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Ros LA, Sleutjes BT, Stikvoort García DJ, Goedee HS, Asselman FL, van den Berg LH, van der Pol WL, Wadman RI. Feasibility and tolerability of multimodal peripheral electrophysiological techniques in a cohort of patients with spinal muscular atrophy. Clin Neurophysiol Pract 2023; 8:123-131. [PMID: 37554725 PMCID: PMC10404501 DOI: 10.1016/j.cnp.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/27/2023] [Accepted: 06/17/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVE Electrophysiological techniques are emerging as an aid in identifying prognostic or therapeutic biomarkers in patients with spinal muscular atrophy (SMA), but electrophysiological assessments may be burdensome for patients. We, therefore, assessed feasibility and tolerability of multimodal peripheral non-invasive electrophysiological techniques in a cohort of patients with SMA. METHODS We conducted a single center, longitudinal cohort study investigating the feasibility and tolerability of applying multimodal electrophysiological techniques to the median nerve unilaterally. Techniques consisted of the compound muscle action potential scan, motor nerve excitability tests, repetitive nerve stimulation and sensory nerve action potential. We assessed tolerability using the numeric rating scale (NRS), ranging from 0 (no pain) to 10 (worst possible pain), and defined the protocol to be tolerable if the NRS score ≤ 3. The protocol was considered feasible if it could be performed according to test and quality standards. RESULTS We included 71 patients with SMA types 1-4 (median 39 years; range 13-67) and 63 patients at follow-up. The protocol was feasible in 98% of patients and was well-tolerated in up to 90% of patients. Median NRS score was 2 (range 0-6 at baseline and range 0-4 at follow-up (p < 0.01)). None of the patients declined follow-up assessment. CONCLUSIONS Multimodal, peripheral, non-invasive, electrophysiological techniques applied to the median nerve are feasible and well-tolerated in adolescents and adults with SMA types 1-4. SIGNIFICANCE Our study supports the use of non-invasive multimodal electrophysiological assessments in adolescents and adults with SMA types 1-4.
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Affiliation(s)
- Leandra A.A. Ros
- Department of Neurology, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Boudewijn T.H.M. Sleutjes
- Department of Neurology, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Diederik J.L. Stikvoort García
- Department of Neurology, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - H. Stephan Goedee
- Department of Neurology, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Fay-Lynn Asselman
- Department of Neurology, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Leonard H. van den Berg
- Department of Neurology, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | | | - Renske I. Wadman
- Corresponding author at: Department of Neurology, University Medical Center Utrecht, UMC Utrecht Brain Center, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands.
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Balaji L, Farrar MA, D'Silva AM, Kariyawasam DS. Decision-making and challenges within the evolving treatment algorithm in spinal muscular atrophy: a clinical perspective. Expert Rev Neurother 2023; 23:571-586. [PMID: 37227306 DOI: 10.1080/14737175.2023.2218549] [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: 02/07/2023] [Accepted: 05/23/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION The clinical application of disease modifying therapies has dramatically changed the paradigm of the management of people with spinal muscular atrophy (SMA), from sole reliance on symptomatic care directed toward the downstream consequences of muscle weakness, to proactive intervention and even preventative care. AREAS COVERED In this perspective, the authors evaluate the contemporary therapeutic landscape of SMA and discuss the evolution of novel phenotypes and the treatment algorithm, including the key factors that define individual treatment choice and treatment response. The benefits achieved by early diagnosis and treatment through newborn screening are highlighted, alongside an appraisal of emerging prognostic methods and classification frameworks to inform clinicians, patients, and families about disease course, manage expectations, and improve care planning. A future perspective of unmet needs and challenges is provided, emphasizing the key role of research. EXPERT OPINION SMN-augmenting therapies have improved health outcomes for people with SMA and powered the practice of personalized medicine. Within this new proactive diagnostic and treatment paradigm, new phenotypes and different disease trajectories are emerging. Ongoing collaborative research efforts to understand the biology of SMA and define optimal response are critical to refining future approaches.
