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Liu L, Zeng S, Li X, Xie Y, Xu K, Yang H, Huang S, Zhao H, Zhang R. Genotype-phenotype correlations of AR-CMT2S in a cohort of axonal Charcot-Marie-Tooth patients from Central South China. J Peripher Nerv Syst 2024; 29:243-251. [PMID: 38772550 DOI: 10.1111/jns.12633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND AND AIMS This study aimed to report nine Charcot-Marie-Tooth disease (CMT) families with six novel IGHMBP2 mutations in our CMT2 cohort and to summarize the genetic and clinical features of all AR-CMT2S patients reported worldwide. METHODS General information, clinical and neurophysiological data of 275 axonal CMT families were collected. Genetic screening was performed by inherited peripheral neuropathy related genes panel or whole exome sequencing. The published papers reporting AR-CMT2S from 2014 to 2023 were searched in Pubmed and Wanfang databases. RESULTS In our CMT2 cohort, we detected 17 AR-CMT2S families carrying IGHMBP2 mutations and eight were published previously. Among these, c.743 T > A (p.Val248Glu), c.884A > G (p.Asp295Gly), c.1256C > A (p.Ser419*), c.2598_2599delGA (p.Lys868Sfs*16), c.1694_1696delATG (p.Asp565del) and c.2509A > T (p.Arg837*) were firstly reported. These patients prominently presented with early-onset typical axonal neuropathy and without respiratory dysfunction. So far, 56 AR-CMT2S patients and 57 different mutations coming from 43 families have been reported in the world. Twenty-nine of 32 missense mutations were clustered in helicase domain and ATPase region. The age at onset ranged from 0.11to 20 years (Mean ± SD: 3.43 ± 3.88 years) and the majority was infantile-onset (<2 years). The initial symptoms included weakness of limbs (19, 29.7%), delayed milestones (12, 18.8%), gait disturbance (11, 17.2%), feet deformity (8, 12.5%), feet drop (8, 12.5%), etc. INTERPRETATION: AR-CMT2S accounted for 6.2% in our CMT2 cohort. We firstly reported six novel IGHMBP2 mutations which expanded the genotypic spectrum of AR-CMT2S. Furthermore, 17 AR-CMT2S families could provide more resources for natural history study, drug research and development.
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Affiliation(s)
- Lei Liu
- Health Management Center, The Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Sen Zeng
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Xiaobo Li
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Yongzhi Xie
- Department of Radiology, The Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Ke Xu
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Honglan Yang
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Shunxiang Huang
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Huadong Zhao
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Ruxu Zhang
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
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Zambon AA, Pini V, Bosco L, Falzone YM, Munot P, Muntoni F, Previtali SC. Early onset hereditary neuronopathies: an update on non-5q motor neuron diseases. Brain 2022; 146:806-822. [PMID: 36445400 PMCID: PMC9976982 DOI: 10.1093/brain/awac452] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/21/2022] [Accepted: 11/12/2022] [Indexed: 11/30/2022] Open
Abstract
Hereditary motor neuropathies (HMN) were first defined as a group of neuromuscular disorders characterized by lower motor neuron dysfunction, slowly progressive length-dependent distal muscle weakness and atrophy, without sensory involvement. Their cumulative estimated prevalence is 2.14/100 000 and, to date, around 30 causative genes have been identified with autosomal dominant, recessive,and X-linked inheritance. Despite the advances of next generation sequencing, more than 60% of patients with HMN remain genetically uncharacterized. Of note, we are increasingly aware of the broad range of phenotypes caused by pathogenic variants in the same gene and of the considerable clinical and genetic overlap between HMN and other conditions, such as Charcot-Marie-Tooth type 2 (axonal), spinal muscular atrophy with lower extremities predominance, neurogenic arthrogryposis multiplex congenita and juvenile amyotrophic lateral sclerosis. Considering that most HMN present during childhood, in this review we primarily aim to summarize key clinical features of paediatric forms, including recent data on novel phenotypes, to help guide differential diagnosis and genetic testing. Second, we describe newly identified causative genes and molecular mechanisms, and discuss how the discovery of these is changing the paradigm through which we approach this group of conditions.
