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Fischer R, Furlong P, Kennedy A, Maynard K, Penrod M, Miller D, Laverty CG, Lowes LP, Kuntz NL, Shieh PB, Kondejewski J, Neumann PJ, Shafrin J, Willke RJ. Healthcare Stakeholder Perspectives on a Value Assessment Approach for Duchenne Muscular Dystrophy Therapies. J Multidiscip Healthc 2024; 17:4199-4212. [PMID: 39224484 PMCID: PMC11368110 DOI: 10.2147/jmdh.s458181] [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: 03/16/2024] [Accepted: 07/15/2024] [Indexed: 09/04/2024] Open
Abstract
Purpose Traditional value assessment frameworks are challenged in comprehensively assessing the societal value new therapies bring to individuals with rare, progressive, genetic, fatal, neuromuscular diseases such as Duchenne muscular dystrophy (DMD). The objective of this study was to identify how value assessment frameworks may need to be adapted to measure the value to society of DMD therapies. Patients and Methods Three stakeholder groups (6 patient advocates, 4 clinicians, 3 health economists; N = 13) participated in semi-structured interviews around the International Society for Pharmacoeconomics and Outcomes Research's Value Flower, which includes elements to consider within value assessments of healthcare technologies. Results All stakeholders agreed that traditional value assessment frameworks based on the quality-adjusted life year (QALY) are narrow and will undervalue new DMD therapies. All stakeholders expressed some level of concern that using the QALY as a key metric of value discriminates against patients with severe progressive diseases and disabilities. Some stakeholders saw value in using the QALY for cross-disease comparisons in resource-constrained environments if the methodology was appropriate. All stakeholders recommended considering additional elements of value in decision-making around new DMD therapies. These elements reflect: economic and humanistic costs incurred by patients, caregivers, and families with Duchenne, such as indirect out-of-pocket costs, lost productivity, and family spillovers; meaningful attributes for individuals with disabilities and high unmet need, such as severity of disease, value of hope, and real option value; and factors that contribute to improvements in population health, such as insurance value, equity, and scientific spillovers. Conclusion These findings highlight the need to expand traditional value assessment frameworks and take a holistic approach that incorporates the perspectives of individuals with Duchenne, caregivers, clinicians, and health economists when assessing the societal value of new DMD therapies. Broadening value assessment will prevent restricted or delayed access to therapies for individuals with Duchenne.
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Affiliation(s)
- Ryan Fischer
- Parent Project Muscular Dystrophy, Washington, DC, USA
| | - Pat Furlong
- Parent Project Muscular Dystrophy, Washington, DC, USA
| | - Annie Kennedy
- EveryLife Foundation for Rare Diseases, Washington, DC, USA
| | - Kelly Maynard
- Little Hercules Foundation, Dublin, OH, USA
- Duchenne Family Assistance Program, Detroit, MI, USA
| | - Marissa Penrod
- Duchenne Family Assistance Program, Detroit, MI, USA
- Team Joseph, West Bloomfield, MI, USA
| | | | - Chamindra G Laverty
- Department of Neuroscience, University of California San Diego, San Diego, CA, USA
| | - Linda P Lowes
- Center for Gene Therapy, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Pediatrics, the Ohio State University, Columbus, OH, USA
| | - Nancy L Kuntz
- Division of Neurology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Neurology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Perry B Shieh
- Department of Neurology and Pediatrics, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
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Covatti C, Mizobuti DS, Rocha GLD, da Silva HNM, de Lourenço CC, Pertille A, Pereira ECL, Minatel E. Low-Level Photobiomodulation Therapy Modulates H 2O 2 Production, TRPC-6, and PGC-1α Levels in the Dystrophic Muscle. Photobiomodul Photomed Laser Surg 2023; 41:389-401. [PMID: 37527194 DOI: 10.1089/photob.2022.0115] [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] [Indexed: 08/03/2023] Open
Abstract
Objective: This study evaluated photobiomodulation therapy (PBMT) effects on the factors involved in mitochondrial biogenesis, on the mitochondrial respiratory complexes, and on the transient receptor potential canonical channels (such as TRPC-1 and TRPC-6) in in vitro (mdx muscle cells) and in vivo studies (gastrocnemius muscle) from mdx mice, the dystrophin-deficient model of Duchenne muscular dystrophy (DMD). Background: There is no successful treatment for DMD, therefore demanding search for new therapies that can improve the muscle role, the quality of life, and the survival of dystrophic patients. Methods: The dystrophic primary muscle cells received PBMT at 0.6 J and 5 J, and the dystrophic gastrocnemius muscle received PBMT at 0.6 J. Results: The dystrophic muscle cells treated with PBMT (0.6 J and 5 J) showed no cytotoxicity and significantly lower levels in hydrogen peroxide (H2O2) production. We also demonstrated, for the first time, the capacity of PBMT, at a low dose (0.6 J), in reducing the TRPC-6 content and in raising the peroxisome proliferator-activated receptor γ coactivator-1α (PGC-1α) content in the dystrophic gastrocnemius muscle. Conclusions: PBMT modulates H2O2 production, TRPC-6, and PGC-1α content in the dystrophic muscle. These results suggest that laser therapy could act as an auxiliary therapy in the treatment of dystrophic patients.
