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Kon E, Anzillotti G, Conte P, Ruosi L, Cole B, Dragoo J, Zaslav K, Frank R, De Girolamo L, Mandelbaum B, Rodeo S, Marcacci M, Filardo G, Di Matteo B. The chimera of reaching a universal consensus on platelet-rich plasma treatment for knee osteoarthritis: a review of recent consensus statements and expert opinion. Expert Opin Biol Ther 2024; 24:827-833. [PMID: 39073848 DOI: 10.1080/14712598.2024.2383865] [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: 04/19/2024] [Revised: 06/28/2024] [Accepted: 07/20/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Osteoarthritis (OA) is a prevalent cause of disability worldwide, affecting millions and posing significant socioeconomic burdens. Various conservative measures like hyaluronic acid (HA) and platelet-rich plasma (PRP) injections aim to manage OA symptoms and delay surgical interventions. Despite the increasing utilization of PRP, consensus on its efficacy remains elusive, reflecting the evolving landscape of OA management. AREAS COVERED This study reviews guidelines and recommendations on intra-articular PRP injections for OA globally, highlighting divergent perspectives among different medical societies. A comprehensive literature search identified 19 relevant guidelines, indicating a temporal and geographic evolution in attitudes toward PRP use. While some guidelines endorse PRP for mild-to-moderate OA, others express caution due to concerns about product standardization and clinical evidence heterogeneity. EXPERT OPINION The lack of universal consensus on PRP for OA underscores the complex interplay between clinical evidence, practice patterns, and evolving perspectives. Recent shifts toward endorsing PRP may reflect advancements in preparation techniques and personalized medicine approaches. However, challenges persist, including patient selection and product standardization. Efforts to develop consensus and refine PRP classification systems are essential for guiding clinical practice and advancing OA management.
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Affiliation(s)
- Elizaveta Kon
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Giuseppe Anzillotti
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Pietro Conte
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Luca Ruosi
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Brian Cole
- Midwest Orthopaedics at Rush University Medical Center, Chicago, IL, USA
| | - Jason Dragoo
- Division of Sports Medicine, Department of Orthopaedic Surgery, School of Medicine, University of Colorado, Boulder, CO, USA
| | - Ken Zaslav
- Center for Regenerative Orthopedic Medicine, Northwell Health-Lenox Hill Hospital, New York, NY, USA
- Orthopedic Surgery Zucker School of Medicine Hofstra University, New York, NY, USA
| | - Rachel Frank
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, CO, USA
| | | | | | - Scott Rodeo
- Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY, USA
- Department of Medicine Weill Cornell Medicine, New York, NY, USA
| | - Maurilio Marcacci
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Giuseppe Filardo
- Department of Surgery, Service of Orthopaedics and Traumatology, Lugano, EOC, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Berardo Di Matteo
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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Rizk E, Tajchman S, Fink E, Aryal DK, Iso T, Flores E, Brown AE, Chokshi SP, Desai SN, Dewan AK, Kazzaz SA, Guevara M, Nagaraj S, Robben CP, Vittone V, Swan JT. Quality indicators for osteoarthritis pain management in the primary care setting. BMC Musculoskelet Disord 2023; 24:538. [PMID: 37391737 DOI: 10.1186/s12891-023-06637-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/14/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Development of valid and feasible quality indicators (QIs) is needed to track quality initiatives for osteoarthritis pain management in primary care settings. METHODS Literature search identified published guidelines that were reviewed for QI extraction. A panel of 14 experts was assembled, including primary care physicians, rheumatologists, orthopedic surgeons, pain specialists, and outcomes research pharmacists. A screening survey excluded QIs that cannot be reliably extracted from the electronic health record or that are irrelevant for osteoarthritis in primary care settings. A validity screening survey used a 9-point Likert scale to rate the validity of each QI based on predefined criteria. During expert panel discussions, stakeholders revised QI wording, added new QIs, and voted to include or exclude each QI. A priority survey used a 9-point Likert scale to prioritize the included QIs. RESULTS Literature search identified 520 references published from January 2015 to March 2021 and 4 additional guidelines from professional/governmental websites. The study included 41 guidelines. Extraction of 741 recommendations yielded 115 candidate QIs. Feasibility screening excluded 28 QIs. Validity screening and expert panel discussion excluded 73 QIs and added 1 QI. The final set of 15 prioritized QIs focused on pain management safety, education, weight-management, psychological wellbeing, optimizing first-line medications, referral, and imaging. CONCLUSION This multi-disciplinary expert panel established consensus on QIs for osteoarthritis pain management in primary care settings by combining scientific evidence with expert opinion. The resulting list of 15 prioritized, valid, and feasible QIs can be used to track quality initiatives for osteoarthritis pain management.
