1
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Toutouna L, Beck-Woedl S, Feige U, Glaeser B, Komlosi K, Eckenweiler M, Luetzen N, Haack TB, Fischer J, Bader I, Tzschach A. Novel homozygous LAMB1 in-frame deletion in a pediatric patient with brain anomalies and cerebrovascular event. Am J Med Genet A 2023; 191:2656-2663. [PMID: 37466007 DOI: 10.1002/ajmg.a.63349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/07/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023]
Abstract
Biallelic pathogenic variants in LAMB1 have been associated with autosomal recessive lissencephaly 5 (OMIM 615191), which is characterized by brain malformations (cobblestone lissencephaly, hydrocephalus), developmental delay, and epilepsy. Pathogenic variants in LAMB1 are rare, with only 11 pathogenic variants and 11 patients reported to date. Here, we report on a 6-year-old patient from a consanguineous family with profound developmental delay, microcephaly, and a history of a perinatal cerebrovascular event. Brain magnetic resonance imaging (MRI) showed cerebellar cystic defects, signal intensity abnormalities, and a hypoplastic corpus callosum. Trio-exome analysis revealed a homozygous in-frame deletion of Exons 23 and 24 of LAMB1 affecting 104 amino acids including the epidermal growth factor (EGF)-like units 11 and 12 in Domain III. To our knowledge, this is the first reported in-frame deletion in LAMB1. Our findings broaden the clinical and molecular spectrum of LAMB1-associated syndromes.
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Affiliation(s)
- Louiza Toutouna
- Faculty of Medicine, Institute of Human Genetics, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Stefanie Beck-Woedl
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany
| | - Ursula Feige
- Department of Neuroradiology, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Birgitta Glaeser
- Faculty of Medicine, Institute of Human Genetics, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Katalin Komlosi
- Faculty of Medicine, Institute of Human Genetics, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Matthias Eckenweiler
- Department of Neuropediatrics and Muscle Disorders, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Niklas Luetzen
- Department of Neuroradiology, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Tobias B Haack
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany
| | - Judith Fischer
- Faculty of Medicine, Institute of Human Genetics, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Ingrid Bader
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany
| | - Andreas Tzschach
- Faculty of Medicine, Institute of Human Genetics, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
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2
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Jacinto JGP, Häfliger IM, Bernardini M, Mandara MT, Bianchi E, Bolcato M, Romagnoli N, Gentile A, Drögemüller C. A homozygous missense variant in laminin subunit beta 1 as candidate causal mutation of hemifacial microsomia in Romagnola cattle. J Vet Intern Med 2021; 36:292-299. [PMID: 34796979 PMCID: PMC8783352 DOI: 10.1111/jvim.16316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022] Open
Abstract
Hemifacial microsomia (HFM) was diagnosed in a 9‐day‐old Romagnola calf. The condition was characterized by microtia of the left ear, anotia of the right ear, asymmetry of the face, and deafness. Magnetic resonance imaging revealed agenesis of the right pinna and both tympanic bullae, asymmetry of the temporal bones and temporomandibular joints, and right pontine meningocele. Brainstem auditory evoked responses confirmed the impaired auditory capacity. At gross post mortem examination, there was agenesis and hypoplasia of the right and the left external ear, respectively. No histological abnormalities were detected in the inner ears. A trio whole‐genome sequencing approach was carried out and identified a private homozygous missense variant in LAMB1 affecting a conserved residue (p.Arg668Cys). Genotyping of 221 Romagnola bulls revealed a carrier prevalence <2%. This represents a report of a LAMB1‐related autosomal recessive inherited disorder in domestic animals and adds LAMB1 to the candidate genes for HFM.
