhood-onset disease resulting from pathogenic variants in the ADCY5 gene. The clinical features, diagnostic options, natural history, and treatments for this disease are poorly characterized and have never been established through a structured approach. Objective This scoping review attempts to summarize all available clinical literature on ADCY5-RMD. Methods Eighty-seven articles were selected for inclusion in this scoping review. The majority of articles identified were case reports or case series. Results These articles demonstrate that patients with ADCY5-RMD suffer from permanent and/ or paroxysmal hyperkinetic movements. The paroxysmal episodes can be worsened by environmental triggers, in particular the sleep-wake transition phase in the early morning. Occurrence of nocturnal paroxysmal dyskinesias and perioral twitches are highly suggestive of the diagnosis when present. In the majority of patients intellectual capacity is preserved. ADCY5-RMD is considered a non-progressive disorder, with inter-individual variations in evolution with aging. Somatic mosaicism, mode of inheritance and the location of the mutation within the protein can influence phenotype. Conclusions The current evidence for therapeutic options for ADCY5-RMD is limited: caffeine, benzodiazepines and deep brain stimulation have been consistently reported to be useful in case reports and case series.
Collapse
Affiliation(s)
- Poornima Jayadev Menon
- Sorbonne University, APHP—Salpêtrière Hospital, CNRS, INSERM, Paris Brain InstituteParisFrance
- School of Postgraduate StudiesRoyal College of Surgeons in IrelandDublinIreland
| | - Christelle Nilles
- Department of Clinical NeurosciencesUniversity of CalgaryCalgaryABCanada
| | | | - Ruiyi Yuan
- Sorbonne University, APHP—Salpêtrière Hospital, CNRS, INSERM, Paris Brain InstituteParisFrance
| | - Claudio M. de Gusmao
- Department of NeurologyUniversity of Campinas (UNICAMP)CampinasBrazil
- Boston Children's HospitalBostonMAUSA
| | | | - Miryam Carecchio
- Center for the Study of Neurodegeneration (CESNE) and Department of NeuroscienceUniversity of PaduaPaduaItaly
| | | | | | - Aurélie Méneret
- Sorbonne University, APHP—Salpêtrière Hospital, CNRS, INSERM, Paris Brain InstituteParisFrance
| | - Emmanuel Roze
- Sorbonne University, APHP—Salpêtrière Hospital, CNRS, INSERM, Paris Brain InstituteParisFrance
| | - Tamara Pringsheim
- Department of Clinical NeurosciencesUniversity of CalgaryCalgaryABCanada
| |
Collapse
|
4
|
Bohlega S, Abusrair AH, Al-Qahtani Z, Guzmán-Vega FJ, Ramakrishnan R, Aldosari H, Aldakheel A, Al-Qahtani S, Monies D, Arold ST. Expanding the genotype-phenotype landscape of PDE10A-associated movement disorders. Parkinsonism Relat Disord 2023; 108:105323. [PMID: 36805523 DOI: 10.1016/j.parkreldis.2023.105323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Phosphodiesterase 10A (PDE10A) controls body movements by regulating cyclic adenosine monophosphate signaling in the basal ganglia. Two classes of PDE10A variants are reported with distinctive genotype-phenotype correlation. The autosomal recessive mutations in the GAF-A and catalytic domains are associated with compromised membrane localization, and manifest with infantile onset chorea, developmental, and cognition delay with normal brain MRI. Conversely, autosomal dominant mutations in the GAF-B domain cause protein aggregates which results in childhood onset chorea in the context of normal cognition and development, with striatal lesions. METHODS Phenotypic characteristics of affected individuals with PDE10A mutations belonging to a single family were recorded. In addition, Sanger sequencing and in silico analysis were used to identify the mutations. Homozygosity mapping was applied together with whole exome sequencing. RESULTS Four individuals from a consanguineous family affected with PDE10A mutations were observed for up to 40 years. Although these individuals displayed a clinical phenotype attributed to the recessive GAF-A mutations, they revealed a bi-allelic GAF-B mutation (c.883G > A:p. D295 N; p.Asp295Asn) that was segregated with all affected individuals. In addition to chorea, we observed peculiar foot deformities and pronounced social phobia, with normal brain MRI. In silico structural analysis suggested that the GAF-B mutation blocked allosteric PDE10A activation. The resulting lack of PDE10A activity likely phenocopies GAF-A mutations, and this is achieved through a distinct mechanism. CONCLUSIONS Collectively, our findings demonstrate the association of recessive and dominant phenotypes of known variants, and further expands the genotype-phenotype landscape of PDE10A-associated movement disorders.
