1
|
Mak CM, Woo PPS, Song FE, Chan FCH, Chan GPY, Pang TLF, Au BSC, Chan TCH, Chong YK, Law ECY, Lam CW. Computer-assisted patient identification tool in inborn errors of metabolism - potential for rare disease patient registry and big data analysis. Clin Chim Acta 2024; 561:119811. [PMID: 38879064 DOI: 10.1016/j.cca.2024.119811] [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: 11/30/2023] [Revised: 05/29/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Patient registries are crucial for rare disease management. However, manual registry construction is labor-intensive and often not user-friendly. Our goal is to establish Hong Kong's first computer-assisted patient identification tool for rare diseases, starting with inborn errors of metabolism (IEM). METHODS Patient data from 2010 to 2019 was retrieved from electronic databases. Through big data analytics, patient data were filtered based on specific IEM-related biochemical and genetic tests. Clinical notes were analyzed using a rule-based natural language processing technique called regular expression. The algorithm classified each extracted paragraph as "IEM-related" or "not IEM-related." Pathologists reviewed the paragraphs for curation, and the algorithm's performance was evaluated. RESULTS Out of 46,419 patients with IEM-related tests, the algorithm identified 100 as "IEM-related." After pathologists' validation, 96 cases were confirmed as true IEM, with 1 uncertain case and 3 false positives. A secondary ascertainment yielded a sensitivity of 92.3% compared to our previously published IEM cohort. CONCLUSIONS Our artificial intelligence approach provides a novel method to identify IEM patients, facilitating the creation of a centralized, computer-assisted rare disease patient registry at the local and national levels. This data can potentially be accessed by multiple stakeholders for collaborative research and to enhance healthcare management for rare diseases.
Collapse
Affiliation(s)
- Chloe Miu Mak
- Chemical Pathology Laboratory, Department of Pathology, Hong Kong Children's Hospital, Hong Kong SAR, China.
| | - Pauline Pao Sun Woo
- Statistics and Data Science Department, Hospital Authority, Hong Kong SAR, China
| | - Felicite Enyu Song
- Chemical Pathology Laboratory, Department of Pathology, Hong Kong Children's Hospital, Hong Kong SAR, China
| | - Felix Chi Hang Chan
- Statistics and Data Science Department, Hospital Authority, Hong Kong SAR, China
| | - Grace Pui Ying Chan
- Statistics and Data Science Department, Hospital Authority, Hong Kong SAR, China
| | - Tony Long Fung Pang
- Statistics and Data Science Department, Hospital Authority, Hong Kong SAR, China
| | - Brian Siu Chun Au
- Statistics and Data Science Department, Hospital Authority, Hong Kong SAR, China
| | - Toby Chun Hei Chan
- Chemical Pathology Laboratory, Department of Pathology, Hong Kong Children's Hospital, Hong Kong SAR, China
| | - Yeow Kuan Chong
- Chemical Pathology Laboratory, Department of Pathology, Princess Margaret Hospital, Hong Kong SAR, China
| | - Eric Chun Yiu Law
- Chemical Pathology Laboratory, Department of Pathology, Hong Kong Children's Hospital, Hong Kong SAR, China
| | - Ching Wan Lam
- Chemical Pathology Laboratory, Department of Pathology, Queen Mary Hospital, Hong Kong SAR, China
| |
Collapse
|
2
|
Fujino H, Takahashi MP, Nakamura H, Heatwole CR, Takada H, Kuru S, Ogata K, Enomoto K, Hayashi Y, Imura O, Matsumura T. Facioscapulohumeral muscular dystrophy Health Index: Japanese translation and validation study. Disabil Rehabil 2024:1-10. [PMID: 38555736 DOI: 10.1080/09638288.2024.2322035] [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: 06/18/2023] [Accepted: 02/17/2024] [Indexed: 04/02/2024]
Abstract
PURPOSE The Facioscapulohumeral Muscular Dystrophy Health Index (FSHD-HI) is a patient-reported outcome measure developed for patients with FSHD. This study aimed to translate the FSHD-HI into Japanese (FSHD-HI-J), evaluate cultural adaptation, and examine its psychometric properties. MATERIALS AND METHODS We created two forward translations, integrated them into a single Japanese version, and evaluated the back-translated version of the FSHD-HI. After finalizing the translation and cultural adaptation, we conducted a survey of 66 patients with FSHD to examine the reliability and validity of the FSHD-HI-J. For psychometric evaluations, we used Cronbach's alpha to assess internal consistency, the intraclass correlation coefficient (ICC) for test-retest reliability, and assessed validity based on the associations between FSHD-HI-J, clinical variables, and quality of life measures. RESULTS The FSHD-HI-J was found to be clinically relevant, indicating high internal consistency and test-retest reliability (ICC = 0.92 [95% confidence interval: 0.86-0.95] for the total score), as well as significant associations with clinical variables (D4Z4 repeats and functional impairment) and other quality of life measures (|rho| = 0.25-0.73). CONCLUSIONS The FSHD-HI-J is a valid and reliable patient-reported outcome measure for Japanese patients with FSHD. This validated, disease-specific patient-reported outcome is essential for future clinical practice and clinical trials.