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Affiliation(s)
- Elsie Rizk
- Department of Pharmacy, Houston Methodist, Houston, TX, USA
- Department of Surgery, Houston Methodist, TX, Houston, USA
| | | | - Ezekiel Fink
- Department of Neurology, Houston Methodist, Houston, TX, USA
| | - Dipendra K Aryal
- Department of Pharmacy, Houston Methodist, Houston, TX, USA
- Department of Surgery, Houston Methodist, TX, Houston, USA
| | - Tomona Iso
- Department of Pharmacy, Houston Methodist, Houston, TX, USA
- Department of Surgery, Houston Methodist, TX, Houston, USA
| | - Eleazar Flores
- Houston Methodist Primary Care Group, Houston Methodist, Houston, TX, USA
| | - Anthony E Brown
- Houston Methodist Primary Care Group, Houston Methodist, Houston, TX, USA
| | - Sagar P Chokshi
- Department of Neurosurgery, Houston Methodist, Houston, TX, USA
| | | | - Ashvin K Dewan
- Department of Orthopedic Surgery, Houston Methodist, Houston, TX, USA
| | - Sarah A Kazzaz
- Houston Methodist Academic Medicine Associates - Rheumatology, Houston Methodist, Houston, TX, USA
| | - Myriam Guevara
- Houston Methodist Academic Medicine Associates - Rheumatology, Houston Methodist, Houston, TX, USA
| | - Sudha Nagaraj
- Houston Methodist Primary Care Group, Houston Methodist, Houston, TX, USA
| | | | - Veronica Vittone
- Houston Methodist Primary Care Group, Houston Methodist, Houston, TX, USA
| | - Joshua T Swan
- Department of Pharmacy, Houston Methodist, Houston, TX, USA.
- Department of Surgery, Houston Methodist, TX, Houston, USA.
- Center for Outcomes Research, Houston Methodist, Houston, TX, USA.
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, SM1661, Houston, TX, 77030, USA.
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Heard BJ, Barton KI, Abubacker S, Chung M, Martin CR, Schmidt TA, Shrive NG, Hart DA. Synovial and cartilage responsiveness to peri-operative hyaluronic acid ± dexamethasone administration following a limited injury to the rabbit stifle joint. J Orthop Res 2022; 40:838-845. [PMID: 34061360 DOI: 10.1002/jor.25108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/03/2021] [Accepted: 05/25/2021] [Indexed: 02/04/2023]
Abstract
Posttraumatic osteoarthritis (PTOA) can develop after an injury to the knee. Previous studies have indicated that an intra-articular (IA) injection of the potent glucocorticoid dexamethasone (DEX) may significantly prevent induction of PTOA. The aim of the present study was to investigate the effectiveness of a single IA injection of hyaluronic acid (HA), alone and in combination with DEX following a localized intra-articular injury as a PTOA-preventing treatment option. An established rabbit model of surgical injury consisting of dual intra-articular (IA) drill holes in a non-cartilaginous area of the femoral notch near the origin of the anterior cruciate ligament (ACL) to allow for bleeding into the joint space was used. Immediately following surgery, subjects were treated with HA, HA + DEX, or received no treatment. An uninjured control group was used for comparison (N = 5/group). Rabbits were sacrificed and investigated at 9 weeks post-injury. At 9 weeks post-injury, there was a significant protective capacity of the single IA treatment of DEX + HA on the histological grade of the synovial tissue, and some variable location-specific effects of HA alone and HA + DEX interactions on cartilage damage. Thus, it is possible that co-treatment with HA may interfere with the effectiveness of the DEX. In vitro friction testing indicated that DEX did not interfere with the lubricating ability of HA or synovial fluid on cartilage. These results suggest that a single IA administration of HA in combination with DEX following an IA injury is not recommended for inhibition of PTOA progression in this model.