Collapse
Affiliation(s)
- Saeed Bohlega
- Movement Disorders Program, Neuroscience Centre, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Kingdom of Saudi Arabia.
| | - Ali H Abusrair
- Movement Disorders Program, Neuroscience Centre, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Kingdom of Saudi Arabia
| | - Zainah Al-Qahtani
- Movement Disorders Program, Neuroscience Centre, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Kingdom of Saudi Arabia
| | - Francisco J Guzmán-Vega
- Bioscience Program, Biological and Environmental Science and Engineering Division, King Abdullah University of Science and Technology (KAUST), Thuwal, Kingdom of Saudi Arabia; Computational Biology Research Center, King Abdullah University of Science and Technology, (KAUST), Thuwal, Kingdom of Saudi Arabia
| | - Reshmi Ramakrishnan
- Bioscience Program, Biological and Environmental Science and Engineering Division, King Abdullah University of Science and Technology (KAUST), Thuwal, Kingdom of Saudi Arabia; Computational Biology Research Center, King Abdullah University of Science and Technology, (KAUST), Thuwal, Kingdom of Saudi Arabia
| | - Haya Aldosari
- Department of Genetics, Research Centre, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Kingdom of Saudi Arabia
| | - Amaal Aldakheel
- Movement Disorders Program, Neuroscience Centre, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Kingdom of Saudi Arabia
| | - Salma Al-Qahtani
- Movement Disorders Program, Neuroscience Centre, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Kingdom of Saudi Arabia
| | - Dorota Monies
- Department of Genetics, Research Centre, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Kingdom of Saudi Arabia
| | - Stefan T Arold
- Bioscience Program, Biological and Environmental Science and Engineering Division, King Abdullah University of Science and Technology (KAUST), Thuwal, Kingdom of Saudi Arabia; Computational Biology Research Center, King Abdullah University of Science and Technology, (KAUST), Thuwal, Kingdom of Saudi Arabia; Centre de Biologie Structurale (CBS), INSERM, CNRS, Université de Montpellier, F-34090, Montpellier, France
| |
Collapse
|
5
|
Online Databases of Genome Editing in Cardiovascular and Metabolic Diseases. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1396:19-33. [DOI: 10.1007/978-981-19-5642-3_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
|
6
|
Magrinelli F, Balint B, Bhatia KP. Challenges in Clinicogenetic Correlations: One Gene - Many Phenotypes. Mov Disord Clin Pract 2021; 8:299-310. [PMID: 33816657 PMCID: PMC8015894 DOI: 10.1002/mdc3.13165] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/02/2020] [Accepted: 12/19/2020] [Indexed: 12/25/2022] Open
Abstract
Background Progress in genetics – particularly the advent of next‐generation sequencing (NGS) – has enabled an unparalleled gene discovery and revealed unmatched complexity of genotype–phenotype correlations in movement disorders. Among other things, it has emerged that mutations in one and the same gene can cause multiple, often markedly different phenotypes. Consequently, movement disorder specialists have increasingly experienced challenges in clinicogenetic correlations. Objectives To deconstruct biological phenomena and mechanistic bases of phenotypic heterogeneity in monogenic movement disorders and neurodegenerative diseases. To discuss the evolving role of movement disorder specialists in reshaping disease phenotypes in the NGS era. Methods This scoping review details phenomena contributing to phenotypic heterogeneity and their underlying mechanisms. Results Three phenomena contribute to phenotypic heterogeneity, namely incomplete penetrance, variable expressivity and pleiotropy. Their underlying mechanisms, which are often shared across phenomena and non‐mutually exclusive, are not fully elucidated. They involve genetic factors (ie, different mutation types, dynamic mutations, somatic mosaicism, intragenic intra‐ and inter‐allelic interactions, modifiers and epistatic genes, mitochondrial heteroplasmy), epigenetic factors (ie, genomic imprinting, X‐chromosome inactivation, modulation of genetic and chromosomal defects), and environmental factors. Conclusion Movement disorders is unique in its reliance on clinical judgment to accurately define disease phenotypes. This has been reaffirmed by the NGS revolution, which provides ever‐growing sequencing data and fuels challenges in variant pathogenicity assertions for such clinically heterogeneous disorders. Deep phenotyping, with characterization and continual updating of “core” phenotypes, and comprehension of determinants of genotype–phenotype complex relationships are crucial for clinicogenetic correlations and have implications for the diagnosis, treatment and counseling.