Collapse
Affiliation(s)
- Haruo Fujino
- United Graduate School of Child Development, Osaka University, Suita, Osaka, Japan
| | - Masanori P Takahashi
- Clinical Neurophysiology, Department of Clinical Laboratory and Biomedical Sciences, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Harumasa Nakamura
- Department of Clinical Research Support, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Chad R Heatwole
- Department of Neurology, University of Rochester, Rochester, NY, USA
- Center for Health and Technology, Rochester, NY, USA
| | - Hiroto Takada
- Department of Neurology, NHO Aomori National Hospital, Aomori, Japan
| | - Satoshi Kuru
- Department of Neurology, NHO Suzuka National Hospital, Suzuka, Mie, Japan
| | - Katsuhisa Ogata
- Department of Neurology, NHO Higashisaitama National Hospital, Hasuda, Saitama, Japan
| | - Kiyoka Enomoto
- United Graduate School of Child Development, Osaka University, Suita, Osaka, Japan
- Pain Management Clinic, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan
| | - Yuto Hayashi
- Department of Neurology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Osamu Imura
- Faculty of Social Sciences, Nara University, Nara, Japan
| | - Tsuyoshi Matsumura
- Department of Neurology, NHO Osaka Toneyama Medical Center, Toyonaka, Osaka, Japan
| |
Collapse
|
3
|
Ivanovic V, Peric S, Pesovic J, Tubic R, Bozovic I, Petrovic Djordjevic I, Savic-Pavicevic D, Meola G, Rakocevic-Stojanovic V. Clinical score for early diagnosis of myotonic dystrophy type 2. Neurol Sci 2023; 44:1059-1067. [PMID: 36401657 PMCID: PMC9925479 DOI: 10.1007/s10072-022-06507-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/12/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Myotonic dystrophy type 2 (DM2) is a rare, multisystemic, autosomal dominant disease with highly variable clinical presentation. DM2 is considered to be highly underdiagnosed. OBJECTIVE The aim of this study was to determine which symptoms, signs, and diagnostic findings in patients referred to neurological outpatient units are the most indicative to arouse suspicion of DM2. We tried to make a useful and easy-to-administer clinical scoring system for early diagnosis of DM2-DM2 early diagnosis score (DM2-EDS). PATIENTS AND METHODS Two hundred ninety-one patients with a clinical suspicion of DM2 were included: 69 were genetically confirmed to have DM2, and 222 patients were DM2 negative. Relevant history, neurological, and paraclinical data were obtained from the electronic medical records. RESULTS The following parameters appeared as significant predictors of DM2 diagnosis: cataracts (beta = 0.410, p < 0.001), myotonia on needle EMG (beta = 0.298, p < 0.001), hand tremor (beta = 0.211, p = 0.001), positive family history (beta = 0.171, p = 0.012), and calf hypertrophy (beta = 0.120, p = 0.043). In the final DM2-EDS, based on the beta values, symptoms were associated with the following values: cataracts (present 3.4, absent 0), myotonia (present 2.5, absent 0), tremor (present 1.7, absent 0), family history (positive 1.4, negative 0), and calf hypertrophy (present 1.0, absent 0). A cut-off value on DM2-EDS of 3.25 of maximum 10 points had a sensitivity of 84% and specificity of 81% to diagnose DM2. CONCLUSION Significant predictors of DM2 diagnosis in the neurology outpatient unit were identified. We made an easy-to-administer DM2-EDS score for early diagnosis of DM2.
Collapse
Affiliation(s)
- Vukan Ivanovic
- University of Belgrade - Faculty of Medicine, University Clinical Center of Serbia - Neurology Clinic, Dr. Subotic Street, 11 000, Belgrade, Serbia
| | - Stojan Peric
- University of Belgrade - Faculty of Medicine, University Clinical Center of Serbia - Neurology Clinic, Dr. Subotic Street, 11 000, Belgrade, Serbia.
| | - Jovan Pesovic
- University of Belgrade - Faculty of Biology, Center for Human Molecular Genetics, Belgrade, Serbia
| | - Radoje Tubic
- Institute of Oncology and Radiology of Serbia, Belgrade, Serbia
| | - Ivo Bozovic
- University of Belgrade - Faculty of Medicine, University Clinical Center of Serbia - Neurology Clinic, Dr. Subotic Street, 11 000, Belgrade, Serbia
| | - Ivana Petrovic Djordjevic
- University of Belgrade - Faculty of Medicine, University Clinical Center of Serbia - Cardiology Clinic, Belgrade, Serbia
| | - Dusanka Savic-Pavicevic
- University of Belgrade - Faculty of Biology, Center for Human Molecular Genetics, Belgrade, Serbia
| | - Giovanni Meola
- Department of Neurorehabilitation Sciences - Casa Di Cura del Policlinico, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Vidosava Rakocevic-Stojanovic
- University of Belgrade - Faculty of Medicine, University Clinical Center of Serbia - Neurology Clinic, Dr. Subotic Street, 11 000, Belgrade, Serbia
| |
Collapse
|
4
|
Puscas M, Martineau G, Bhella G, Bonnen PE, Carr P, Lim R, Mitchell J, Osmond M, Urquieta E, Flamenbaum J, Iaria G, Joly Y, Richer É, Saary J, Saint-Jacques D, Buckley N, Low-Decarie E. Rare diseases and space health: optimizing synergies from scientific questions to care. NPJ Microgravity 2022; 8:58. [PMID: 36550172 PMCID: PMC9780351 DOI: 10.1038/s41526-022-00224-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 08/23/2022] [Indexed: 12/24/2022] Open
Abstract
Knowledge transfer among research disciplines can lead to substantial research progress. At first glance, astronaut health and rare diseases may be seen as having little common ground for such an exchange. However, deleterious health conditions linked to human space exploration may well be considered as a narrow sub-category of rare diseases. Here, we compare and contrast research and healthcare in the contexts of rare diseases and space health and identify common barriers and avenues of improvement. The prevalent genetic basis of most rare disorders contrasts sharply with the occupational considerations required to sustain human health in space. Nevertheless small sample sizes and large knowledge gaps in natural history are examples of the parallel challenges for research and clinical care in the context of both rare diseases and space health. The two areas also face the simultaneous challenges of evidence scarcity and the pressure to deliver therapeutic solutions, mandating expeditious translation of research knowledge into clinical care. Sharing best practices between these fields, including increasing participant involvement in all stages of research and ethical sharing of standardized data, has the potential to contribute to humankind's efforts to explore ever further into space while caring for people on Earth in a more inclusive fashion.