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Affiliation(s)
- Caroline Covatti
- Departamento de Biologia Estrutural e Funcional, Instituto de Biologia, Universidade Estadual de Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Daniela Sayuri Mizobuti
- Departamento de Biologia Estrutural e Funcional, Instituto de Biologia, Universidade Estadual de Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Guilherme Luiz da Rocha
- Departamento de Biologia Estrutural e Funcional, Instituto de Biologia, Universidade Estadual de Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Heloina Nathalliê Mariano da Silva
- Departamento de Biologia Estrutural e Funcional, Instituto de Biologia, Universidade Estadual de Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Caroline Caramano de Lourenço
- Departamento de Biologia Estrutural e Funcional, Instituto de Biologia, Universidade Estadual de Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Adriana Pertille
- Graduate Program in Science of Human Movement, Universidade Metodista de Piracicaba (UNIMEP), Piracicaba, São Paulo, Brazil
| | - Elaine Cristina Leite Pereira
- Departamento de Biologia Estrutural e Funcional, Instituto de Biologia, Universidade Estadual de Campinas (UNICAMP), Campinas, São Paulo, Brazil
- Universidade de Brasília (UnB), Faculdade de Ceilândia, Brasília, Distrito Federal, Brazil
| | - Elaine Minatel
- Departamento de Biologia Estrutural e Funcional, Instituto de Biologia, Universidade Estadual de Campinas (UNICAMP), Campinas, São Paulo, Brazil
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Mendell JR, Shieh PB, McDonald CM, Sahenk Z, Lehman KJ, Lowes LP, Reash NF, Iammarino MA, Alfano LN, Sabo B, Woods JD, Skura CL, Mao HC, Staudt LA, Griffin DA, Lewis S, Wang S, Potter RA, Singh T, Rodino-Klapac LR. Expression of SRP-9001 dystrophin and stabilization of motor function up to 2 years post-treatment with delandistrogene moxeparvovec gene therapy in individuals with Duchenne muscular dystrophy. Front Cell Dev Biol 2023; 11:1167762. [PMID: 37497476 PMCID: PMC10366687 DOI: 10.3389/fcell.2023.1167762] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/09/2023] [Indexed: 07/28/2023] Open
Abstract
Introduction: Delandistrogene moxeparvovec (SRP-9001) is an investigational gene transfer therapy designed for targeted expression of SRP-9001 dystrophin protein, a shortened dystrophin retaining key functional domains of the wild-type protein. Methods: This Phase 2, double-blind, two-part (48 weeks per part) crossover study (SRP-9001-102 [Study 102]; NCT03769116) evaluated delandistrogene moxeparvovec in patients, aged ≥4 to <8 years with Duchenne muscular dystrophy. Primary endpoints (Part 1) were change from baseline (CFBL) in SRP-9001 dystrophin expression (Week 12), by Western blot, and in North Star Ambulatory Assessment (NSAA) score (Week 48). Safety assessments included treatment-related adverse events (TRAEs). Patients were randomized and stratified by age to placebo (n = 21) or delandistrogene moxeparvovec (n = 20) and crossed over for Part 2. Results: SRP-9001 dystrophin expression was achieved in all patients: mean CFBL to Week 12 was 23.82% and 39.64% normal in Parts 1 and 2, respectively. In Part 1, CFBL to Week 48 in NSAA score (least-squares mean, LSM [standard error]) was +1.7 (0.6) with treatment versus +0.9 (0.6) for placebo; p = 0.37. Disparity in baseline motor function between groups likely confounded these results. In 4- to 5-year-olds with matched baseline motor function, CFBL to Week 48 in NSAA scores was significantly different (+2.5 points; p = 0.0172), but not significantly different in 6-to-7-year-olds with imbalanced baseline motor function (-0.7 points; p = 0.5384). For patients treated with delandistrogene moxeparvovec in Part 2, CFBL to Week 48 in NSAA score was +1.3 (2.7), whereas for those treated in Part 1, NSAA scores were maintained. As all patients in Part 2 were exposed to treatment, results were compared with a propensity-score-weighted external control (EC) cohort. The LSM difference in NSAA score between the Part 2 treated group and EC cohort was statistically significant (+2.0 points; p = 0.0009). The most common TRAEs were vomiting, decreased appetite, and nausea. Most occurred within the first 90 days and all resolved. Discussion: Results indicate robust expression of SRP-9001 dystrophin and overall stabilization in NSAA up to 2 years post-treatment. Differences in NSAA between groups in Part 1 were not significant for the overall population, likely because cohorts were stratified only by age, and other critical prognostic factors were not well matched at baseline.
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Affiliation(s)
- Jerry R. Mendell
- Center for Gene Therapy, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Pediatrics, The Ohio State University, Columbus, OH, United States
- Department of Neurology, The Ohio State University, Columbus, OH, United States
| | | | - Craig M. McDonald
- Departments of Physical Medicine and Rehabilitation and Pediatrics, Lawrence J. Ellison Ambulatory Care Center, UC Davis Health, Sacramento, CA, United States
| | - Zarife Sahenk
- Center for Gene Therapy, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Pediatrics, The Ohio State University, Columbus, OH, United States
- Department of Neurology, The Ohio State University, Columbus, OH, United States
| | - Kelly J. Lehman
- Center for Gene Therapy, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Linda P. Lowes
- Center for Gene Therapy, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Pediatrics, The Ohio State University, Columbus, OH, United States
| | - Natalie F. Reash
- Center for Gene Therapy, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Megan A. Iammarino
- Center for Gene Therapy, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Lindsay N. Alfano
- Center for Gene Therapy, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Brenna Sabo
- Center for Gene Therapy, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH, United States
| | | | | | | | | | | | - Sarah Lewis
- Sarepta Therapeutics Inc, Cambridge, MA, United States
| | - Shufang Wang
- Sarepta Therapeutics Inc, Cambridge, MA, United States
| | | | - Teji Singh
- Sarepta Therapeutics Inc, Cambridge, MA, United States
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Farrar MA, Kariyawasam D, Grattan S, Bayley K, Davis M, Holland S, Waddel LB, Jones K, Lorentzos M, Ravine A, Wotton T, Wiley V. Newborn Screening for the Diagnosis and Treatment of Duchenne Muscular Dystrophy. J Neuromuscul Dis 2023; 10:15-28. [PMID: 36373292 PMCID: PMC9881031 DOI: 10.3233/jnd-221535] [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] [Indexed: 11/13/2022]
Abstract
A pilot newborn screening (NBS) program for Duchenne muscular dystrophy (DMD) study proposes to assess the feasibility of the screening procedure, temporal course of the various steps of screening, and the public acceptability of the program. This is particularly vital to ascertain as DMD is considered a 'non-treatable' disease and thus does not fit the traditional criteria for newborn screening. However, modern perspectives of NBS for DMD are changing and point to possible net benefits for children and their families undertaking NBS for DMD. The aim of this workshop was to establish pathways for the successful implementation and evaluation of a pilot NBS for DMD program in Australia. Consensus was reached as to the rationale for, potential benefits, risks, barriers and facilitators of screening, alongside the establishment of screening protocols and clinical referral pathways.