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Affiliation(s)
- Alberto A Zambon
- Correspondence to: Alberto A. Zambon Neuromuscular Repair Unit InSpe and Division of Neuroscience IRCCS Ospedale San Raffaele, Milan, Italy E-mail:
| | - Veronica Pini
- Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital, London, WC1N 1EH, UK
| | - Luca Bosco
- Neuromuscular Repair Unit, Institute of Experimental Neurology (InSpe), Division of Neuroscience, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Yuri M Falzone
- Neuromuscular Repair Unit, Institute of Experimental Neurology (InSpe), Division of Neuroscience, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Pinki Munot
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, WC1N 1EH, UK
| | - Francesco Muntoni
- Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital, London, WC1N 1EH, UK,NIHR Great Ormond Street Hospital Biomedical Research Centre, London, WC1N 1EH, UK
| | - Stefano C Previtali
- Neuromuscular Repair Unit, Institute of Experimental Neurology (InSpe), Division of Neuroscience, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
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Clinical and genetic features of Charcot-Marie-Tooth disease patients with IGHMBP2 mutations. Neuromuscul Disord 2022; 32:564-571. [DOI: 10.1016/j.nmd.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 11/18/2022]
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Tiago T, Hummel B, Morelli FF, Basile V, Vinet J, Galli V, Mediani L, Antoniani F, Pomella S, Cassandri M, Garone MG, Silvestri B, Cimino M, Cenacchi G, Costa R, Mouly V, Poser I, Yeger-Lotem E, Rosa A, Alberti S, Rota R, Ben-Zvi A, Sawarkar R, Carra S. Small heat-shock protein HSPB3 promotes myogenesis by regulating the lamin B receptor. Cell Death Dis 2021; 12:452. [PMID: 33958580 PMCID: PMC8102500 DOI: 10.1038/s41419-021-03737-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 02/03/2023]
Abstract
One of the critical events that regulates muscle cell differentiation is the replacement of the lamin B receptor (LBR)-tether with the lamin A/C (LMNA)-tether to remodel transcription and induce differentiation-specific genes. Here, we report that localization and activity of the LBR-tether are crucially dependent on the muscle-specific chaperone HSPB3 and that depletion of HSPB3 prevents muscle cell differentiation. We further show that HSPB3 binds to LBR in the nucleoplasm and maintains it in a dynamic state, thus promoting the transcription of myogenic genes, including the genes to remodel the extracellular matrix. Remarkably, HSPB3 overexpression alone is sufficient to induce the differentiation of two human muscle cell lines, LHCNM2 cells, and rhabdomyosarcoma cells. We also show that mutant R116P-HSPB3 from a myopathy patient with chromatin alterations and muscle fiber disorganization, forms nuclear aggregates that immobilize LBR. We find that R116P-HSPB3 is unable to induce myoblast differentiation and instead activates the unfolded protein response. We propose that HSPB3 is a specialized chaperone engaged in muscle cell differentiation and that dysfunctional HSPB3 causes neuromuscular disease by deregulating LBR.