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Affiliation(s)
- Lakshmi Balaji
- Department of Neurology, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health UNSW, Sydney, Australia
| | - Michelle A Farrar
- Department of Neurology, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health UNSW, Sydney, Australia
- UNSW Kensington Campus, Sydney, Australia
| | - Arlene M D'Silva
- Department of Neurology, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health UNSW, Sydney, Australia
- UNSW Kensington Campus, Sydney, Australia
| | - Didu S Kariyawasam
- Department of Neurology, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health UNSW, Sydney, Australia
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Ros LAA, Goedee HS, Franssen H, Asselman FL, Bartels B, Cuppen I, van Eijk RPA, Sleutjes BTHM, van der Pol WL, Wadman RI. Longitudinal prospective cohort study to assess peripheral motor function with extensive electrophysiological techniques in patients with Spinal Muscular Atrophy (SMA): the SMA Motor Map protocol. BMC Neurol 2023; 23:164. [PMID: 37095427 PMCID: PMC10124000 DOI: 10.1186/s12883-023-03207-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/14/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Hereditary spinal muscular atrophy (SMA) is a motor neuron disorder with a wide range in severity in children and adults. Two therapies that alter splicing of the Survival Motor Neuron 2 (SMN2) gene, i.e. nusinersen and risdiplam, improve motor function in SMA, but treatment effects vary. Experimental studies indicate that motor unit dysfunction encompasses multiple features, including abnormal function of the motor neuron, axon, neuromuscular junction and muscle fibres. The relative contributions of dysfunction of different parts of the motor unit to the clinical phenotype are unknown. Predictive biomarkers for clinical efficacy are currently lacking. The goals of this project are to study the association of electrophysiological abnormalities of the peripheral motor system in relation to 1) SMA clinical phenotypes and 2) treatment response in patients treated with SMN2-splicing modifiers (nusinersen or risdiplam). METHODS We designed an investigator-initiated, monocentre, longitudinal cohort study using electrophysiological techniques ('the SMA Motor Map') in Dutch children (≥ 12 years) and adults with SMA types 1-4. The protocol includes the compound muscle action potential scan, nerve excitability testing and repetitive nerve stimulation test, executed unilaterally at the median nerve. Part one cross-sectionally assesses the association of electrophysiological abnormalities in relation to SMA clinical phenotypes in treatment-naïve patients. Part two investigates the predictive value of electrophysiological changes at two-months treatment for a positive clinical motor response after one-year treatment with SMN2-splicing modifiers. We will include 100 patients in each part of the study. DISCUSSION This study will provide important information on the pathophysiology of the peripheral motor system of treatment-naïve patients with SMA through electrophysiological techniques. More importantly, the longitudinal analysis in patients on SMN2-splicing modifying therapies (i.e. nusinersen and risdiplam) intents to develop non-invasive electrophysiological biomarkers for treatment response in order to improve (individualized) treatment decisions. TRIAL REGISTRATION NL72562.041.20 (registered at https://www.toetsingonline.nl . 26-03-2020).
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Affiliation(s)
- Leandra A A Ros
- Department of Neurology & Neurosurgery, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - H Stephan Goedee
- Department of Neurology & Neurosurgery, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - Hessel Franssen
- Department of Neurology & Neurosurgery, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - Fay-Lynn Asselman
- Department of Neurology & Neurosurgery, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - Bart Bartels
- Child Development and Exercise Centre, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Inge Cuppen
- Department of Neurology & Neurosurgery, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - Ruben P A van Eijk
- Department of Neurology & Neurosurgery, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
- Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Boudewijn T H M Sleutjes
- Department of Neurology & Neurosurgery, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - W Ludo van der Pol
- Department of Neurology & Neurosurgery, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - Renske I Wadman
- Department of Neurology & Neurosurgery, University Medical Center Utrecht, UMC Utrecht Brain Center, Utrecht University, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands.