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Affiliation(s)
- Michelle A. Farrar
- Department of Paediatric Neurology, Sydney Children’s Hospital Network, Sydney, NSW, Australia,Discipline of Paediatrics, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
| | - Didu Kariyawasam
- Department of Paediatric Neurology, Sydney Children’s Hospital Network, Sydney, NSW, Australia,Discipline of Paediatrics, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
| | - Sarah Grattan
- Department of Paediatric Neurology, Sydney Children’s Hospital Network, Sydney, NSW, Australia,Discipline of Paediatrics, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
| | - Klair Bayley
- Harry Perkins Institute of Medical Research, The University of Western Australia, Nedlands, WA, Australia
| | - Mark Davis
- Department of Diagnostic Genomics, PathWest Laboratory Medicine, QEII Medical Centre, Perth, WA, Australia
| | - Sandra Holland
- Department of Paediatric Neurology, Sydney Children’s Hospital Network, Sydney, NSW, Australia,Discipline of Paediatrics, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
| | - Leigh B. Waddel
- Discipline of Child and Adolescent Health, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia,Kids Neuroscience Centre, The Children’s Hospital at Westmead, Westmead, NSW, Australia,Discipline of Paediatrics, University of Sydney, Sydney, NSW, Australia
| | - Kristi Jones
- Discipline of Child and Adolescent Health, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Michelle Lorentzos
- The T.Y. Nelson Department of Neurology and Neurosurgery, The Children’s Hospital at Westmead, Sydney, NSW, Australia,Kids Neuroscience Centre, The Children’s Hospital at Westmead, Westmead, NSW, Australia,Discipline of Paediatrics, University of Sydney, Sydney, NSW, Australia
| | - Anja Ravine
- NSW Newborn Screening Programme, Children’s Hospital Westmead, Westmead, NSW, Australia
| | - Tiffany Wotton
- NSW Newborn Screening Programme, Children’s Hospital Westmead, Westmead, NSW, Australia
| | - Veronica Wiley
- NSW Newborn Screening Programme, Children’s Hospital Westmead, Westmead, NSW, Australia
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5
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Ulm EA, Nagaraj CB, Tian C, Smolarek TA. Identification of Biallelic dystrophin gene variants during maternal carrier testing for Becker muscular dystrophy and review of the DMD exon 49-51 deletion phenotype. Mol Genet Genomic Med 2022; 11:e2088. [PMID: 36424846 PMCID: PMC9834199 DOI: 10.1002/mgg3.2088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Dystrophinopathies are X-linked recessive conditions caused by pathogenic variants in the dystrophin (DMD) gene. In a family that included two boys with Becker muscular dystrophy (BMD) due to a DMD deletion of exons 45-47, maternal carrier testing unexpectedly identified biallelic DMD deletions of exons 45-47 and 49-51. METHODS The patient's mild phenotype in the setting of biallelic DMD variants prompted further investigation of the exon 49-51 deletion in particular, via literature review and retrospective chart review of patients who have been evaluated in our institution's comprehensive neuromuscular center and/or diagnosed in our clinical genetic testing laboratory. RESULTS To our knowledge, this is only the fifth case of confirmed biallelic DMD variants in a female. In males, the DMD exon 49-51 deletion appears to result in a mild BMD phenotype with low or normal creatine kinase levels. This deletion comprised 19% (4/21) of dystrophinopathies diagnosed by chromosomal microarray (CMA) in males during the past ten years in our clinical laboratory. Most individuals identified by chart review were diagnosed through CMA, despite the fact that microarray was genome-wide and not DMD-specific. This case raised important genetic counseling issues. CONCLUSION The DMD exon 49-51 deletion appears to cause a variable but generally mild BMD phenotype. Its relatively frequent detection by CMA suggests it may be underdiagnosed.
