1
|
Chuang K. Symptomatic Treatment of Myelopathy. Continuum (Minneap Minn) 2024; 30:224-242. [PMID: 38330480 DOI: 10.1212/con.0000000000001383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE This article discusses the effects of myelopathy on multiple organ systems and reviews the treatment and management of some of these effects. LATEST DEVELOPMENTS Recent advances in functional electrical stimulation, epidural spinal cord stimulation, robotics, and surgical techniques such as nerve transfer show promise in improving function in patients with myelopathy. Ongoing research in stem cell therapy and neurotherapeutic drugs may provide further therapeutic avenues in the future. ESSENTIAL POINTS Treatment for symptoms of spinal cord injury should be targeted toward patient goals. If nerve transfer for upper extremity function is considered, the patient should be evaluated at around 6 months from injury to assess for lower motor neuron involvement and possible time limitations of surgery. A patient with injury at or above the T6 level is at risk for autonomic dysreflexia, a life-threatening condition that presents with elevated blood pressure and can lead to emergent hypertensive crisis. Baclofen withdrawal due to baclofen pump failure or programming errors may also be life-threatening. Proper management of symptoms may help avoid complications such as autonomic dysreflexia, renal failure, heterotopic ossification, and fractures.
Collapse
|
2
|
Gialanella B, Comini L, Prometti P, Vanoglio F, Santoro R. Effects of Motor Rehabilitation on Balance and Functional Activities in Elderly Patients with Peripheral Neuropathy and Recurrent Falls. Life (Basel) 2023; 13:life13041059. [PMID: 37109588 PMCID: PMC10144929 DOI: 10.3390/life13041059] [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: 03/16/2023] [Revised: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
To date, little is known about the effects of motor rehabilitation in peripheral neuropathy (PN) patients with a history of recurrent falls (RFH). This study aimed to assess balance and the activities of daily living (ADLs) in elderly lower limb PN patients with and without RFH and to verify the effects of motor rehabilitation on balance and ADLs in these patients. We collected data from 64 lower limb PN patients, who underwent a conventional motor rehabilitation program: 35 patients had a history of recurrent falls, and 29 did not. The Berg Balance Scale (BBS) and motor FIM, before and after rehabilitation, were the outcome measures. After rehabilitation, lower limb PN patients with RFH had significantly higher scores in BBS and motor FIM (p < 0.001, for both) than at entry. The final BBS score and effectiveness in the BBS score of lower limb PN patients with RFH were lower than those of patients without RFH (p < 0.05 and p = 0.009, respectively). The study shows that conventional motor rehabilitation improves both balance and ADLs in patients, but balance improvement is lower in those with RFH. Thus, motor rehabilitation can be a therapeutic option for the management of these patients.
Collapse
Affiliation(s)
- Bernardo Gialanella
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation of the Institute of Lumezzane, 25065 Lumezzane, Italy
| | - Laura Comini
- Istituti Clinici Scientifici Maugeri IRCCS, Scientific Direction of the Institute of Lumezzane, 25065 Lumezzane, Italy
| | | | - Fabio Vanoglio
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation of the Institute of Lumezzane, 25065 Lumezzane, Italy
| | - Raffaele Santoro
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation of the Institute of Lumezzane, 25065 Lumezzane, Italy
| |
Collapse
|
3
|
Gialanella B, Comini L, Prometti P. Determinants of improvement in functional abilities in peripheral neuropathy patients undergoing rehabilitation: the role of Berg Balance Scale items. Acta Neurol Belg 2023; 123:173-179. [PMID: 34608595 DOI: 10.1007/s13760-021-01806-y] [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: 06/21/2021] [Accepted: 09/15/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE This prospective observational cohort study aimed to verify whether single Berg Balance Scale (BBS) items were important determinants of improvement in functional abilities in patients with peripheral neuropathy (PN). METHODS Data were collected in 75 older patients with PN performing a standard motor rehabilitation program. Backward stepwise multiple regression analyses were performed to identify determinants of outcome measures. Gain in total and motor Functional Independence Measure (FIM) and gain in motor-FIM areas were the outcome measures. RESULTS Among BBS items, at the end of rehabilitation, the score was higher in "sitting unsupported" (3.94 ± 0.22) and lower in "standing on one foot" (1.18 ± 1.06). The gain was higher in "standing to sitting" (1.02 ± 0.67) and "standing unsupported" (1.00 ± 1.00), and lower in "sitting unsupported" (0.22 ± 0.60) and "standing on one foot" (0.65 ± 0.77). "Standing unsupported" was the only determinant of gain in motor-FIM (beta - 0.36, p = 0.002) and gain in self-care (beta - 0.37, p = 0.002). The R2 value of the models was 0.13 and 0.14, respectively. No independent variable was a determinant of gain in total-FIM. CONCLUSIONS The study shows that "unsupported standing" is an important determinant of results of ADL rehabilitation in PN patients and indicates that ability to stand without support for a fairly long time is an essential requirement to achieve with rehabilitation higher gain levels in functional abilities in PN patients.