Collapse
Affiliation(s)
- Maria Puscas
- Astronauts, Life Sciences and Space Medicine Canadian Space Agency, Government of Canada, Longueil, Canada
- The School of Health Sciences, University of Western Ontario, London, Canada
| | - Gabrielle Martineau
- Astronauts, Life Sciences and Space Medicine Canadian Space Agency, Government of Canada, Longueil, Canada
- Hawaii Institute of Marine Biology (HIMB), Kaneohe, HI, USA
| | - Gurjot Bhella
- Astronauts, Life Sciences and Space Medicine Canadian Space Agency, Government of Canada, Longueil, Canada
- University of Waterloo, Waterloo, Canada
| | - Penelope E Bonnen
- Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Phil Carr
- The Strategic Review Group Inc., Ottawa, Canada
| | - Robyn Lim
- Legislative and Regulatory Modernization, Health Canada, Ottawa, Canada
| | - John Mitchell
- Pediatric Endocrinology and Biochemical Genetics, Montreal Children's Hospital-McGill University, Human Genetics and Pediatrics, McGill University, Montreal, Canada
| | - Matthew Osmond
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Emmanuel Urquieta
- Translational Research Institute for Space Health (TRISH) and Department of Emergency Medicine and Center for Space Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jaime Flamenbaum
- Canadian Institutes of Health Research Ethics Office, Ottawa, Canada
| | - Giuseppe Iaria
- Department of Psychology, Hotchkiss Brain Institute, and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada
| | - Yann Joly
- Centre of Genomics and Policy, Faculty of Medicine, Human Genetics, McGill University, Montreal, Canada
| | - Étienne Richer
- Canadian Institutes of Health Research Institute of Genetics, Ottawa, Canada
| | - Joan Saary
- Department of Medicine, Division of Occupational Medicine, University of Toronto, Toronto, Canada
| | - David Saint-Jacques
- Astronauts, Life Sciences and Space Medicine Canadian Space Agency, Government of Canada, Longueil, Canada
- Astronauts, Life Sciences and Space Medicine Canadian Space Agency, Government of Canada, Longueil, Canada
| | - Nicole Buckley
- Astronauts, Life Sciences and Space Medicine Canadian Space Agency, Government of Canada, Longueil, Canada.
- Directorate of Human Spaceflight and Robotic Exploration, European Space Agency, Noordwijk, Holland.
| | - Etienne Low-Decarie
- Astronauts, Life Sciences and Space Medicine Canadian Space Agency, Government of Canada, Longueil, Canada.
- Agriculture and Agri-Food Canada, Government of Canada, Montreal, Canada.
| |
Collapse
|
5
|
Tieleman AA, Damen MJ, Verrips A, Roelofs M, Kamsteeg EJ, Voermans NC. Child Neurology: Maternal Transmission of Congenital Myotonic Dystrophy Type 2: Case Report. Neurology 2022; 99:1112-1114. [PMID: 36180234 DOI: 10.1212/wnl.0000000000201427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 09/02/2022] [Indexed: 11/15/2022] Open
Abstract
Congenital manifestations in Myotonic Dystrophy type 2 (DM2) point to anticipation and have only rarely been described. We report a three-generation family with genetically confirmed DM2. The youngest family member presented with unilateral congenital pes planovalgus and equinus. Genetic analysis in four family members showed a CCTG repeat expansion in the CNBP gene. We highlight the association between foot deformities and congenital DM2. Remarkably, the transmission to the congenital form of DM2 has been exclusively maternal so far. If this association is confirmed in other families, clinical practice and genetic counseling in DM2 families need to be adapted.