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Affiliation(s)
- Joana G P Jacinto
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano, Italy.,Institute of Genetics, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Irene M Häfliger
- Institute of Genetics, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Marco Bernardini
- Anicura Portoni Rossi Veterinary Hospital, Zola Predosa, Bologna, Italy.,Department of Animal Medicine, Productions and Health, University of Padua, Padua, Italy
| | - Maria Teresa Mandara
- Department of Veterinary Medicine, Neuropathology Laboratory, University of Perugia, Perugia, Italy
| | - Ezio Bianchi
- Department of Veterinary Medical Sciences, University of Parma, Parma, Italy
| | - Marilena Bolcato
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano, Italy
| | - Noemi Romagnoli
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano, Italy
| | - Arcangelo Gentile
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano, Italy
| | - Cord Drögemüller
- Institute of Genetics, Vetsuisse Faculty, University of Bern, Bern, Switzerland
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3
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Aloui C, Hervé D, Marenne G, Savenier F, Le Guennec K, Bergametti F, Verdura E, Ludwig TE, Lebenberg J, Jabeur W, Morel H, Coste T, Demarquay G, Bachoumas P, Cogez J, Mathey G, Bernard E, Chabriat H, Génin E, Tournier-Lasserve E. End-Truncated LAMB1 Causes a Hippocampal Memory Defect and a Leukoencephalopathy. Ann Neurol 2021; 90:962-975. [PMID: 34606115 DOI: 10.1002/ana.26242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 10/01/2021] [Accepted: 10/02/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The majority of patients with a familial cerebral small vessel disease (CSVD) referred for molecular screening do not show pathogenic variants in known genes. In this study, we aimed to identify novel CSVD causal genes. METHODS We performed a gene-based collapsing test of rare protein-truncating variants identified in exome data of 258 unrelated CSVD patients of an ethnically matched control cohort and of 2 publicly available large-scale databases, gnomAD and TOPMed. Western blotting was used to investigate the functional consequences of variants. Clinical and magnetic resonance imaging features of mutated patients were characterized. RESULTS We showed that LAMB1 truncating variants escaping nonsense-mediated messenger RNA decay are strongly overrepresented in CSVD patients, reaching genome-wide significance (p < 5 × 10-8 ). Using 2 antibodies recognizing the N- and C-terminal parts of LAMB1, we showed that truncated forms of LAMB1 are expressed in the endogenous fibroblasts of patients and trapped in the cytosol. These variants are associated with a novel phenotype characterized by the association of a hippocampal type episodic memory defect and a diffuse vascular leukoencephalopathy. INTERPRETATION These findings are important for diagnosis and clinical care, to avoid unnecessary and sometimes invasive investigations, and also from a mechanistic point of view to understand the role of extracellular matrix proteins in neuronal homeostasis. ANN NEUROL 2021;90:962-975.
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Affiliation(s)
- Chaker Aloui
- Université de Paris, INSERM UMR 1141 NeuroDiderot, Paris, France
| | - Dominique Hervé
- Université de Paris, INSERM UMR 1141 NeuroDiderot, Paris, France.,AP-HP, Groupe Hospitalier Saint-Louis Lariboisière-Fernand-Widal, Service de Neurologie, Centre de Référence des Maladies Vasculaires Rares du Cerveau et de l'Œil (CERVCO), Paris, France
| | - Gaelle Marenne
- Université de Brest, Inserm, EFS, CHU Brest, UMR 1078, GGB, Brest, France
| | - Florian Savenier
- Université de Paris, INSERM UMR 1141 NeuroDiderot, Paris, France
| | - Kilan Le Guennec
- Université de Paris, INSERM UMR 1141 NeuroDiderot, Paris, France
| | | | - Edgard Verdura
- Université de Paris, INSERM UMR 1141 NeuroDiderot, Paris, France
| | - Thomas E Ludwig
- Université de Brest, Inserm, EFS, CHU Brest, UMR 1078, GGB, Brest, France
| | | | - Waliyde Jabeur
- Université de Paris, INSERM UMR 1141 NeuroDiderot, Paris, France
| | - Hélène Morel
- Université de Paris, INSERM UMR 1141 NeuroDiderot, Paris, France.,AP-HP, Service de Génétique Moléculaire Neurovasculaire, Hôpital Saint-Louis, Paris, France
| | - Thibault Coste
- Université de Paris, INSERM UMR 1141 NeuroDiderot, Paris, France.,AP-HP, Service de Génétique Moléculaire Neurovasculaire, Hôpital Saint-Louis, Paris, France
| | - Geneviève Demarquay
- Hôpital Neurologique, Hospices Civils de Lyon, Lyon Neuroscience Research Center (CRNL), Brain Dynamics and Cognition Team (Dycog), INSERM U1028, CNRS UMR5292, Lyon, France
| | | | - Julien Cogez
- CHU Caen, Department of Neurology, CHU de Caen Côte de Nacre, Caen, France
| | | | - Emilien Bernard
- Department of Neurology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France.,Institut NeuroMyoGène, INSERM-CNRS-UMR, Université Claude Bernard, Lyon, France
| | | | - Hugues Chabriat
- Université de Paris, INSERM UMR 1141 NeuroDiderot, Paris, France.,AP-HP, Groupe Hospitalier Saint-Louis Lariboisière-Fernand-Widal, Service de Neurologie, Centre de Référence des Maladies Vasculaires Rares du Cerveau et de l'Œil (CERVCO), Paris, France
| | - Emmanuelle Génin