Collapse
Affiliation(s)
- Bernardo Gialanella
- Istituti Clinici Scientifici Maugeri IRCCS, Operative Unit for Recovery and Functional Rehabilitation of the Institute of Lumezzane, Via G Mazzini, 129, 25065, Lumezzane, Brescia, Italy.
| | - Laura Comini
- Istituti Clinici Scientifici Maugeri IRCCS, Scientific Direction of the Institute of Lumezzane, Brescia, Italy
| | - Paola Prometti
- Istituti Clinici Scientifici Maugeri IRCCS, Operative Unit for Recovery and Functional Rehabilitation of the Institute of Lumezzane, Via G Mazzini, 129, 25065, Lumezzane, Brescia, Italy
| |
Collapse
|
4
|
Gialanella B, Prometti P, Comini L, Monguzzi V, Santoro R. Predictive factors of functional abilities in older patients with peripheral neuropathy. Aging Clin Exp Res 2022; 34:193-199. [PMID: 34258734 DOI: 10.1007/s40520-021-01910-2] [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: 02/13/2021] [Accepted: 06/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Little is known about the outcome predictors in peripheral neuropathy (PN). This prospective observational study aimed to identify possible factors predicting the functional abilities in older patients with PN undergoing motor rehabilitation. METHODS Data were collected in 80 PN patients, aged over 65 years, performing a standard inpatient motor rehabilitation program. The total Functional Independence Measure (FIM) score after rehabilitation, as well as efficiency and effectiveness in total-FIM, were the outcome measures. Backward multiple regression analyses identified the predictors of functional status. RESULTS At the end of rehabilitation, total-FIM score was 102.66 ± 10.75, efficiency in total-FIM 0.64 ± 0.29 and effectiveness in total-FIM 48.81 ± 15.35%. Katz index at admission was a predictor of the final total-FIM score (beta 0.46, p < 0.001) and efficiency in total-FIM (beta - 0.38, p = 0.001). Conversely, age was a predictor of the final total-FIM score (beta - 0.31, p = 0.002) and effectiveness in total-FIM (beta - 0.49, p < 0.001). The R2 values of the models were, respectively, 0.39, 0.15, and 0.24. DISCUSSION In PN patients, functional impairment at admission and age are important predictors of functional abilities at the end of rehabilitation. CONCLUSIONS These findings suggest the need for more intensive rehabilitation in older, more disabled PN patients because they risk achieving lower functional levels with standard rehabilitation programs.