Collapse
Affiliation(s)
- Francesca Magrinelli
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology University College London London United Kingdom.,Department of Neurosciences, Biomedicine and Movement Sciences University of Verona Verona Italy
| | - Bettina Balint
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology University College London London United Kingdom.,Department of Neurology University Hospital Heidelberg Heidelberg Germany
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology University College London London United Kingdom
| |
Collapse
|
7
|
Gannamani R, van der Veen S, van Egmond M, de Koning TJ, Tijssen MAJ. Challenges in Clinicogenetic Correlations: One Phenotype - Many Genes. Mov Disord Clin Pract 2021; 8:311-321. [PMID: 33816658 PMCID: PMC8015914 DOI: 10.1002/mdc3.13163] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 01/13/2021] [Accepted: 01/16/2021] [Indexed: 12/11/2022] Open
Abstract
Background In the field of movement disorders, what you see (phenotype) is seldom what you get (genotype). Whereas 1 phenotype was previously associated to 1 gene, the advent of next‐generation sequencing (NGS) has facilitated an exponential increase in disease‐causing genes and genotype–phenotype correlations, and the “one‐phenotype‐many‐genes” paradigm has become prominent. Objectives To highlight the “one‐phenotype‐many‐genes” paradigm by discussing the main challenges, perspectives on how to address them, and future directions. Methods We performed a scoping review of the various aspects involved in identifying the underlying molecular cause of a movement disorder phenotype. Results The notable challenges are (1) the lack of gold standards, overlap in clinical spectrum of different movement disorders, and variability in the interpretation of classification systems; (2) selecting which patients benefit from genetic tests and the choice of genetic testing; (3) problems in the variant interpretation guidelines; (4) the filtering of variants associated with disease; and (5) the lack of standardized, complete, and up‐to‐date gene lists. Perspectives to address these include (1) deep phenotyping and genotype–phenotype integration, (2) adherence to phenotype‐specific diagnostic algorithms, (3) implementation of current and complementary bioinformatic tools, (4) a clinical‐molecular diagnosis through close collaboration between clinicians and genetic laboratories, and (5) ongoing curation of gene lists and periodic reanalysis of genetic sequencing data. Conclusions Despite the rapidly emerging possibilities of NGS, there are still many steps to take to improve the genetic diagnostic yield. Future directions, including post‐NGS phenotyping and cohort analyses enriched by genotype–phenotype integration and gene networks, ought to be pursued to accelerate identification of disease‐causing genes and further improve our understanding of disease biology.
Collapse
Affiliation(s)
- Rahul Gannamani
- Department of Neurology University of Groningen, University Medical Centre Groningen Groningen The Netherlands.,Department of Genetics University of Groningen, University Medical Centre Groningen Groningen The Netherlands.,Expertise Centre Movement Disorders Groningen University Medical Centre Groningen Groningen The Netherlands
| | - Sterre van der Veen
- Department of Neurology University of Groningen, University Medical Centre Groningen Groningen The Netherlands.,Expertise Centre Movement Disorders Groningen University Medical Centre Groningen Groningen The Netherlands
| | - Martje van Egmond
- Department of Neurology University of Groningen, University Medical Centre Groningen Groningen The Netherlands.,Expertise Centre Movement Disorders Groningen University Medical Centre Groningen Groningen The Netherlands
| | - Tom J de Koning
- Department of Genetics University of Groningen, University Medical Centre Groningen Groningen The Netherlands.,Expertise Centre Movement Disorders Groningen University Medical Centre Groningen Groningen The Netherlands.,Pediatrics, Department of Clinical Sciences Lund University Lund Sweden
| | - Marina A J Tijssen
- Department of Neurology University of Groningen, University Medical Centre Groningen Groningen The Netherlands.,Expertise Centre Movement Disorders Groningen University Medical Centre Groningen Groningen The Netherlands
| |
Collapse
|
8
|
van Riesen AK, Biskup S, Kühn AA, Kaindl AM, van Riesen C. Novel Mutation in the TSFM Gene Causes an Early-Onset Complex Chorea without Basal Ganglia Lesions. Mov Disord Clin Pract 2021; 8:453-455. [PMID: 33816677 PMCID: PMC8015916 DOI: 10.1002/mdc3.13144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/08/2020] [Accepted: 11/17/2020] [Indexed: 12/21/2022] Open
Affiliation(s)
- Anne K van Riesen
- Charité - Universitätsmedizin Berlin, Center for Chronically Sick Children Berlin Germany.,Department of Pediatric Neurology University Medical Center Göttingen Göttingen Germany
| | - Saskia Biskup
- CeGaT GmbH, Center for Genomics and Transcriptomics Tübingen Germany
| | - Andrea A Kühn
- Department of Neurology, Movement Disorder and Neuromodulation Unit Charité - Universitätsmedizin Berlin Berlin Germany
| | - Angela M Kaindl
- Department of Pediatrics, Division of Neurology Charité - Universitätsmedizin Berlin Berlin Germany.,Charité - Universitätsmedizin Berlin, Institute of Cell Biology and Neurobiology Berlin Germany
| | - Christoph van Riesen
- Department of Neurology, Movement Disorder and Neuromodulation Unit Charité - Universitätsmedizin Berlin Berlin Germany.,Department of Neurology University Medical Center Göttingen Göttingen Germany
| |
Collapse
|
9
|
Abstract
Chorea is a movement disorder characterized by ongoing random-appearing sequences of discrete involuntary movements or movement fragments. Chorea results from dysfunction of the complex neuronal networks that interconnect the basal ganglia, thalamus, and related frontal lobe cortical areas. The complexity of basal ganglia circuitry and vulnerability of those circuits to injury explains why chorea results from a wide variety of conditions. Because etiology-specific treatments or effective symptomatic treatments are available for causes of chorea, defining the underlying disease is important. The treatment of chorea can be considered in three main categories: (1) terminating or modifying exposure to the causative agent, (2) symptomatic treatment of chorea, and (3) treatment targeting the underlying etiology. Symptomatic treatment decision of chorea should be based on the functional impact on the child caused by chorea itself. There have been no reported randomized, placebo-controlled trials of symptomatic treatment for chorea in childhood. Thus the recommendations are based on clinical experience, case reports, expert opinions, and small comparative studies. Better knowledge of mechanisms underlying childhood chorea will provide more etiology-based treatments in the future.