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Affiliation(s)
- B J Heard
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.,Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - K I Barton
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.,Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - S Abubacker
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.,Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - M Chung
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | - C R Martin
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.,Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - T A Schmidt
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.,Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Sculich School of Engineering, University of Calgary, Calgary, Alberta, Canada
| | - N G Shrive
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.,Sculich School of Engineering, University of Calgary, Calgary, Alberta, Canada
| | - D A Hart
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.,Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Bone & Joint Health Strategic Clinical Network, Edmonton, Alberta, Canada
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Degen RM, Hiemstra LA, Lobo J, Woodmass JM, Sommerfeldt M, Khan M, Carsen S, Pauyo T, Chahal J, Urquhart N, Grant J, Rousseau-Saine A, Lebel ME, Sheehan B, Sandman E, Tucker A, Kopka M, Wong I. Arthroscopy Association of Canada Position Statement on Intra-articular Injections for Hip Osteoarthritis. Orthop J Sports Med 2022; 10:23259671211066966. [PMID: 35155702 PMCID: PMC8832617 DOI: 10.1177/23259671211066966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Ryan M. Degen
- Arthroscopy Association of Canada
- Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
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Long DM, Fitzpatrick J. Safety and efficacy of a single intra-articular injection of hyaluronic acid in osteoarthritis of the hip: a case series of 87 patients. BMC Musculoskelet Disord 2021; 22:797. [PMID: 34530784 PMCID: PMC8447787 DOI: 10.1186/s12891-021-04672-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 09/01/2021] [Indexed: 01/16/2023] Open
Abstract
Background Osteoarthritis (OA) is the most prevalent form of joint disease and commonly affects the hip. Hip OA is associated with a high socioeconomic burden. Intra-articular hyaluronic acid (HA) injection may be of benefit but quality evidence for HA use in hip OA is lacking. The purpose of this study was to assess the safety and efficacy of ultrasound guided injection of a high molecular weight, non-animal derived, stabilised HA (NASHA) in patients with mild to moderate hip OA. Methods This single site study is an analysis of prospectively collected outcome data for 87 consecutive patients over a 2-year period who received a single HA (Durolane) injection for symptomatic hip OA. Inclusion criteria were male or female patients over 18-years of age with mild to moderate hip OA on x-ray. Patients with severe hip OA were excluded. The primary outcome measure was a modified Harris Hip Score (mHHS) questionnaire at baseline and 6-weeks with a minimal clinically important difference (MCID) of 10 points. All adverse events were recorded and assessed. Results Data from 87 patients, 49 women and 38 men with mean age of 54 (SD = 10.8) were analysed. At baseline, mean mHHS was 58.47 (SD 14.31). At the 6 week follow up, mean mHHS improved to 71.30 (SD 16.46), a difference of 12.83 (p < 0.01). This was greater than the MCID of 10. No significant adverse events were encountered. Five patients reported short-lived injection site pain. Conclusion A single injection of HA (NASHA) in the setting of hip joint OA was both safe and efficacious in this 87 patient cohort. Improvement in pain and function as measured with mHHS was statistically significant and reached the MCID of 10. Trial registration The study was retrospectively registered on the 1st of February 2021 in the Australian New Zealand Clinical Trials Registry with registry number ACTRN12621000098831. All research was performed in accordance with the Declaration of Helsinki.
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Affiliation(s)
- David M Long
- Olympic Park Sports Medicine Centre, 60 Olympic Blvd, Melbourne, 3004, Australia.,School of Medicine, Deakin University, Little Malop St, Geelong, Victoria, 3220, Australia
| | - Jane Fitzpatrick
- Centre for Health and Exercise Sports Medicine, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Level 7, Alan Gilbert Building, 161 Barry Street, Parkville, Victoria, 3010, Australia. .,Joint Health Institute, Malvern, Victoria, 3144, Australia.