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Kong L, Hassinan CW, Gerstner F, Buettner JM, Petigrow JB, Valdivia DO, Chan-Cortés MH, Mistri A, Cao A, McGaugh SA, Denton M, Brown S, Ross J, Schwab MH, Simon CM, Sumner CJ. Boosting neuregulin 1 type-III expression hastens SMA motor axon maturation. Acta Neuropathol Commun 2023; 11:53. [PMID: 36997967 PMCID: PMC10061791 DOI: 10.1186/s40478-023-01551-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/12/2023] [Indexed: 04/01/2023] Open
Abstract
Intercellular communication between axons and Schwann cells is critical for attaining the complex morphological steps necessary for axon maturation. In the early onset motor neuron disease spinal muscular atrophy (SMA), many motor axons are not ensheathed by Schwann cells nor grow sufficiently in radial diameter to become myelinated. These developmentally arrested motor axons are dysfunctional and vulnerable to rapid degeneration, limiting efficacy of current SMA therapeutics. We hypothesized that accelerating SMA motor axon maturation would improve their function and reduce disease features. A principle regulator of peripheral axon development is neuregulin 1 type III (NRG1-III). Expressed on axon surfaces, it interacts with Schwann cell receptors to mediate axon ensheathment and myelination. We examined NRG1 mRNA and protein expression levels in human and mouse SMA tissues and observed reduced expression in SMA spinal cord and in ventral, but not dorsal root axons. To determine the impact of neuronal NRG1-III overexpression on SMA motor axon development, we bred NRG1-III overexpressing mice to SMA∆7 mice. Neonatally, elevated NRG1-III expression increased SMA ventral root size as well as axon segregation, diameter, and myelination resulting in improved motor axon conduction velocities. NRG1-III was not able to prevent distal axonal degeneration nor improve axon electrophysiology, motor behavior, or survival of older mice. Together these findings demonstrate that early SMA motor axon developmental impairments can be ameliorated by a molecular strategy independent of SMN replacement providing hope for future SMA combinatorial therapeutic approaches.
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Affiliation(s)
- Lingling Kong
- Departments of Neurology, Johns Hopkins University School of Medicine, 855 North Wolfe Street, Rangos Building Room 234, Baltimore, MD, 21205, USA
| | - Cera W Hassinan
- Departments of Neurology, Johns Hopkins University School of Medicine, 855 North Wolfe Street, Rangos Building Room 234, Baltimore, MD, 21205, USA
| | - Florian Gerstner
- Carl-Ludwig-Institute for Physiology, Leipzig University, Leipzig, Germany
| | - Jannik M Buettner
- Carl-Ludwig-Institute for Physiology, Leipzig University, Leipzig, Germany
| | - Jeffrey B Petigrow
- Departments of Neurology, Johns Hopkins University School of Medicine, 855 North Wolfe Street, Rangos Building Room 234, Baltimore, MD, 21205, USA
| | - David O Valdivia
- Departments of Neurology, Johns Hopkins University School of Medicine, 855 North Wolfe Street, Rangos Building Room 234, Baltimore, MD, 21205, USA
| | - Michelle H Chan-Cortés
- Departments of Neurology, Johns Hopkins University School of Medicine, 855 North Wolfe Street, Rangos Building Room 234, Baltimore, MD, 21205, USA
| | - Amy Mistri
- Departments of Neurology, Johns Hopkins University School of Medicine, 855 North Wolfe Street, Rangos Building Room 234, Baltimore, MD, 21205, USA
| | - Annie Cao
- Departments of Neurology, Johns Hopkins University School of Medicine, 855 North Wolfe Street, Rangos Building Room 234, Baltimore, MD, 21205, USA
| | - Scott Alan McGaugh
- Departments of Neurology, Johns Hopkins University School of Medicine, 855 North Wolfe Street, Rangos Building Room 234, Baltimore, MD, 21205, USA
| | - Madeline Denton
- Departments of Neurology, Johns Hopkins University School of Medicine, 855 North Wolfe Street, Rangos Building Room 234, Baltimore, MD, 21205, USA
| | - Stephen Brown
- Departments of Neurology, Johns Hopkins University School of Medicine, 855 North Wolfe Street, Rangos Building Room 234, Baltimore, MD, 21205, USA
| | - Joshua Ross
- Departments of Neurology, Johns Hopkins University School of Medicine, 855 North Wolfe Street, Rangos Building Room 234, Baltimore, MD, 21205, USA
| | - Markus H Schwab
- Department of Neuropathology, University Hospital Leipzig, Leipzig, Germany
| | - Christian M Simon
- Carl-Ludwig-Institute for Physiology, Leipzig University, Leipzig, Germany
| | - Charlotte J Sumner
- Departments of Neurology, Johns Hopkins University School of Medicine, 855 North Wolfe Street, Rangos Building Room 234, Baltimore, MD, 21205, USA.