Collapse
|
10
|
Abstract
PURPOSE OF REVIEW This article provides an overview of the clinical features and disorders associated with movement disorders in childhood. This article discusses movement disorder phenomena and their clinical presentation in infants and children and presents a diagnostic approach to suspected genetic disorders with a focus on treatable conditions. RECENT FINDINGS Technologic advances in molecular genetic testing over the past decade continue to lead to the discovery of new diseases. This article discusses the clinical presentation and early experience with treatment for several recently described genetic forms of infantile-onset and childhood-onset dystonia and chorea. SUMMARY The clinical spectrum of pediatric movement disorders is broad and heterogeneous, ranging from acute or transient self-limited conditions to conditions that cause profound lifelong motor disability. Most movement disorders in childhood are chronic, and the large number of rare, genetic conditions associated with pediatric movement disorders can pose a significant diagnostic challenge. Recognition of distinctive diagnostic clues in the history and examination can facilitate the diagnosis of potentially treatable disorders.
Collapse
|
11
|
Autosomal recessive ADCY5-Related dystonia and myoclonus: Expanding the genetic spectrum of ADCY5-Related movement disorders. Parkinsonism Relat Disord 2019; 64:145-149. [DOI: 10.1016/j.parkreldis.2019.02.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 02/20/2019] [Accepted: 02/23/2019] [Indexed: 11/23/2022]
|
12
|
Restless Legs Syndrome in NKX2-1-related chorea: An expansion of the disease spectrum. Brain Dev 2019; 41:250-256. [PMID: 30352709 DOI: 10.1016/j.braindev.2018.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/13/2018] [Accepted: 10/01/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Molecular technologies are expanding our knowledge about genetic variability underlying early-onset non-progressive choreic syndromes. Focusing on NKX2-1-related chorea, the clinical phenotype and sleep related disorders have been only partially characterized. METHODS We propose a retrospective and longitudinal observational study in 7 patients with non-progressive chorea due to NKX2-1 mutations. In all subjects sleep and awake EEG, brain MRI with study of pituitary gland, chest X-rays, endocrinological investigations were performed. Movement disorders, pattern of sleep and related disorders were investigated using structured clinical evaluation and several validated questionnaires. RESULTS In patients carrying NKX2-1 mutations, chorea was mainly distributed in the upper limbs and tended to improve with age. All patients presented clinical or subclinical hypothyroidism and delayed motor milestones. Three subjects had symptoms consistent with Restless Legs Syndrome (RLS) that improved with Levodopa. CONCLUSIONS Patients with NKX2-1 gene mutations should be investigated for RLS, which, similarly to chorea, can sometimes be ameliorated by Levodopa.
Collapse
|
13
|
Testa CM, Jankovic J. Huntington disease: A quarter century of progress since the gene discovery. J Neurol Sci 2019; 396:52-68. [DOI: 10.1016/j.jns.2018.09.022] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 09/14/2018] [Accepted: 09/18/2018] [Indexed: 01/21/2023]
|
14
|
Fazio P, Paucar M, Svenningsson P, Varrone A. Novel Imaging Biomarkers for Huntington's Disease and Other Hereditary Choreas. Curr Neurol Neurosci Rep 2018; 18:85. [PMID: 30291526 PMCID: PMC6182636 DOI: 10.1007/s11910-018-0890-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF THE REVIEW Imaging biomarkers for neurodegenerative disorders are primarily developed with the goal to aid diagnosis, to monitor disease progression, and to assess the efficacy of disease-modifying therapies in support to clinical outcomes that may either show limited sensitivity or need extended time for their evaluation. This article will review the most recent concepts and findings in the field of neuroimaging applied to Huntington's disease and Huntington-like syndromes. Emphasis will be given to the discussion of potential pharmacodynamic biomarkers for clinical trials in Huntington's disease (HD) and of neuroimaging tools that can be used as diagnostic biomarkers in HD-like syndromes. RECENT FINDINGS Several magnetic resonance (MR) and positron emission tomography (PET) molecular imaging tools have been identified as potential pharmacodynamic biomarkers and others are in the pipeline after preclinical validation. MRI and 18F-fluorodeoxyglucose PET can be considered useful supportive diagnostic tools for the differentiation of other HD-like syndromes. New trials in HD have the primary goal to lower mutant huntingtin (mHTT) protein levels in the brain in order to reduce or alter the progression of the disease. MR and PET molecular imaging markers have been developed as tools to monitor disease progression and to evaluate treatment outcomes of disease-modifying trials in HD. These markers could be used alone or in combination for detecting structural and pharmacodynamic changes potentially associated with the lowering of mHTT.