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Affiliation(s)
- Elizabeth A. Ulm
- Division of Human GeneticsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Chinmayee B. Nagaraj
- Division of Human GeneticsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA,Division of NeurologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Cuixia Tian
- Division of NeurologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA,Department of PediatricsUniversity of Cincinnati School of MedicineCincinnatiOhioUSA
| | - Teresa A. Smolarek
- Division of Human GeneticsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA,Department of PediatricsUniversity of Cincinnati School of MedicineCincinnatiOhioUSA
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miRNome profiling in Duchenne muscular dystrophy; identification of asymptomatic and manifesting female carriers. Biosci Rep 2021; 41:229711. [PMID: 34472584 PMCID: PMC8450315 DOI: 10.1042/bsr20211325] [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: 06/03/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 11/17/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) is a fatal neuromuscular disorder that occurs due to inactivating mutations in DMD gene, leading to muscular dystrophy. Prediction of pathological complications of DMD and the identification of female carriers are important research points that aim to reduce disease burden. Herein, we describe a case of a late DMD patient and his immediate female family members, who all carry same DMD mutation and exhibited varied degrees of symptoms. In our study, we sequenced the whole miRNome in leukocytes and plasma of the family members and results were validated using real-time PCR. Our results highlighted the role of miR-409-3p, miR-424-5p, miR-144-3p as microRNAs that show correlation with the extent of severity of muscular weakness and can be used for detection of asymptomatic carriers. Cellular and circulating levels of miR-494-3p had shown significant increase in symptomatic carriers, which may indicate significant roles played by this miRNA in the onset of muscular weakness. Interestingly, circulating levels of miR-206 and miR-410-3p were significantly increased only in the severely symptomatic carrier. In conclusion, our study highlighted several miRNA species, which could be used in predicting the onset of muscle and/or neurological complications in DMD carriers.
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Kincl V, Panovský R, Pešl M, Máchal J, Juříková L, Haberlová J, Masárová L. Echocardiographic signs of subclinical cardiac function impairment in Duchenne dystrophy gene carriers. Sci Rep 2020; 10:20794. [PMID: 33247228 PMCID: PMC7695725 DOI: 10.1038/s41598-020-77882-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 11/17/2020] [Indexed: 11/16/2022] Open
Abstract
To assess subclinical cardiac function impairment in Duchenne dystrophy (DMD) female carriers. Forty-four female subjects proved as DMD carriers underwent echocardiographic examination including tissue Doppler imaging (TDI) of mitral and tricuspid annulus. Seventeen age-matched healthy female subjects served as controls. A significant differences in peak systolic annular velocity (Sa) between carriers and controls were found for lateral and septal part of the mitral annulus and for tricuspid annulus (0.09 vs. 0.11 m/s, p < 0.001, 0.08 vs. 0.09 m/s, p < 0.01 and 0.13 vs. 0.14 m/s, p = 0.02 respectively). There was also difference in early diastolic velocity (Ea) of the septal part of the mitral annulus (0.11 vs. 0.13 m/s, p = 0.03). The subclinical deterioration of systolic function is presented even in asymptomatic DMD female carriers.
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Affiliation(s)
- Vladimír Kincl
- Department of Internal Medicine/Cardiology, Faculty of Medicine, St. Anne's University Hospital, Masaryk University, Brno, Czech Republic. .,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic.
| | - Roman Panovský
- Department of Internal Medicine/Cardiology, Faculty of Medicine, St. Anne's University Hospital, Masaryk University, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Martin Pešl
- Department of Internal Medicine/Cardiology, Faculty of Medicine, St. Anne's University Hospital, Masaryk University, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic.,Department of Biology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan Máchal
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic.,Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Lenka Juříková
- Department of Pediatric Neurology, Faculty of Medicine, University Hospital Brno, Masaryk University, Brno, Czech Republic
| | - Jana Haberlová
- Department of Pediatric Neurology, Second Faculty of Medicine, University Hospital Motol, Charles University, Prague, Czech Republic
| | - Lucia Masárová
- Department of Internal Medicine/Cardiology, Faculty of Medicine, St. Anne's University Hospital, Masaryk University, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
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