- Université de Brest, Inserm, EFS, CHU Brest, UMR 1078, GGB, Brest, France
| | - Elisabeth Tournier-Lasserve
- Université de Paris, INSERM UMR 1141 NeuroDiderot, Paris, France.,AP-HP, Service de Génétique Moléculaire Neurovasculaire, Hôpital Saint-Louis, Paris, France
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4
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Bu T, Wang L, Wu X, Li L, Mao B, Wong CKC, Perrotta A, Silvestrini B, Sun F, Cheng CY. A laminin-based local regulatory network in the testis that supports spermatogenesis. Semin Cell Dev Biol 2021; 121:40-52. [PMID: 33879391 DOI: 10.1016/j.semcdb.2021.03.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/24/2021] [Accepted: 03/29/2021] [Indexed: 12/13/2022]
Abstract
In adult rat testes, the basement membrane is structurally constituted by laminin and collagen chains that lay adjacent to the blood-testis barrier (BTB). It plays a crucial scaffolding role to support spermatogenesis. On the other hand, laminin-333 comprised of laminin-α3/ß3/γ3 at the apical ES (ectoplasmic specialization, a testis-specific cell-cell adherens junction at the Sertoli cell-step 8-19 spermatid interface) expressed by spermatids serves as a unique cell adhesion protein that forms an adhesion complex with α6ß1-integrin expressed by Sertoli cells to support spermiogenesis. Emerging evidence has shown that biologically active fragments are derived from basement membrane and apical ES laminin chains through proteolytic cleavage mediated by matrix metalloproteinase 9 (MMP9) and MMP2, respectively. Two of these laminin bioactive fragments: one from the basement membrane laminin-α2 chain called LG3/4/5-peptide, and one from the apical ES laminin-γ3 chain known as F5-peptide, are potent regulators that modify cell adhesion function at the Sertoli-spermatid interface (i.e., apical ES) but also at the Sertoli cell-cell interface designated basal ES at the blood-testis barrier (BTB) with contrasting effects. These findings not only highlight the physiological significance of these bioactive peptides that create a local regulatory network to support spermatogenesis, they also open a unique area of research. For instance, it is likely that several other bioactive peptides remain to be identified. These bioactive peptides including their downstream signaling proteins and cascades should be studied collectively in future investigations to elucidate the underlying mechanism(s) by which they coordinate with each other to maintain spermatogenesis. This is the goal of this review.
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Affiliation(s)
- Tiao Bu
- The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China; Institute of Reproductive Medicine, Nantong University School of Medicine, Nantong, Jiangsu 226001, China
| | - Lingling Wang
- The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China; Institute of Reproductive Medicine, Nantong University School of Medicine, Nantong, Jiangsu 226001, China
| | - Xiaolong Wu
- Institute of Reproductive Medicine, Nantong University School of Medicine, Nantong, Jiangsu 226001, China
| | - Linxi Li
- The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China
| | - Baiping Mao
- The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China
| | - Chris K C Wong
- Department of Biology, Croucher Institute for Environmental Sciences, Hong Kong Baptist University, Kowloon, Hong Kong, China
| | - Adolfo Perrotta
- Department of Translational & Precision Medicine, La Sapienza University of Rome, 00185 Rome, Italy
| | | | - Fei Sun
- Institute of Reproductive Medicine, Nantong University School of Medicine, Nantong, Jiangsu 226001, China
| | - C Yan Cheng
- The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China; Institute of Reproductive Medicine, Nantong University School of Medicine, Nantong, Jiangsu 226001, China.
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5
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Yasuda R, Yoshida T, Mizuta I, Watanabe M, Nakano M, Sato R, Tokuda Y, Omi N, Sakai N, Nakagawa M, Tashiro K, Mizuno T. Adult-onset leukoencephalopathy with homozygous LAMB1 missense mutation. NEUROLOGY-GENETICS 2020; 6:e442. [PMID: 32548278 PMCID: PMC7251513 DOI: 10.1212/nxg.0000000000000442] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/20/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Rei Yasuda
- Department of Neurology (R.Y., T.Y., I.M., T.M.), Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Neurology (M.W.), Ehime Prefectural Central Hospital, Ehime, Japan; Department of Genomic Medical Sciences (M. Nakano, R.S., Y.T., N.O., K.T.), Kyoto Prefectural University of Medicine, Kyoto, Japan; Child Healthcare and Genetic Science Laboratory (N.S.), Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan; and Department of Neurology (M. Nakagawa), North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomokatsu Yoshida
- Department of Neurology (R.Y., T.Y., I.M., T.M.), Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Neurology (M.W.), Ehime Prefectural Central Hospital, Ehime, Japan; Department of Genomic Medical Sciences (M. Nakano, R.S., Y.T., N.O., K.T.), Kyoto Prefectural University of Medicine, Kyoto, Japan; Child Healthcare and Genetic Science Laboratory (N.S.), Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan; and Department of Neurology (M. Nakagawa), North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ikuko Mizuta