Collapse
Affiliation(s)
- Patrik Fazio
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet and Stockholm County Council, R5:02 Karolinska University Hospital, SE-171 76, Stockholm, Sweden.
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.
| | - Martin Paucar
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Per Svenningsson
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Andrea Varrone
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet and Stockholm County Council, R5:02 Karolinska University Hospital, SE-171 76, Stockholm, Sweden
| |
Collapse
|
15
|
Feng H, Khalil S, Neubig RR, Sidiropoulos C. A mechanistic review on GNAO1-associated movement disorder. Neurobiol Dis 2018; 116:131-141. [PMID: 29758257 DOI: 10.1016/j.nbd.2018.05.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/28/2018] [Accepted: 05/10/2018] [Indexed: 02/07/2023] Open
Abstract
Mutations in the GNAO1 gene cause a complex constellation of neurological disorders including epilepsy, developmental delay, and movement disorders. GNAO1 encodes Gαo, the α subunit of Go, a member of the Gi/o family of heterotrimeric G protein signal transducers. Go is the most abundant membrane protein in the mammalian central nervous system and plays major roles in synaptic neurotransmission and neurodevelopment. GNAO1 mutations were first reported in early infantile epileptic encephalopathy 17 (EIEE17) but are also associated with a more common syndrome termed neurodevelopmental disorder with involuntary movements (NEDIM). Here we review a mechanistic model in which loss-of-function (LOF) GNAO1 alleles cause epilepsy and gain-of-function (GOF) alleles are primarily associated with movement disorders. We also develop a signaling framework related to cyclic AMP (cAMP), synaptic vesicle release, and neural development and discuss gene mutations perturbing those mechanisms in a range of genetic movement disorders. Finally, we analyze clinical reports of patients carrying GNAO1 mutations with respect to their symptom onset and discuss pharmacological/surgical treatments in the context of our mechanistic model.
Collapse
Affiliation(s)
- Huijie Feng
- Department of Pharmacology & Toxicology, Michigan State University, East Lansing, MI 48824, USA
| | - Suad Khalil
- Department of Neurology & Ophthalmology, Michigan State University, East Lansing, MI 48824, USA
| | - Richard R Neubig
- Department of Pharmacology & Toxicology, Michigan State University, East Lansing, MI 48824, USA.
| | - Christos Sidiropoulos
- Department of Neurology & Ophthalmology, Michigan State University, East Lansing, MI 48824, USA.
| |
Collapse
|
16
|
Di Fonzo A, Monfrini E, Erro R. Genetics of Movement Disorders and the Practicing Clinician; Who and What to Test for? Curr Neurol Neurosci Rep 2018; 18:37. [PMID: 29789954 DOI: 10.1007/s11910-018-0847-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This review aims to provide the basic knowledge on the genetics of hypokinetic and hyperkinetic movement disorders to guide clinicians in the decision of "who and what to test for?" RECENT FINDINGS In recent years, the identification of various genetic causes of hypokinetic and hyperkinetic movement disorders has had a great impact on a better definition of different clinical syndromes. Indeed, the advent of next-generation sequencing (NGS) techniques has provided an impressive step forward in the easy identification of genetic forms. However, this increased availability of genetic testing has challenges, including the ethical issue of genetic testing in unaffected family members, "commercially" available home testing kits and the increasing number and relevance of "variants of unknown significance." The emergent role of genetic factors has important implications on clinical practice and counseling. As a consequence, it is fundamental that practicing neurologists have a proper knowledge of the genetic background of the diseases and perform an accurate selection of who has to be tested and for which gene mutations.
Collapse
Affiliation(s)
- Alessio Di Fonzo
- IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Dino Ferrari Center, Neuroscience Section, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Edoardo Monfrini
- IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Dino Ferrari Center, Neuroscience Section, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Roberto Erro
- Neurodegenerative disease center (CEMAND), Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, SA, Italy.
| |
Collapse
|
17
|
Abstract
Chorea is a symptom of a broad array of genetic, structural, and metabolic disorders. While chorea can result from systemic illness and damage to diverse brain structures, injury to the basal ganglia, especially the putamen or globus pallidus, appears to be a uniting features of these diverse neuropathologies. The timing of onset, rate of progression, and the associated neurological or systemic symptoms can often narrow the differential diagnosis to a few disorders. Recognizing the correct etiology for childhood chorea is critical, as numerous disorders in this category are potentially curable, or are remediable, with early treatment.