- Departments of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA.
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Kariyawasam DS, D'Silva AM, Sampaio H, Briggs N, Herbert K, Wiley V, Farrar MA. Newborn screening for spinal muscular atrophy in Australia: a non-randomised cohort study. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:159-170. [PMID: 36669516 DOI: 10.1016/s2352-4642(22)00342-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/03/2022] [Accepted: 11/10/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND In light of a new therapeutic era for spinal muscular atrophy (SMA), newborn screening has been proposed as a gateway to facilitate expedient diagnosis and access to therapeutics. However, there is paucity of evidence on health outcomes outside the homogenous populations in clinical trials to justify broader implementation of newborn screening for SMA. In this real-world study, we aimed to investigate the effectiveness of newborn screening coupled with access to disease-modifying therapeutics, as an intervention for SMA. METHODS In this prospective, non-randomised cohort study done at Sydney Children's Hospital Network (NSW, Australia), we included children younger than 16 years with homozygous exon 7 deletions of survival motor neuron 1 gene (SMN1) mutations, non-selectively assigned to a screening group (incident population diagnosed by newborn screening) from Aug 1, 2018, to Aug 1, 2020, or a comparator group (incident population diagnosed by clinical referral) from Aug 1, 2016, to July 31, 2018. We excluded infants with compound heterozygous SMN1 mutations and those participating in ongoing and unpublished clinical trials. Effectiveness of newborn screening for SMA was compared using motor development milestone attainment defined by WHO Multicentre Growth Reference Study at 2 years post diagnosis. Secondary outcome measures included mortality and change in Hammersmith Infant Neurological Examination-2 (HINE-2) score, ventilation requirements, and enteral requirements 2 years from the time of diagnosis. FINDINGS 34 children met the study inclusion criteria, but 33 children were included in the study population after one neonate was excluded due to participation in an ongoing unpublished clinical trial. 15 children were included in the screening group (seven [47%] male and eight [53%] female; median age 2·1 weeks [IQR 1·9-2·7]) and 18 children (nine [50%] male and nine [50%] female) were included in the comparator group (median age 47·8 weeks [13·0-99·9]). The 2-year survival rate was 93% (14 of 15 children) in the screening group and 89% (16 of 18) in the comparator group. Among survivors, 11 (79%) of 14 walked independently or with assistance in the screening group, compared with one (6%) of 16 children in the comparator group (χ2=16·27; p<0·0001). A significantly greater change in motor function was observed in the screening group compared with the comparator group over 2 years (HINE-2 score group difference, 12·32; p<0·0001). The requirement for non-intensive ventilation or feeding support at follow-up was higher in the comparator group than in the screening group (odds ratio 7·1 [95% CI 0·7-70·2]). Significant predictors of functional motor outcomes as determined by HINE-2 score at 2 years post diagnosis were HINE-2 score (p=0·0022), CHOP-INTEND (p=0·0001), compound muscle action potential (CMAP; p=0·0006), and disease status (p=0·023) at diagnosis. INTERPRETATION Newborn screening for SMA, coupled with early access to disease-modifying therapies, effectively ameliorates the functional burden and associated comorbidities for affected children. For children diagnosed through newborn screening, motor score, CMAP, and disease status at diagnosis has clinical utility to determine functional independence. FUNDING Brain Foundation and National Health and Medical Research Council.