Collapse
Affiliation(s)
- Alide A Tieleman
- From the Department of Neurology (A.A.T., M.J.D., N.C.V.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen; Department of Neurology (A.V.), Canisius Wilhelmina Hospital, Nijmegen; Basalt Medical Rehabilitation Center (M.R.), the Hague; and Department of Genetics (E.-J.K.), Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Manon J Damen
- From the Department of Neurology (A.A.T., M.J.D., N.C.V.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen; Department of Neurology (A.V.), Canisius Wilhelmina Hospital, Nijmegen; Basalt Medical Rehabilitation Center (M.R.), the Hague; and Department of Genetics (E.-J.K.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Aad Verrips
- From the Department of Neurology (A.A.T., M.J.D., N.C.V.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen; Department of Neurology (A.V.), Canisius Wilhelmina Hospital, Nijmegen; Basalt Medical Rehabilitation Center (M.R.), the Hague; and Department of Genetics (E.-J.K.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Monique Roelofs
- From the Department of Neurology (A.A.T., M.J.D., N.C.V.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen; Department of Neurology (A.V.), Canisius Wilhelmina Hospital, Nijmegen; Basalt Medical Rehabilitation Center (M.R.), the Hague; and Department of Genetics (E.-J.K.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Erik-Jan Kamsteeg
- From the Department of Neurology (A.A.T., M.J.D., N.C.V.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen; Department of Neurology (A.V.), Canisius Wilhelmina Hospital, Nijmegen; Basalt Medical Rehabilitation Center (M.R.), the Hague; and Department of Genetics (E.-J.K.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Nicol C Voermans
- From the Department of Neurology (A.A.T., M.J.D., N.C.V.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen; Department of Neurology (A.V.), Canisius Wilhelmina Hospital, Nijmegen; Basalt Medical Rehabilitation Center (M.R.), the Hague; and Department of Genetics (E.-J.K.), Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
6
|
Nguyen CQ, Alba-Concepcion K, Palmer EE, Scully JL, Millis N, Farrar MA. The involvement of rare disease patient organisations in therapeutic innovation across rare paediatric neurological conditions: a narrative review. Orphanet J Rare Dis 2022; 17:167. [PMID: 35436886 PMCID: PMC9014615 DOI: 10.1186/s13023-022-02317-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 03/22/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The patient voice is becoming increasingly prominent across all stages of therapeutic innovation. It pervades research domains from funding and recruitment, to translation, care, and support. Advances in genomic technologies have facilitated novel breakthrough therapies, whose global developments, regulatory approvals, and confined governmental subsidisations have stimulated renewed hope amongst rare disease patient organisations (RDPOs). With intensifying optimism characterising the therapeutic landscape, researcher-advocate partnerships have reached an inflexion point, at which stakeholders may evaluate their achievements and formulate frameworks for future refinement.
Main text
Through this narrative review, we surveyed relevant literature around the roles of RDPOs catering to the rare paediatric neurological disease community. Via available literature, we considered RDPO interactions within seven domains of therapeutic development: research grant funding, industry sponsorship, study recruitment, clinical care and support, patient-reported outcome measures, and research prioritisation. In doing so, we explored practical and ethical challenges, gaps in understanding, and future directions of inquiry. Current literature highlights the increasing significance of ethical and financial challenges to patient advocacy. Biomedical venture philanthropy is gaining momentum amongst RDPOs, whose small grants can incrementally assist laboratories in research, training, and pursuits of more substantial grants. However, RDPO seed funding may encounter long-term sustainability issues and difficulties in selecting appropriate research investments. Further challenges include advocate-industry collaborations, commercial biases, and unresolved controversies regarding orphan drug subsidisation. Beyond their financial interactions, RDPOs serve instrumental roles in project promotion, participant recruitment, biobank creation, and patient registry establishment. They are communication conduits between carers, patients, and other stakeholders, but their contributions may be susceptible to bias and unrealistic expectations.
Conclusion
Further insights into how RDPOs navigate practical and ethical challenges in therapeutic development may enhance cooperative efforts. They may also inform resources, whose distribution among advocates, parents, and clinicians, may assist decision-making processes around rare disease clinical trials and treatments.
Collapse
|
7
|
Improving clinical trial readiness to accelerate development of new therapeutics for Rett syndrome. Orphanet J Rare Dis 2022; 17:108. [PMID: 35246185 PMCID: PMC8894842 DOI: 10.1186/s13023-022-02240-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 02/06/2022] [Indexed: 12/16/2022] Open
Abstract
Rett syndrome is associated with severe functional impairments and many comorbidities, each in urgent need of treatments. Mutations in the MECP2 gene were identified as causing Rett syndrome in 1999. Over the past 20 years there has been an abundance of preclinical research with some studies leading to human clinical trials. Despite this, few viable therapeutic options have emerged from this investment of effort. Reasons for this lack of success as they relate both to preclinical research and the clinical trial landscape are discussed. Considering what needs to be done to promote further success in the field, we take a positive and constructive approach and introduce the concept of clinical trial readiness and its necessary ingredients for Rett syndrome. These include: listening to the needs of families; support from advocacy groups; optimising use of existing clinic infrastructures and available natural history data; and, finally, the validation of existing outcome measures and/or the development and validation of new measures. We conclude by reiterating the need for a collaborative and coordinated approach amongst the many different stakeholder groups and the need to engage in new types of trial design which could be much more efficient, less costly and much less burdensome on families.
Collapse
|
8
|
Myotonic Dystrophies: A Genetic Overview. Genes (Basel) 2022; 13:genes13020367. [PMID: 35205411 PMCID: PMC8872148 DOI: 10.3390/genes13020367] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 02/01/2023] Open
Abstract
Myotonic dystrophies (DM) are the most common muscular dystrophies in adults, which can affect other non-skeletal muscle organs such as the heart, brain and gastrointestinal system. There are two genetically distinct types of myotonic dystrophy: myotonic dystrophy type 1 (DM1) and myotonic dystrophy type 2 (DM2), both dominantly inherited with significant overlap in clinical manifestations. DM1 results from CTG repeat expansions in the 3′-untranslated region (3′UTR) of the DMPK (dystrophia myotonica protein kinase) gene on chromosome 19, while DM2 is caused by CCTG repeat expansions in intron 1 of the CNBP (cellular nucleic acid-binding protein) gene on chromosome 3. Recent advances in genetics and molecular biology, especially in the field of RNA biology, have allowed better understanding of the potential pathomechanisms involved in DM. In this review article, core clinical features and genetics of DM are presented followed by a discussion on the current postulated pathomechanisms and therapeutic approaches used in DM, including the ones currently in human clinical trial phase.