Collapse
Affiliation(s)
- Claudio M de Gusmao
- Department of Neurology, Boston Children's Hospital, Boston, MA; Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Jeff L Waugh
- Department of Neurology, Boston Children's Hospital, Boston, MA; Department of Neurology, Massachusetts General Hospital, Boston, MA.
| |
Collapse
|
18
|
Salpietro V, Perez-Dueñas B, Nakashima K, San Antonio-Arce V, Manole A, Efthymiou S, Vandrovcova J, Bettencourt C, Mencacci NE, Klein C, Kelly MP, Davies CH, Kimura H, Macaya A, Houlden H. A homozygous loss-of-function mutation in PDE2A associated to early-onset hereditary chorea. Mov Disord 2018; 33:482-488. [PMID: 29392776 PMCID: PMC5873427 DOI: 10.1002/mds.27286] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/01/2017] [Accepted: 12/04/2017] [Indexed: 01/05/2023] Open
Abstract
Background: We investigated a family that presented with an infantile‐onset chorea‐predominant movement disorder, negative for NKX2‐1, ADCY5, and PDE10A mutations. Methods: Phenotypic characterization and trio whole‐exome sequencing was carried out in the family. Results: We identified a homozygous mutation affecting the GAF‐B domain of the 3’,5’‐cyclic nucleotide phosphodiesterase PDE2A gene (c.1439A>G; p.Asp480Gly) as the candidate novel genetic cause of chorea in the proband. PDE2A hydrolyzes cyclic adenosine/guanosine monophosphate and is highly expressed in striatal medium spiny neurons. We functionally characterized the p.Asp480Gly mutation and found that it severely decreases the enzymatic activity of PDE2A. In addition, we showed equivalent expression in human and mouse striatum of PDE2A and its homolog gene, PDE10A. Conclusions: We identified a loss‐of‐function homozygous mutation in PDE2A associated to early‐onset chorea. Our findings possibly strengthen the role of cyclic adenosine monophosphate and cyclic guanosine monophosphate metabolism in striatal medium spiny neurons as a crucial pathophysiological mechanism in hyperkinetic movement disorders. © 2018 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.
Collapse
Affiliation(s)
- Vincenzo Salpietro
- Department of Molecular Neuroscience, University College of London, London, United Kingdom
| | - Belen Perez-Dueñas
- Department of Pediatric Neurology, Hospital Universitari Sant Joan de Déu, Barcelona, Spain
| | - Kosuke Nakashima
- CNS Drug Discovery Unit, Pharmaceutical Research Division, Takeda Pharmaceutical Company Limited, Fujisawa, Japan
| | - Victoria San Antonio-Arce
- Unit of Epilepsy, Sleep and Neurophysiology, Hospital Universitari Sant Joan de Déu, Barcelona, Spain
| | - Andreea Manole
- Department of Molecular Neuroscience, University College of London, London, United Kingdom
| | - Stephanie Efthymiou
- Department of Molecular Neuroscience, University College of London, London, United Kingdom
| | - Jana Vandrovcova
- Department of Molecular Neuroscience, University College of London, London, United Kingdom
| | - Conceicao Bettencourt
- Department of Molecular Neuroscience, University College of London, London, United Kingdom
| | - Niccolò E Mencacci
- Department of Molecular Neuroscience, University College of London, London, United Kingdom.,Center for Genetic Medicine, Feinberg school of medicine, Northwestern University, Chicago, Illinois, USA
| | - Christine Klein
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Michy P Kelly
- Department of Pharmacology, Physiology and Neuroscience, School of Medicine, University of South Carolina, Columbia, South Carolina, USA
| | - Ceri H Davies
- CNS Drug Discovery Unit, Pharmaceutical Research Division, Takeda Pharmaceutical Company Limited, Fujisawa, Japan
| | - Haruhide Kimura
- CNS Drug Discovery Unit, Pharmaceutical Research Division, Takeda Pharmaceutical Company Limited, Fujisawa, Japan
| | - Alfons Macaya
- Department of Pediatric Neurology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Henry Houlden
- Department of Molecular Neuroscience, University College of London, London, United Kingdom
| |
Collapse
|
19
|
Abstract
INTRODUCTION Chorea is defined as jerk-like movements that move randomly from one body part to another. It is due to a variety of disorders and although current symptomatic therapy is quite effective there are few etiology- or pathogenesis-targeted therapies. The aim of this review is to summarize our own experience and published evidence in the treatment of chorea. Areas covered: After evaluating current guidelines and clinical practices for chorea of all etiologies, PubMed was searched for the most recent clinical trials and reviews using the term 'chorea' cross referenced with specific drug names. Expert commentary: Inhibitors of presynaptic vesicular monoamine transporter type 2 (VMAT2) that cause striatal dopamine depletion, such as tetrabenazine, deutetrabenazine, and valbenazine, are considered the treatment of choice in patients with chorea. Some clinicians also use dopamine receptor blockers (e.g. antipsychotics) and other drugs, including anti-epileptics and anti-glutamatargics. 'Dopamine stabilizers' such as pridopidine and other experimental drugs are currently being investigated in the treatment of chorea. Deep brain stimulation is usually reserved for patients with disabling chorea despite optimal medical therapy.