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Affiliation(s)
- Tatiana Tiago
- Centre for Neuroscience and Nanotechnology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125, Modena, Italy
| | - Barbara Hummel
- Max Planck Institute of Immunobiology and Epigenetics, 79108, Freiburg, Germany
| | - Federica F Morelli
- Centre for Neuroscience and Nanotechnology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125, Modena, Italy
| | - Valentina Basile
- Centre for Neuroscience and Nanotechnology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125, Modena, Italy
| | - Jonathan Vinet
- Centre for Neuroscience and Nanotechnology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125, Modena, Italy
| | - Veronica Galli
- Centre for Neuroscience and Nanotechnology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125, Modena, Italy
| | - Laura Mediani
- Centre for Neuroscience and Nanotechnology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125, Modena, Italy
| | - Francesco Antoniani
- Centre for Neuroscience and Nanotechnology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125, Modena, Italy
| | - Silvia Pomella
- Department of Oncohematology, Bambino Gesù Children's Hospital, IRCCS, 00165, Rome, Italy
| | - Matteo Cassandri
- Department of Oncohematology, Bambino Gesù Children's Hospital, IRCCS, 00165, Rome, Italy
| | - Maria Giovanna Garone
- Department of Biology and Biotechnologies "Charles Darwin", Sapienza University of Rome, 00185, Rome, Italy
| | - Beatrice Silvestri
- Department of Biology and Biotechnologies "Charles Darwin", Sapienza University of Rome, 00185, Rome, Italy
- Center for Life Nano- & Neuro-Science, Fondazione Istituto Italiano di Tecnologia (IIT), 00161, Rome, Italy
| | - Marco Cimino
- Centre for Neuroscience and Nanotechnology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125, Modena, Italy
| | - Giovanna Cenacchi
- Department of Biomedical and Neuromotor Sciences DIBINEM, University of Bologna, Bologna, Italy; Centre for Applied Biomedical Research - CRBA, University of Bologna, IRCCS St. Orsola Hospital, Bologna, Italy
| | - Roberta Costa
- Department of Biomedical and Neuromotor Sciences DIBINEM, University of Bologna, Bologna, Italy; Centre for Applied Biomedical Research - CRBA, University of Bologna, IRCCS St. Orsola Hospital, Bologna, Italy
| | - Vincent Mouly
- Centre de Recherche en Myologie, Sorbonne Université, Inserm, Institut de Myologie, F-75013, Paris, France
| | - Ina Poser
- Max Planck Institute of Molecular Cell Biology and Genetics, 01307, Dresden, Germany
- Dewpoint Therapeutics GmbH, Tatzberg 47, 01307, Dresden, Germany
| | - Esti Yeger-Lotem
- Department of Clinical Biochemistry and Pharmacology and the National Institute for Biotechnology in the Negev, Ben-Gurion University of the Negev, Beer Sheva, 84105, Israel
| | - Alessandro Rosa
- Department of Biology and Biotechnologies "Charles Darwin", Sapienza University of Rome, 00185, Rome, Italy
- Center for Life Nano- & Neuro-Science, Fondazione Istituto Italiano di Tecnologia (IIT), 00161, Rome, Italy
| | - Simon Alberti
- Biotechnology Center (BIOTEC), Center for Molecular and Cellular Bioengineering (CMCB), Technische Universität Dresden, Tatzberg 47/49, 01307, Dresden, Germany
| | - Rossella Rota
- Department of Oncohematology, Bambino Gesù Children's Hospital, IRCCS, 00165, Rome, Italy
| | - Anat Ben-Zvi
- Department of Life Sciences, Ben-Gurion University of the Negev, Beer Sheva, 84105, Israel
| | - Ritwick Sawarkar
- Max Planck Institute of Immunobiology and Epigenetics, 79108, Freiburg, Germany
- Medical Research Council (MRC), University of Cambridge, Cambridge, CB2 1QR, UK
| | - Serena Carra
- Centre for Neuroscience and Nanotechnology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125, Modena, Italy.
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Spinal muscular atrophy with respiratory distress type 1: A multicenter retrospective study. Neuromuscul Disord 2019; 29:114-126. [DOI: 10.1016/j.nmd.2018.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 08/14/2018] [Accepted: 10/25/2018] [Indexed: 12/14/2022]
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Yuan JH, Hashiguchi A, Yoshimura A, Yaguchi H, Tsuzaki K, Ikeda A, Wada-Isoe K, Ando M, Nakamura T, Higuchi Y, Hiramatsu Y, Okamoto Y, Takashima H. Clinical diversity caused by novel IGHMBP2 variants. J Hum Genet 2017; 62:599-604. [PMID: 28202949 DOI: 10.1038/jhg.2017.15] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 01/08/2017] [Accepted: 01/12/2017] [Indexed: 11/09/2022]
Abstract
Immunoglobulin helicase μ-binding protein 2 (IGHMBP2) gene is responsible for Charcot-Marie-Tooth disease (CMT) type 2S and spinal muscular atrophy with respiratory distress type 1 (SMARD1). From June 2014 to December 2015, we collected 408 cases, who referred to our genetic laboratory for genetic analysis, suspected with CMT disease or other inherited peripheral neuropathies (IPNs) on the basis of clinical manifestations and electrophysiological studies. Mutation screening was performed using Ion AmpliSeq Custom Panels, which comprise 72 disease-causing or candidate genes of IPNs. We identified novel homozygous or compound heterozygous variants of IGHMBP2 in four patients. Three patients presented with childhood-onset axonal predominant sensorimotor polyneuropathies, whereas the other case was diagnosed with SMARD1, manifesting as low birth weight, weak cry, reduced spontaneous movement and developed respiratory distress 4 months after birth. We present the original report of CMT type 2S in Japan, and illustrate that recessive IGHMBP2 variants account for ~1.6% of axonal CMT in our cohort.