Collapse
|
9
|
Characteristics of myotonic dystrophy patients in the national registry of Japan. J Neurol Sci 2022; 432:120080. [PMID: 34923335 DOI: 10.1016/j.jns.2021.120080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 11/23/2022]
Abstract
Myotonic dystrophies (DM) are inherited autosomal dominant disorders affecting multiple organs. Currently available therapeutics for DM are limited; therefore, a patient registry is essential for therapeutic development and success of clinical trials targeting the diseases. We have developed a nationwide DM registry in Japan under the Registry of Muscular Dystrophy (Remudy). The registration process was patient-initiated; however, physicians certified the clinical information. The dataset includes all Naarden and TREAT-NMD core datasets and additional items covering major DM clinical features. As of March 2020, we enrolled 976 patients with genetically confirmed DM. The majority (99.9%) of these patients had DM1, with 11.4% having the congenital form. However, 1 patient had DM2. Upon classifying 969 symptomatic DM1 patients based on their age at onset, an earlier onset was associated with a longer CTG repeat length. Myotonia was the most frequent symptom, followed by hand disability, fatigue, and daytime sleepiness. The frequency of hand disabilities, constipation, and visual disturbances was higher for patients with congenital DM. According to a multiple regression analysis of objective clinical measurements related to prognosis and activities of daily living, CTG repeat length strongly influenced the grip strength, forced vital capacity, and QRS time in an electrocardiogram. However, the grip strength was only modestly related to disease duration. This report will shed light on the Japanese national DM registry, which has recruited a significant number of patients. The registry will provide invaluable data for planning clinical trials and improving the standard of care for patients.
Collapse
|
10
|
Peric S, Rakocevic-Stojanovic V, Meola G. Cerebral involvement and related aspects in myotonic dystrophy type 2. Neuromuscul Disord 2021; 31:681-694. [PMID: 34244019 DOI: 10.1016/j.nmd.2021.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 01/18/2023]
Abstract
Myotonic dystrophy type 2 (DM2) is an autosomal dominant multisystemic disorder caused by CCTG repeats expansion in the first intron of the CNBP gene. In this review we focus on the brain involvement in DM2, including its pathogenic mechanisms, microstructural, macrostructural and functional brain changes, as well as the effects of all these impairments on patients' everyday life. We also try to understand how brain abnormalities in DM2 should be adequately measured and potentially treated. The most important pathogenetic mechanisms in DM2 are RNA gain-of-function and repeat-associated non-ATG (RAN) translation. One of the main neuroimaging findings in DM2 is the presence of diffuse periventricular white matter hyperintensity lesions (WMHLs). Brain atrophy has been described in DM2 patients, but it is not clear if it is mostly caused by a decrease of the white or gray matter volume. The most commonly reported specific cognitive symptoms in DM2 are dysexecutive syndrome, visuospatial and memory impairments. Fatigue, sleep-related disorders and pain are also frequent in DM2. The majority of key symptoms and signs in DM2 has a great influence on patients' daily lives, their psychological status, economic situation and quality of life.
Collapse
Affiliation(s)
- Stojan Peric
- Neurology Clinic, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Giovanni Meola
- Department of Neurorehabilitation Sciences, Casa Di Cura del Policlinico, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| |
Collapse
|
11
|
Peric S. Non-routine cardiac tests still have no defined role in assessment of myotonic dystrophy type 2. Acta Neurol Belg 2020; 120:967-968. [PMID: 31228022 DOI: 10.1007/s13760-019-01174-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/14/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Stojan Peric
- Department for Neuromuscular Disorders, Neurology Clinic, School of Medicine, Clinical Centre of Serbia, University of Belgrade, 6, Dr Subotic Street, 11000, Belgrade, Serbia.
| |
Collapse
|
12
|
Puy V, Mayeur A, Levy A, Hesters L, Raad J, Monnot S, Steffann J, Frydman N. CTG Expansion in the DMPK Gene: Semen Quality Assessment and Outcome of Preimplantation Genetic Diagnosis. J Clin Endocrinol Metab 2020; 105:5717685. [PMID: 31996899 DOI: 10.1210/clinem/dgaa041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 01/28/2020] [Indexed: 01/23/2023]
Abstract
CONTEXT Myotonic dystrophy (DM) is an autosomal dominant disorder characterized mainly by myotonia but also by primary hypogonadism. No study has reported on fertility management of patients affected by DM type 1 (DM1). OBJECTIVE This study investigates the impact of CTG repeats in the DMPK gene on semen quality and preimplantation genetic diagnosis (PGD) outcome. DESIGN This is a monocentric retrospective observational study conducted from January 2003 to January 2019. SETTING Antoine Béclère University Hospital, Clamart, France. PATIENTS Three groups were compared in this study: male DM1 patients (Group A, n = 18), unaffected partners of DM1 female patients (Group B, n = 30), and proven fertile men (Group C, n = 33). Reproductive outcomes after PGD were compared between groups A and B. RESULTS Sperm volume was reduced in group A (2.0 mL) when compared with groups B (3.0 mL; P < 0.01) and C (3.5 mL; P < 0.01). Progressive motility in raw sperm was also decreased in group A (30%) as compared to group C (40%; P < 0.01). The median number of progressive spermatozoa retrieved after sperm preparation was 2.7 million (M) in group A, which was significantly less than those of groups B (10.0 M; P < 0.01) and C (62.2 M; P < 0.01). Sperm motility was inversely correlated to the number of CTG repeats (Spearman r2 = 0.48, Pearson r2 = 0.35). Cumulative live birth rate per transfer was similar between groups, with 32.2% in group A versus 26.8% in group B. CONCLUSIONS As a precautionary measure, we advise physicians to perform regular monitoring of semen quality in affected males, which would allow sperm cryopreservation should semen parameters fall. PGD allows good reproductive outcomes without disease transmission.