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Phillips M, Bhandari M, Grant J, Bedi A, Trojian T, Johnson A, Schemitsch E. A Systematic Review of Current Clinical Practice Guidelines on Intra-articular Hyaluronic Acid, Corticosteroid, and Platelet-Rich Plasma Injection for Knee Osteoarthritis: An International Perspective. Orthop J Sports Med 2021; 9:23259671211030272. [PMID: 34485586 PMCID: PMC8414628 DOI: 10.1177/23259671211030272] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/01/2021] [Indexed: 12/31/2022] Open
Abstract
Background: There are many clinical practice guidelines (CPGs) for the prevention,
diagnosis, and treatment of knee osteoarthritis (OA). They differ by region,
considering local health care systems, along with cultural and economic
factors. Currently, there are conflicting CPG recommendations across the
various publications, which makes it difficult for clinicians to fully
understand the optimal treatment decisions for knee OA management. Purpose: To summarize the current published CPG recommendations for the role of
injections in the nonoperative management of knee OA, specifically with the
use of intra-articular hyaluronic acid (IA-HA), intra-articular
corticosteroids (IA-CS), and platelet-rich plasma (PRP). Study Design: Systematic review. Methods: A comprehensive search identified all nonoperative knee OA CPGs within the
ECRI (formerly Emergency Care Research Institute) Guidelines Trust database,
the Guidelines International Network database, Google Scholar, and the Trip
(formerly Turning Research Into Practice) database. Guideline
recommendations were categorized into strong, conditional, or uncertain
recommendations for or against the use of IA-HA, IA-CS, or PRP. Guideline
recommendations were summarized and depicted graphically to identify trends
in recommendations over time. Results: The search strategy identified 27 CPGs that provided recommendations. There
were 20 recommendations in favor of IA-HA use, 21 recommendations in favor
of IA-CS use, and 9 recommendations that were uncertain or unable to make a
formal recommendation for or against PRP use based on current evidence. Most
recommendations considered IA-HA and IA-CS use for symptom relief when other
nonoperative options are ineffective. IA-CS were noted to provide fast and
short-acting symptom relief for acute episodes of disease exacerbation,
while IA-HA may demonstrate a relatively delayed but prolonged effect in
comparison. The CPGs concluded that PRP recommendations currently lack
evidence to definitively recommend for or against use. Conclusion: Available CPGs provide recommendations on injectables for knee OA treatment.
General guidance from a global perspective concluded that IA-CS and IA-HA
are favored for different needed responses and can be utilized within the
knee OA treatment paradigm, while PRP currently has insufficient evidence to
make a conclusive recommendation for or against its use.
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Affiliation(s)
- Mark Phillips
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.,Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - John Grant
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas Trojian
- Department of Family Medicine, WellSpan Health, York, Pennsylvania, USA
| | - Aaron Johnson
- Department of Orthopaedics, University of Maryland, College Park, Maryland, USA
| | - Emil Schemitsch
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
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Jayaram P, Liu C, Dawson B, Ketkar S, Patel SJ, Lee BH, Grol MW. Leukocyte-dependent effects of platelet-rich plasma on cartilage loss and thermal hyperalgesia in a mouse model of post-traumatic osteoarthritis. Osteoarthritis Cartilage 2020; 28:1385-1393. [PMID: 32629163 PMCID: PMC7787501 DOI: 10.1016/j.joca.2020.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 06/14/2020] [Accepted: 06/22/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Platelet-rich plasma (PRP) is an emerging therapeutic strategy for treatment of osteoarthritis (OA); however, there is a lack of preclinical and clinical evidence for its efficacy and its mechanism of action is unclear. In the current study, we utilized leukocyte poor-PRP (LP-PRP) and leukocyte rich-PRP (LR-PRP) to mimic clinical point of care formulations and assessed their potential to alter disease progression in a mouse model of post-traumatic OA. METHOD Three-month-old wild-type male FVB/N mice received destabilization of the medial meniscus (DMM) surgery to induce OA. To assess the efficacy of LP-PRP and LR-PRP, mice were given intraarticular injections at 2-, 7- and 28-days post-surgery. Mice were then assessed at 5-, 9-, and 13-weeks post-surgery for changes in chronic pain using the hot plate nociceptive assay. At 14-weeks, OA pathogenesis was evaluated using histology and phase-contrast μCT. RESULTS Treatment with LP-PRP and to a lesser extent LR-PRP preserved cartilage volume and surface area compared to phosphate-buffered saline (PBS) as measured by phase-contrast μCT. However, both treatments had higher Osteoarthritis Research Society International (OARSI) and synovitis scores compared to sham, and neither substantially improved scores compared to PBS controls. With respect to thermal hyperalgesia, PBS-treated mice displayed reduced latency to response compared to sham, and LR-PRP but not LP-PRP improved latency to response at 5-, 9- and 13-weeks post-surgery compared to PBS. CONCLUSION The results of this study suggest that effects of PRP therapy on OA progression and disease-induced hyperalgesia may be leukocyte-dependent. And while LP-PRP and to a lesser extent LR-PRP protect from volume and surface loss, significant pathology is still seen within OA joints. Future work is needed to understand how the different components of PRP effect OA pathogenesis and pain, and how these could be modified to achieve greater therapeutic efficacy.
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Affiliation(s)
- P Jayaram
- H. Ben Taub Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX, USA; Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - C Liu
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - B Dawson
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - S Ketkar
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - S J Patel
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - B H Lee
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA.
| | - M W Grol
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA.
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