Collapse
Affiliation(s)
- Bernardo Gialanella
- Istituti Clinici Scientifici Maugeri IRCCS, Operative Unit for Recovery and Functional Rehabilitation of the Institute of Lumezzane, Via G. Mazzini 129, Lumezzane, Brescia, Italy.
| | - Paola Prometti
- Istituti Clinici Scientifici Maugeri IRCCS, Operative Unit for Recovery and Functional Rehabilitation of the Institute of Lumezzane, Via G. Mazzini 129, Lumezzane, Brescia, Italy
| | - Laura Comini
- Istituti Clinici Scientifici Maugeri IRCCS, Scientific Direction of the Institute of Lumezzane, Brescia, Italy
| | - Vittoria Monguzzi
- Istituti Clinici Scientifici Maugeri IRCCS, Operative Unit for Recovery and Functional Rehabilitation of the Institute of Lissone, Monza-Brianza, Italy
| | - Raffaele Santoro
- Istituti Clinici Scientifici Maugeri IRCCS, Operative Unit for Recovery and Functional Rehabilitation of the Institute of Lumezzane, Via G. Mazzini 129, Lumezzane, Brescia, Italy
| |
Collapse
|
5
|
Responsiveness to rehabilitation of balance and gait impairment in elderly with peripheral neuropathy. J Biomech 2019; 94:31-38. [DOI: 10.1016/j.jbiomech.2019.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 07/05/2019] [Accepted: 07/06/2019] [Indexed: 12/14/2022]
|
6
|
Campagnolo M, Ruiz M, Falzone YM, Ermani M, Bianco M, Martinelli D, Cerri F, Quattrini A, Salvalaggio A, Castellani F, Comi G, Giannini F, Nobile-Orazio E, Fazio R, Riva N, Briani C. Limitations in daily activities and general perception of quality of life: Long term follow-up in patients with anti-myelin-glycoprotein antibody polyneuropathy. J Peripher Nerv Syst 2019; 24:276-282. [PMID: 31397934 DOI: 10.1111/jns.12342] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/22/2019] [Accepted: 08/02/2019] [Indexed: 12/01/2022]
Abstract
In this study, we assessed the modifications over time of daily activities and quality of life (QoL) in 32 subjects with anti-myelin-glycoprotein (MAG) antibody neuropathy. A widespread panel including clinical scores and patient-reported questionnaires, in compliance of the terms by the International Classification of Functioning, Disability, and Health (ICF) of the World Health Organization (WHO), was employed at enrollment (T0) and at follow-up evaluation (T1) after a mean interval of 15.4 ± 5.7 months. The Sensory Modality Sum score (SMS) at four limbs showed a significant worsening over time (mean score 27.2 ± 3.9 at T0 vs 25.7 ± 3 at T1 at upper limbs, P = .03; 20.5 ± 4.8 at T0 vs 18.6 ± 5.9 at T1 at lower limbs, P = .04). The Visual Analogue Scale (VAS) for pain significantly worsened at upper limbs at T1 (mean values 0.84 ± 1.95 at T0 vs 1.78 ± 2.6 at T1, P = .03). All the other tests did not show significant differences between T0 and T1. In the subgroup who underwent rituximab (15/32 treated before T0, 3/32 patients treated between T0 and T1 with median interval of 1 year), no significant differences were observed between T0 and T1. Despite the quite long follow-up, statistical significance was not achieved either for the limited number of patients or for the lack of sensitive outcome measures. In our cohort, the significant worsening of the SMS and VAS after a median of 14 months can be considered as a reliable expression of the natural history of the disease, and suggest that these scales might represent possible outcome measures in anti-MAG antibody neuropathy.