Collapse
Affiliation(s)
- Vincent Puy
- Reproductive Biology Unit CECOS, Paris-Saclay University, Antoine Béclère Hospital, APHP Clamart, France
- Laboratoire de Développement des Gonades, UMRE008 Stabilité Génétique Cellules Souches et Radiations, Université de Paris, Université Paris-Saclay, CEA, Fontenay-aux-Roses, France
| | - Anne Mayeur
- Reproductive Biology Unit CECOS, Paris-Saclay University, Antoine Béclère Hospital, APHP Clamart, France
| | - Alexandre Levy
- Reproductive Biology Unit CECOS, Paris-Saclay University, Antoine Béclère Hospital, APHP Clamart, France
| | - Laetitia Hesters
- Reproductive Biology Unit CECOS, Paris-Saclay University, Antoine Béclère Hospital, APHP Clamart, France
| | - Jade Raad
- Department of Reproductive Medicine and Fertility Preservation, Paris-Saclay University, Antoine Béclère Hospital, APHP Clamart, France
| | - Sophie Monnot
- Institut Imagine et Service de Génétique Moléculaire, Université de Paris, Hôpital Necker Enfants Malades, Paris, France
| | - Julie Steffann
- Institut Imagine et Service de Génétique Moléculaire, Université de Paris, Hôpital Necker Enfants Malades, Paris, France
| | - Nelly Frydman
- Reproductive Biology Unit CECOS, Paris-Saclay University, Antoine Béclère Hospital, APHP Clamart, France
- Laboratoire de Développement des Gonades, UMRE008 Stabilité Génétique Cellules Souches et Radiations, Université de Paris, Université Paris-Saclay, CEA, Fontenay-aux-Roses, France
| |
Collapse
|
13
|
Takahashi MP, Yamamoto R, Kubota T, Matsuura T, Ishigaki K, Sunada Y, Komaki H, Takada H, Kuru S, Matsumura T. [Study of care practices for patients with myotonic dystrophy in Japan-Nationwide patient survey]. Rinsho Shinkeigaku 2020; 60:130-136. [PMID: 31956156 DOI: 10.5692/clinicalneurol.cn-001349] [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: 06/10/2023]
Abstract
We conducted a comprehensive anonymous questionnaire survey on medical care and treatment for patients with myotonic dystrophy, who registered in the Japanese national registry (Remudy) or were undergoing care in seven hospitals specializing neuromuscular diseases. The questionnaire consisted of 49 questions were distributed to 813 patients, and 342 valid responses were collected. Most prevalent symptoms or complaints were dysfunction of fingers and fatigue. One-third of the adult patients left the job, half of which was due to the disease. Twelve percent of the patients did not visit the specialist regularly, the main reason being distance. The most common reason that the patients did not follow the advice of using a ventilator by medical professionals was lack of feeling the need. One-fourth of the adult female patients had infertility treatment, 80% of which was before a diagnosis of this disorder. This first-time nationwide survey revealed the actual condition of Japanese patients with myotonic dystrophy and raised various care-related issues.
Collapse
Affiliation(s)
- Masanori P Takahashi
- Department of Functional Diagnostic Science, Osaka University Graduate School of Medicine
| | - Risa Yamamoto
- Department of Functional Diagnostic Science, Osaka University Graduate School of Medicine
| | - Tomoya Kubota
- Department of Functional Diagnostic Science, Osaka University Graduate School of Medicine
| | - Tohru Matsuura
- Division of Neurology, Department of Medicine, Jichi Medical University School of Medicine
| | - Keiko Ishigaki
- Department of Pediatrics, Tokyo Women's Medical University, School of Medicine
| | | | - Hirofumi Komaki
- Translational Medical Center, National Center of Neurology and Psychiatry
| | - Hiroto Takada
- Department of Neurology, National Hospital Organization Aomori National Hospital
| | - Satoshi Kuru
- Department of Neurology, National Hospital Organization Suzuka National Hospital
| | - Tsuyoshi Matsumura
- Department of Neurology, National Hospital Organization Osaka Toneyama Medical Center
| |
Collapse
|
14
|
Tomé S, Gourdon G. DM1 Phenotype Variability and Triplet Repeat Instability: Challenges in the Development of New Therapies. Int J Mol Sci 2020; 21:ijms21020457. [PMID: 31936870 PMCID: PMC7014087 DOI: 10.3390/ijms21020457] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/02/2020] [Accepted: 01/08/2020] [Indexed: 02/07/2023] Open
Abstract
Myotonic dystrophy type 1 (DM1) is a complex neuromuscular disease caused by an unstable cytosine thymine guanine (CTG) repeat expansion in the DMPK gene. This disease is characterized by high clinical and genetic variability, leading to some difficulties in the diagnosis and prognosis of DM1. Better understanding the origin of this variability is important for developing new challenging therapies and, in particular, for progressing on the path of personalized treatments. Here, we reviewed CTG triplet repeat instability and its modifiers as an important source of phenotypic variability in patients with DM1.