Collapse
Affiliation(s)
- H Bashir
- a Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology , Baylor College of Medicine , Houston , TX , USA
| | - J Jankovic
- a Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology , Baylor College of Medicine , Houston , TX , USA
| |
Collapse
|
20
|
Carecchio M, Mencacci NE, Iodice A, Pons R, Panteghini C, Zorzi G, Zibordi F, Bonakis A, Dinopoulos A, Jankovic J, Stefanis L, Bhatia KP, Monti V, R'Bibo L, Veneziano L, Garavaglia B, Fusco C, Wood N, Stamelou M, Nardocci N. ADCY5-related movement disorders: Frequency, disease course and phenotypic variability in a cohort of paediatric patients. Parkinsonism Relat Disord 2017; 41:37-43. [PMID: 28511835 PMCID: PMC5549507 DOI: 10.1016/j.parkreldis.2017.05.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 04/27/2017] [Accepted: 05/08/2017] [Indexed: 12/11/2022]
Abstract
Introduction ADCY5 mutations have been recently identified as an important cause of early-onset hyperkinetic movement disorders. The phenotypic spectrum associated with mutations in this gene is expanding. However, the ADCY5 mutational frequency in cohorts of paediatric patients with hyperkinetic movement disorders has not been evaluated. Methods We performed a screening of the entire ADCY5 coding sequence in 44 unrelated subjects with genetically undiagnosed childhood-onset hyperkinetic movement disorders, featuring chorea alone or in combination with myoclonus and dystonia. All patients had normal CSF analysis and brain imaging and were regularly followed-up in tertiary centers for paediatric movement disorders. Results We identified five unrelated subjects with ADCY5 mutations (11% of the cohort). Three carried the p. R418W mutation, one the p. R418Q and one the p. R418G mutation. Mutations arose de novo in four cases, while one patient inherited the mutation from his similarly affected father. All patients had delayed motor and/or language milestones with or without axial hypotonia and showed generalized chorea and dystonia, with prominent myoclonic jerks in one case. Episodic exacerbations of the baseline movement disorder were observed in most cases, being the first disease manifestation in two patients. The disease course was variable, from stability to spontaneous improvement during adolescence. Conclusion Mutations in ADCY5 are responsible for a hyperkinetic movement disorder that can be preceded by episodic attacks before the movement disorder becomes persistent and is frequently misdiagnosed as dyskinetic cerebral palsy. A residual degree of neck hypotonia and a myopathy-like facial appearance are frequently observed in patients with ADCY5 mutations. ADCY5 mutational frequency in paediatric patients is unknown. 5/44 (11%) subjects in our cohort carried pathogenic ADCY5 mutations. Chorea-dystonia, exacerbations and developmental delay are often observed together. Disease course and clinical features are variable among patients with ADCY5 mutations. Residual cervical hypotonia and a myopathy-like face are additional diagnostic clues.
Collapse
Affiliation(s)
- Miryam Carecchio
- Molecular Neurogenetics Unit, IRCCS Foundation Neurological Institute C. Besta, Via L. Temolo 4, 20126 Milan, Italy; Department of Pediatric Neurology, IRCCS Foundation Neurological Institute C. Besta, Via Celoria 11, 20133 Milan, Italy; Department of Medicine and Surgery, PhD Programme in Molecular and Translational Medicine, University of Milan Bicocca, Via Cadore 48, 20900 Monza, Italy
| | - Niccolò E Mencacci
- Department of Molecular Neuroscience, UCL Institute of Neurology, WC1N 3BG London, United Kingdom; Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, 60611 Illinois, USA.