Collapse
Affiliation(s)
- Marta Campagnolo
- Department of Neurosciences, University of Padova, Padova, Italy
| | - Marta Ruiz
- Department of Neurosciences, University of Padova, Padova, Italy
| | - Yuri M Falzone
- Department of Neurology, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mario Ermani
- Department of Neurosciences, University of Padova, Padova, Italy
| | - Mariangela Bianco
- Neuromuscular and Neuroimmunology Service, Department of Medical Biotechnology and Translational Medicine, Milan University, IRCCS Humanitas Clinical and Research Institute, Milan, Italy
| | - Daniele Martinelli
- Department of Neurology, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federica Cerri
- Department of Neurology, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Angelo Quattrini
- Department of Neurology, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | | | - Giancarlo Comi
- Department of Neurology, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Università Vita e Salute San Raffaele, Milan, Italy
| | - Fabio Giannini
- Department of Medical and Surgical Sciences and Neurosciences, Siena University, Siena, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, Department of Medical Biotechnology and Translational Medicine, Milan University, IRCCS Humanitas Clinical and Research Institute, Milan, Italy
| | - Raffaella Fazio
- Department of Neurology, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nilo Riva
- Department of Neurology, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Briani
- Department of Neurosciences, University of Padova, Padova, Italy
| |
Collapse
|
7
|
Motor neuron degeneration, severe myopathy and TDP-43 increase in a transgenic pig model of SOD1-linked familiar ALS. Neurobiol Dis 2018; 124:263-275. [PMID: 30471417 DOI: 10.1016/j.nbd.2018.11.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 10/26/2018] [Accepted: 11/19/2018] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic Lateral Sclerosis (ALS) is a neural disorder gradually leading to paralysis of the whole body. Alterations in superoxide dismutase SOD1 gene have been linked with several variants of familial ALS. Here, we investigated a transgenic (Tg) cloned swine model expressing the human pathological hSOD1G93A allele. As in patients, these Tg pigs transmitted the disease to the progeny with an autosomal dominant trait and showed ALS onset from about 27 months of age. Post mortem analysis revealed motor neuron (MN) degeneration, gliosis and hSOD1 protein aggregates in brainstem and spinal cord. Severe skeletal muscle pathology including necrosis and inflammation was observed at the end stage, as well. Remarkably, as in human patients, these Tg pigs showed a quite long presymptomatic phase in which gradually increasing amounts of TDP-43 were detected in peripheral blood mononuclear cells. Thus, this transgenic swine model opens the unique opportunity to investigate ALS biomarkers even before disease onset other than testing novel drugs and possible medical devices.
Collapse
|
8
|
Falzone YM, Campagnolo M, Bianco M, Dacci P, Martinelli D, Ruiz M, Bocci S, Cerri F, Quattrini A, Comi G, Benedetti L, Giannini F, Lauria G, Nobile-Orazio E, Briani C, Fazio R, Riva N. Functioning and quality of life in patients with neuropathy associated with anti-MAG antibodies. J Neurol 2018; 265:2927-2933. [PMID: 30306264 PMCID: PMC6244677 DOI: 10.1007/s00415-018-9081-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/17/2018] [Accepted: 10/01/2018] [Indexed: 11/30/2022]
Abstract
Although anti-myelin-associated glycoprotein (MAG) antibody neuropathy is reported as a slowly progressive disease, it can lead to significant disability and impairment of health-related quality of life (HR-QoL) and social participation. The aim of this cross-sectional study was to evaluate the functioning and HR-QoL determinants in 67 patients with anti-MAG neuropathy in terms of the International Classification of Functioning, Disability, and Health (ICF). Evaluations included: Medical Research Council (MRC) sum score, Sensory Modality Sum score (SMS), Berg balance scale (BBS), Fatigue Severity Scale (FSS), Visual Analogue Scale (VAS) for pain, 9-Hole Peg Test (9-HPT), 6-min Walk Distance (6MWD), Impact on Participation and Autonomy (IPA) and the physical component score (PCS) and mental component score (MCS) of the short-form-36 health status scale (SF-36) HR-QoL measure. In the regression models, 6MWD was the most reliable predictor of PCS, explaining the 52% of its variance, while the strongest determinants of 6MWD were BBS and FSS, explaining the 41% of its variance. Consistently, VAS and BBS were good predictor of PCS, explaining together 54% of its variance. FSS was the most reliable determinant of MCS, explaining 25% of its variance. SMS and MRC were not QoL determinants. The results of our study suggest that 6MWD and FSS might be considered as potential meaningful outcome measures in future clinical trials. Furthermore, neurorehabilitation interventions aimed at improving balance and walking performance, fatigue management, and specific pain relief therapy should be considered to ameliorate participation in social life and HR-QoL in anti-MAG neuropathy patients.