Collapse
|
15
|
Wood L, Bassez G, Bleyenheuft C, Campbell C, Cossette L, Jimenez-Moreno AC, Dai Y, Dawkins H, Díaz-Manera J, Dogan C, el Sherif R, Fossati B, Graham C, Hilbert J, Kastreva K, Kimura E, Korngut L, Kostera-Pruszczyk A, Lindberg C, Lindvall B, Luebbe E, Lusakowska A, Mazanec R, Meola G, Orlando L, Takahashi MP, Peric S, Puymirat J, Rakocevic-Stojanovic V, Rodrigues M, Roxburgh R, Schoser B, Segovia S, Shatillo A, Thiele S, Tournev I, van Engelen B, Vohanka S, Lochmüller H. Correction to: Eight years after an international workshop on myotonic dystrophy patient registries: case study of a global collaboration for a rare disease. Orphanet J Rare Dis 2019; 14:199. [PMID: 31416449 PMCID: PMC6696685 DOI: 10.1186/s13023-019-1157-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 07/18/2019] [Indexed: 05/30/2023] Open
|
16
|
Alonso-Pérez J, Segovia S, Domínguez-González C, Olivé M, Mendoza Grimón MD, Fernández-Torrón R, López de Munain A, Muñoz-Blanco JL, Ramos-Fransi A, Almendrote M, Illa I, Díaz-Manera J. Spanish Pompe registry: Baseline characteristics of first 49 patients with adult onset of Pompe disease. Med Clin (Barc) 2019; 154:80-85. [PMID: 31253477 DOI: 10.1016/j.medcli.2019.03.036] [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: 01/21/2019] [Revised: 03/21/2019] [Accepted: 03/21/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND OBJECTIVES Pompe disease is a rare autosomal recessive disorder produced by a deficiency of acid maltase. This deficit produces an accumulation of glycogen in tissues. Clinically it is mainly characterized by limb girdle and respiratory muscle weakness. In 2013, we developed the Spanish Pompe Registry. The objective of this article was to analyse the characteristics of the first 49 patients and disclose the existence of this registry within the medical community. MATERIAL AND METHODS An observational retrospective study was undertaken. We analysed the 49 patients included in the Spanish Registry of Pompe Disease from May 2013 to October 2018. RESULTS Patients were visited at 7 different Spanish hospitals. Twenty-six patients were women and 23 were men. The average age at the time of the analysis was 47.2 years. Ten patients were asymptomatic. The mean age of onset of symptoms was 29, and low limb girdle weakness was the most frequent initial symptom. Of the patients, 49% had respiratory involvement, and 70.8% of them required non-invasive mechanical ventilation. The most common mutation found was IVS1-13T>G in 85.3% of the patients. All symptomatic patients received treatment with ERT. CONCLUSIONS This registry allows us to know the clinical and genetic characteristics of adult patients with Pompe disease in Spain. Moreover, it can be the basis for future studies of natural history to understand the impact of ERT in the course of the disease.
Collapse
Affiliation(s)
- Jorge Alonso-Pérez
- Unidad de Patología Neuromuscular, Departamento de Neurología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España
| | - Sonia Segovia
- Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER)
| | - Cristina Domínguez-González
- Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER); Unidad de Neuromuscular, Servicio de Neurología, Hospital Universitario 12 de Octubre, Instituto de investigación i+12, Madrid, España
| | - Montse Olivé
- Servicio de Anatomía Patológica (Neuropatología) y Unidad de Patología Neuromuscular, Hospital Universitari de Bellvitge, Barcelona, España
| | | | | | | | | | - Alba Ramos-Fransi
- Servicio de Neurología, Hospital Germans Trias i Pujol, Badalona, España
| | - Miriam Almendrote
- Servicio de Neurología, Hospital Germans Trias i Pujol, Badalona, España
| | - Isabel Illa
- Unidad de Patología Neuromuscular, Departamento de Neurología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España; Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER)
| | - Jordi Díaz-Manera
- Unidad de Patología Neuromuscular, Departamento de Neurología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España; Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER).