- Department of Neurology (R.Y., T.Y., I.M., T.M.), Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Neurology (M.W.), Ehime Prefectural Central Hospital, Ehime, Japan; Department of Genomic Medical Sciences (M. Nakano, R.S., Y.T., N.O., K.T.), Kyoto Prefectural University of Medicine, Kyoto, Japan; Child Healthcare and Genetic Science Laboratory (N.S.), Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan; and Department of Neurology (M. Nakagawa), North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masashi Watanabe
- Department of Neurology (R.Y., T.Y., I.M., T.M.), Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Neurology (M.W.), Ehime Prefectural Central Hospital, Ehime, Japan; Department of Genomic Medical Sciences (M. Nakano, R.S., Y.T., N.O., K.T.), Kyoto Prefectural University of Medicine, Kyoto, Japan; Child Healthcare and Genetic Science Laboratory (N.S.), Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan; and Department of Neurology (M. Nakagawa), North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masakazu Nakano
- Department of Neurology (R.Y., T.Y., I.M., T.M.), Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Neurology (M.W.), Ehime Prefectural Central Hospital, Ehime, Japan; Department of Genomic Medical Sciences (M. Nakano, R.S., Y.T., N.O., K.T.), Kyoto Prefectural University of Medicine, Kyoto, Japan; Child Healthcare and Genetic Science Laboratory (N.S.), Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan; and Department of Neurology (M. Nakagawa), North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ryuichi Sato
- Department of Neurology (R.Y., T.Y., I.M., T.M.), Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Neurology (M.W.), Ehime Prefectural Central Hospital, Ehime, Japan; Department of Genomic Medical Sciences (M. Nakano, R.S., Y.T., N.O., K.T.), Kyoto Prefectural University of Medicine, Kyoto, Japan; Child Healthcare and Genetic Science Laboratory (N.S.), Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan; and Department of Neurology (M. Nakagawa), North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuichi Tokuda
- Department of Neurology (R.Y., T.Y., I.M., T.M.), Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Neurology (M.W.), Ehime Prefectural Central Hospital, Ehime, Japan; Department of Genomic Medical Sciences (M. Nakano, R.S., Y.T., N.O., K.T.), Kyoto Prefectural University of Medicine, Kyoto, Japan; Child Healthcare and Genetic Science Laboratory (N.S.), Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan; and Department of Neurology (M. Nakagawa), North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Natsue Omi
- Department of Neurology (R.Y., T.Y., I.M., T.M.), Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Neurology (M.W.), Ehime Prefectural Central Hospital, Ehime, Japan; Department of Genomic Medical Sciences (M. Nakano, R.S., Y.T., N.O., K.T.), Kyoto Prefectural University of Medicine, Kyoto, Japan; Child Healthcare and Genetic Science Laboratory (N.S.), Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan; and Department of Neurology (M. Nakagawa), North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Norio Sakai
- Department of Neurology (R.Y., T.Y., I.M., T.M.), Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Neurology (M.W.), Ehime Prefectural Central Hospital, Ehime, Japan; Department of Genomic Medical Sciences (M. Nakano, R.S., Y.T., N.O., K.T.), Kyoto Prefectural University of Medicine, Kyoto, Japan; Child Healthcare and Genetic Science Laboratory (N.S.), Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan; and Department of Neurology (M. Nakagawa), North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masanori Nakagawa
- Department of Neurology (R.Y., T.Y., I.M., T.M.), Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Neurology (M.W.), Ehime Prefectural Central Hospital, Ehime, Japan; Department of Genomic Medical Sciences (M. Nakano, R.S., Y.T., N.O., K.T.), Kyoto Prefectural University of Medicine, Kyoto, Japan; Child Healthcare and Genetic Science Laboratory (N.S.), Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan; and Department of Neurology (M. Nakagawa), North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kei Tashiro
- Department of Neurology (R.Y., T.Y., I.M., T.M.), Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Neurology (M.W.), Ehime Prefectural Central Hospital, Ehime, Japan; Department of Genomic Medical Sciences (M. Nakano, R.S., Y.T., N.O., K.T.), Kyoto Prefectural University of Medicine, Kyoto, Japan; Child Healthcare and Genetic Science Laboratory (N.S.), Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan; and Department of Neurology (M. Nakagawa), North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshiki Mizuno
- Department of Neurology (R.Y., T.Y., I.M., T.M.), Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Neurology (M.W.), Ehime Prefectural Central Hospital, Ehime, Japan; Department of Genomic Medical Sciences (M. Nakano, R.S., Y.T., N.O., K.T.), Kyoto Prefectural University of Medicine, Kyoto, Japan; Child Healthcare and Genetic Science Laboratory (N.S.), Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan; and Department of Neurology (M. Nakagawa), North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
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