Collapse
Affiliation(s)
- Yuri M Falzone
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marta Campagnolo
- Department of Neurosciences, Sciences University of Padova, Padova, Italy
| | - Mariangela Bianco
- Neuromuscular and Neuroimmunology Service, Department of Medical Biotechnology and Translational Medicine, IRCCS Humanitas Clinical and Research Institute, Milan University, Rozzano, Milan, Italy
| | - Patrizia Dacci
- Neurologia III, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Daniele Martinelli
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marta Ruiz
- Department of Neurosciences, Sciences University of Padova, Padova, Italy
| | - Silvia Bocci
- Department of Medical, Surgical and Neurological Sciences, Neurology and Clinical Neurophysiology Unit, University of Siena, Siena, Italy
| | - Federica Cerri
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Angelo Quattrini
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giancarlo Comi
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy
- Università Vita e Salute San Raffaele, Milan, Italy
| | - Luana Benedetti
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, IRCCS Policlinico San Martino, Genova, Italy
| | - Fabio Giannini
- Department of Medical, Surgical and Neurological Sciences, Neurology and Clinical Neurophysiology Unit, University of Siena, Siena, Italy
| | - Giuseppe Lauria
- Neurologia III, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, Department of Medical Biotechnology and Translational Medicine, IRCCS Humanitas Clinical and Research Institute, Milan University, Rozzano, Milan, Italy
| | - Chiara Briani
- Department of Neurosciences, Sciences University of Padova, Padova, Italy
| | - Raffaella Fazio
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nilo Riva
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy.
| |
Collapse
|
9
|
D'Sa S, Kersten MJ, Castillo JJ, Dimopoulos M, Kastritis E, Laane E, Leblond V, Merlini G, Treon SP, Vos JM, Lunn MP. Investigation and management of IgM and Waldenström-associated peripheral neuropathies: recommendations from the IWWM-8 consensus panel. Br J Haematol 2017; 176:728-742. [PMID: 28198999 DOI: 10.1111/bjh.14492] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Paraproteinaemic neuropathies are a heterogeneous group of disorders most frequently associated with IgM monoclonal gammopathies including Waldenström macroglobulinaemia (WM). Their consequences are significant for affected patients, and their management challenging for their physicians. The variability in clinical presentation and time course hamper classification and management. The indications for invasive investigations such as cerebrospinal fluid analysis, nerve conduction tests and sensory nerve biopsies are unclear, and the optimum way to measure clinical response to treatment unknown. When to intervene and and how to treat, also present challenges to physicians. As part of its latest deliberations at the International Workshops on WM (IWWM) in London, UK (August 2014), the IWWM8 panel have proposed a consensus approach to the diagnosis and management of peripheral neuropathies associated with IgM monoclonal gammopathies, including WM. Importantly, a consensus regarding the use of clinical outcome measures and recommended models of care for this group of patients is discussed, as well as appropriate treatment interventions.
Collapse
Affiliation(s)
- Shirley D'Sa
- Waldenström Clinic, Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Marie José Kersten
- Department of Haematology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Meletios Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Edward Laane
- Department of Haematology, North Estonia Medical Centre, Tallinn, Estonia
| | - Véronique Leblond
- AP-HP Hôpital Pitié Salpêtrière, UPMC Univ. Paris 6 GRC-11, Grechy, Paris, France
| | - Giampaolo Merlini
- Centre for Research and Treatment of Systemic Amyloidosis, University of Pavia, Pavia, Italy
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Josephine M Vos
- Department of Haematology, Academic Medical Centre, Amsterdam, the Netherlands.,Cancer Centre, Sint Antonius Ziekenhuis, Nieuwegein, the Netherlands
| | - Michael P Lunn
- Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| |
Collapse
|