| |
Collapse
|
17
|
De Antonio M, Dogan C, Daidj F, Eymard B, Puymirat J, Mathieu J, Gagnon C, Katsahian S, Hamroun D, Bassez G. The DM-scope registry: a rare disease innovative framework bridging the gap between research and medical care. Orphanet J Rare Dis 2019; 14:122. [PMID: 31159885 PMCID: PMC6547518 DOI: 10.1186/s13023-019-1088-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 05/06/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The relevance of registries as a key component for developing clinical research for rare diseases (RD) and improving patient care has been acknowledged by most stakeholders. As recent studies pointed to several limitations of RD registries our challenge was (1) to improve standardization and data comparability; (2) to facilitate interoperability between existing RD registries; (3) to limit the amount of incomplete data; (4) to improve data quality. This report describes the innovative concept of the DM-Scope Registry that was developed to achieve these objectives for Myotonic Dystrophy (DM), a prototypical example of highly heterogeneous RD. By the setting up of an integrated platform attractive for practitioners use, we aimed to promote DM epidemiology, clinical research and patients care management simultaneously. RESULTS The DM-Scope Registry is a result of the collaboration within the French excellence network established by the National plan for RDs. Inclusion criteria is all genetically confirmed DM individuals, independently of disease age of onset. The dataset includes social-demographic data, clinical features, genotype, and biomaterial data, and is adjustable for clinical trial data collection. To date, the registry has a nationwide coverage, composed of 55 neuromuscular centres, encompassing the whole disease clinical and genetic spectrum. This widely used platform gathers almost 3000 DM patients (DM1 n = 2828, DM2 n = 142), both children (n = 322) and adults (n = 2648), which accounts for > 20% of overall registered DM patients internationally. The registry supported 10 research studies of various type i.e. observational, basic science studies and patient recruitment for clinical trials. CONCLUSION The DM-Scope registry represents the largest collection of standardized data for the DM population. Our concept improved collaboration among health care professionals by providing annual follow-up of quality longitudinal data collection. The combination of clinical features and biomolecular materials provides a comprehensive view of the disease in a given population. DM-Scope registry proves to be a powerful device for promoting both research and medical care that is suitable to other countries. In the context of emerging therapies, such integrated platform contributes to the standardisation of international DM research and for the design of multicentre clinical trials. Finally, this valuable model is applicable to other RDs.
Collapse
Affiliation(s)
- Marie De Antonio
- Neuromuscular Reference Center, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
- INSERM U1138, Centre de Recherche des Cordeliers, Sorbonne University, Paris Descartes University, Paris, France
| | - Céline Dogan
- Neuromuscular Reference Center, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Ferroudja Daidj
- Neuromuscular Reference Center, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Bruno Eymard
- Neuromuscular Reference Center, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | | | - Jean Mathieu
- Groupe de recherche interdisciplinaire sur les maladies neuromusculaires (GRIMN), CIUSSS du Saguenay-Lac-St-Jean, Québec, Canada
| | - Cynthia Gagnon
- Groupe de recherche interdisciplinaire sur les maladies neuromusculaires (GRIMN), CIUSSS du Saguenay-Lac-St-Jean, Québec, Canada
- Centre de recherche Charles-Le-Moyne-Saguenay-Lac-St-Jean sur les innovations en santé (CR-CSIS), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Québec, Canada
| | - Sandrine Katsahian
- INSERM U1138, Centre de Recherche des Cordeliers, Sorbonne University, Paris Descartes University, Paris, France
- Unit of Epidemiology and Clinical Research, AP-HP, Georges-Pompidou Hospital, Paris, France
| | - Dalil Hamroun
- University Institute of Clinical Research, CHU, Montpellier, France
| | - Guillaume Bassez
- Neuromuscular Reference Center, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
- INSERM, Research Center in Myology, Sorbonne University, Paris, France
| |
Collapse
|
18
|
Pešović J, Perić S, Brkušanin M, Brajušković G, Rakočević-Stojanović V, Savić-Pavićević D. Repeat Interruptions Modify Age at Onset in Myotonic Dystrophy Type 1 by Stabilizing DMPK Expansions in Somatic Cells. Front Genet 2018; 9:601. [PMID: 30546383 PMCID: PMC6278776 DOI: 10.3389/fgene.2018.00601] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/15/2018] [Indexed: 12/19/2022] Open
Abstract
CTG expansions in DMPK gene, causing myotonic dystrophy type 1 (DM1), are characterized by pronounced somatic instability. A large proportion of variability of somatic instability is explained by expansion size and patient's age at sampling, while individual-specific differences are attributed to additional factors. The age at onset is extremely variable in DM1, and inversely correlates with the expansion size and individual-specific differences in somatic instability. Three to five percent of DM1 patients carry repeat interruptions and some appear with later age at onset than expected for corresponding expansion size. Herein, we characterized somatic instability of interrupted DMPK expansions and the effect on age at onset in our previously described patients. Repeat-primed PCR showed stable structures of different types and patterns of repeat interruptions in blood cells over time and buccal cells. Single-molecule small-pool PCR quantification of somatic instability and mathematical modeling showed that interrupted expansions were characterized by lower level of somatic instability accompanied by slower progression over time. Mathematical modeling demonstrated that individual-specific differences in somatic instability had greater influence on age at onset in patients with interrupted expansions. Therefore, repeat interruptions have clinical importance for disease course in DM1 patients due to stabilizing effect on DMPK expansions in somatic cells.
Collapse
Affiliation(s)
- Jovan Pešović
- Center for Human Molecular Genetics, Faculty of Biology, University of Belgrade, Belgrade, Serbia
| | - Stojan Perić
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Neurology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Miloš Brkušanin
- Center for Human Molecular Genetics, Faculty of Biology, University of Belgrade, Belgrade, Serbia
| | - Goran Brajušković
- Center for Human Molecular Genetics, Faculty of Biology, University of Belgrade, Belgrade, Serbia
| | - Vidosava Rakočević-Stojanović
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Neurology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Dušanka Savić-Pavićević
- Center for Human Molecular Genetics, Faculty of Biology, University of Belgrade, Belgrade, Serbia
| |
Collapse
|