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Affiliation(s)
- Didu S Kariyawasam
- Department of Neurology, Sydney Children's Hospital Network, Sydney, NSW, Australia; Discipline of Paediatrics and Child Health, School of Clinical Medicine, Medicine and Health, University of New South Wales, Sydney, NSW, Australia.
| | - Arlene M D'Silva
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Hugo Sampaio
- Department of Neurology, Sydney Children's Hospital Network, Sydney, NSW, Australia
| | - Nancy Briggs
- Mark Wainwright Analytical Centre, University of New South Wales, Sydney, NSW, Australia
| | - Karen Herbert
- Department of Physiotherapy, Sydney Children's Hospital Network, Sydney, NSW, Australia
| | - Veronica Wiley
- New South Wales Newborn Screening Program, Children's Hospital Westmead, Westmead, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Michelle A Farrar
- Department of Neurology, Sydney Children's Hospital Network, Sydney, NSW, Australia; Discipline of Paediatrics and Child Health, School of Clinical Medicine, Medicine and Health, University of New South Wales, Sydney, NSW, Australia
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D’Silva AM, Kariyawasam D, Venkat P, Mayoh C, Farrar MA. Identification of Novel CSF-Derived miRNAs in Treated Paediatric Onset Spinal Muscular Atrophy: An Exploratory Study. Pharmaceutics 2023; 15:pharmaceutics15010170. [PMID: 36678797 PMCID: PMC9865256 DOI: 10.3390/pharmaceutics15010170] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 01/05/2023] Open
Abstract
The availability of disease modifying therapies for spinal muscular atrophy (SMA) have created an urgent need to identify clinically meaningful biomarkers that provide insight into disease progression and therapeutic response. microRNAs (miRNA) have been shown to be involved in the pathogenesis of SMA and have the potential to provide insight within the field of SMA. miRNA-sequencing was utilized to identify differential miRNA expression in the cerebrospinal fluid (CSF) in six children with SMA treated with nusinersen in this exploratory study. Fourteen differentially expressed miRNAs were significantly altered in CSF from baseline to follow-up during treatment with nusinersen. The greatest magnitude of change was noted in miR-7-5p, miR-15a-5p, miR-15b-3p/5p, miR-126-5p, miR-128-2-5p and miR-130a-3p which encompassed a spectrum of functions predominantly in neurogenesis, neuronal differentiation and growth. The dominant signaling pathways identified in this study were the mammalian target of rapamycin and the mitogen-activated protein kinase signaling pathways. This study identified multiple miRNAs that were involved in the complex interplay between neurodevelopment and neurodegeneration.
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Affiliation(s)
- Arlene M. D’Silva
- Department of Neurology, Sydney Children’s Hospital Network, Sydney, NSW 2031, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
- Correspondence: ; Tel.: +61-2-9382-5517
| | - Didu Kariyawasam
- Department of Neurology, Sydney Children’s Hospital Network, Sydney, NSW 2031, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
| | - Pooja Venkat
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
- Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Sydney, NSW 2052, Australia
| | - Chelsea Mayoh
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
- Children’s Cancer Institute, Lowy Cancer Research Centre, UNSW Sydney, Sydney, NSW 2052, Australia
| | - Michelle A. Farrar
- Department of Neurology, Sydney Children’s Hospital Network, Sydney, NSW 2031, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2052, Australia
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