| | - Alessandro Iodice
- Child Neurology and Psychiatry Unit, Department of Pediatrics, IRCCS Santa Maria Nuova Hospital, Viale Risorgimento 80, 42123 Reggio nell'Emilia, Italy
| | - Roser Pons
- First Pediatric Clinic, University of Athens, Agia Sofia Children's Hospital, Thivon and Levadias, 11527 Athens, Greece
| | - Celeste Panteghini
- Molecular Neurogenetics Unit, IRCCS Foundation Neurological Institute C. Besta, Via L. Temolo 4, 20126 Milan, Italy
| | - Giovanna Zorzi
- Department of Pediatric Neurology, IRCCS Foundation Neurological Institute C. Besta, Via Celoria 11, 20133 Milan, Italy
| | - Federica Zibordi
- Department of Pediatric Neurology, IRCCS Foundation Neurological Institute C. Besta, Via Celoria 11, 20133 Milan, Italy
| | - Anastasios Bonakis
- Second Department of Neurology, Attiko University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Argyris Dinopoulos
- Third Department of Paediatrics, Attiko University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Athens, Greece
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, 7200 Cambridge, Houston, TX 77030-4202, USA
| | - Leonidas Stefanis
- Second Department of Neurology, Attiko University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, University College London, Institute of Neurology, London WC1N 3BG, United Kingdom
| | - Valentina Monti
- Molecular Neurogenetics Unit, IRCCS Foundation Neurological Institute C. Besta, Via L. Temolo 4, 20126 Milan, Italy
| | - Lea R'Bibo
- Department of Molecular Neuroscience, UCL Institute of Neurology, WC1N 3BG London, United Kingdom
| | - Liana Veneziano
- Institute of Translational Pharmacology, National Research Council, Via Fosso del Cavaliere, 100, 00133 Rome, Italy
| | - Barbara Garavaglia
- Molecular Neurogenetics Unit, IRCCS Foundation Neurological Institute C. Besta, Via L. Temolo 4, 20126 Milan, Italy
| | - Carlo Fusco
- Child Neurology and Psychiatry Unit, Department of Pediatrics, IRCCS Santa Maria Nuova Hospital, Viale Risorgimento 80, 42123 Reggio nell'Emilia, Italy
| | - Nicholas Wood
- Department of Molecular Neuroscience, UCL Institute of Neurology, WC1N 3BG London, United Kingdom
| | - Maria Stamelou
- Movement Disorders Department, HYGEIA Hospital, Athens, Greece; Second Department of Neurology, Attiko University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nardo Nardocci
- Department of Pediatric Neurology, IRCCS Foundation Neurological Institute C. Besta, Via Celoria 11, 20133 Milan, Italy
| |
Collapse
|
21
|
Salvatori I, Valle C, Ferri A, Carrì MT. SIRT3 and mitochondrial metabolism in neurodegenerative diseases. Neurochem Int 2017; 109:184-192. [PMID: 28449871 DOI: 10.1016/j.neuint.2017.04.012] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 04/12/2017] [Accepted: 04/21/2017] [Indexed: 02/07/2023]
Abstract
The NAD+-dependent deacetylase protein Sirtuin 3 (SIRT3) is emerging among the factors playing a key role in the regulation of mitochondrial function and in the prevention of oxidative stress. This deacetylase activates protein substrates directly involved in the production and detoxification of ROS, such as superoxide dismutase 2 and catalase, but also enzymes in the lipid beta-oxidation pathway. In this paper we review existing evidence on the role of SIRT3 in neurodegenerative diseases such as Alzheimer's disease, Parkinson's disease and Huntington disease, including data from new experiments in a model for amyotrophic lateral sclerosis linked to mutations in superoxide dismutase 1. Specifically, we report that expression of the mitochondrial isoform of SIRT3 is altered in muscle from the G93A-SOD1 mice during progression of disease; this alteration influences mitochondrial metabolism, which may be relevant for the well known energetic alterations taking place in ALS patients. These data reinforce the concept that SIRT3 may be a relevant therapeutic target is ALS as well as in other neurodegenerative diseases.
Collapse
Affiliation(s)
| | - Cristiana Valle
- Fondazione Santa Lucia IRCCS, Rome, Italy; Institute for Cell Biology and Neurobiology, CNR, Rome, Italy
| | - Alberto Ferri
- Fondazione Santa Lucia IRCCS, Rome, Italy; Institute for Cell Biology and Neurobiology, CNR, Rome, Italy
| | - Maria Teresa Carrì
- Fondazione Santa Lucia IRCCS, Rome, Italy; Department of Biology, University of Rome Tor Vergata, Rome, Italy.
| |
Collapse
|
22
|
Bonifati V. Will New Genetic Techniques Like Exome Sequencing and Others Obviate the Need for Clinical Expertise? Yes. Mov Disord Clin Pract 2017; 4:36-38. [PMID: 30713946 DOI: 10.1002/mdc3.12438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/08/2016] [Accepted: 08/12/2016] [Indexed: 12/24/2022] Open
Affiliation(s)
- Vincenzo Bonifati
- Department of Clinical Genetics Erasmus Medical Center Rotterdam the Netherlands
| |
Collapse
|