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Affiliation(s)
- Jun-Hui Yuan
- Department of Neurology and Geriatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima City, Japan
| | - Akihiro Hashiguchi
- Department of Neurology and Geriatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima City, Japan
| | - Akiko Yoshimura
- Department of Neurology and Geriatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima City, Japan
| | - Hiroshi Yaguchi
- Department of Neurology, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Koji Tsuzaki
- Department of Neurology, Kansai Electric Power Hospital, Osaka, Japan
| | - Azusa Ikeda
- Kanagawa Children's Medical Center, Yokohama, Japan
| | - Kenji Wada-Isoe
- Division of Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Masahiro Ando
- Department of Neurology and Geriatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima City, Japan
| | - Tomonori Nakamura
- Department of Neurology and Geriatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima City, Japan
| | - Yujiro Higuchi
- Department of Neurology and Geriatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima City, Japan
| | - Yu Hiramatsu
- Department of Neurology and Geriatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima City, Japan
| | - Yuji Okamoto
- Department of Neurology and Geriatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima City, Japan
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima City, Japan
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Liu L, Li X, Hu Z, Mao X, Zi X, Xia K, Tang B, Zhang R. IGHMBP2 -related clinical and genetic features in a cohort of Chinese Charcot–Marie–Tooth disease type 2 patients. Neuromuscul Disord 2017; 27:193-199. [DOI: 10.1016/j.nmd.2016.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 11/12/2016] [Indexed: 02/01/2023]
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CHCHD2 gene mutations in familial and sporadic Parkinson's disease. Neurobiol Aging 2016; 38:217.e9-217.e13. [DOI: 10.1016/j.neurobiolaging.2015.10.040] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 10/30/2015] [Accepted: 10/31/2015] [Indexed: 11/20/2022]
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Mao CY, Yang J, Zhang SY, Luo HY, Song B, Liu YT, Wu J, Sun SL, Yang ZH, Du P, Wang YH, Shi CH, Xu YM. Exome capture sequencing identifies a novel CCM1 mutation in a Chinese family with multiple cerebral cavernous malformations. Int J Neurosci 2015; 126:1071-6. [PMID: 26643368 DOI: 10.3109/00207454.2015.1118628] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Cerebral cavernous malformations (CCMs) are vascular anomalies predominantly in the central nervous system but may include lesions in other tissues, such as the retina, skin and liver. The main clinical manifestations include seizures, hemorrhage, recurrent headaches and focal neurological deficits. Previous studies of familial CCMs (FCCMs) have mainly reported in Hispanic and Caucasian cases. Here, we report on FCCMs in a Chinese family further characterized by a novel CCM1 gene mutation. MATERIALS AND METHODS We investigated clinical and neuroradiological features of a Chinese family of 30 members. Furthermore, we used exome capture sequencing to identify the causing gene. The CCM1 mRNA expression level in three patients of the family and 10 wild-type healthy individuals were detected by real-time quantitative polymerase chain reaction (real-time RT-PCR). RESULTS Brain magnetic resonance imaging demonstrated multiple intracranial lesions in seven members. The clinical manifestation of CCM was found in five of these cases, including recurrent headaches, weakness, hemorrhage and seizures. Moreover, we identified a novel nonsense mutation c.1159G>T (p. E387*) in the CCM1 gene in the pedigree. Based on real-time RT-PCR results, we have found that the CCM1 mRNA expression level in three patients was reduced by 35% than that in wild-type healthy individuals. CONCLUSIONS Our finding suggests that the novel nonsense mutation c.1159G>T in CCM1 gene is associated with FCCM, and that CCM1 haploinsufficiency may be the underlying mechanism of CCMs. Furthermore, it also demonstrates that exome capture sequencing is an efficient and direct diagnostic tool to identify causes of genetically heterogeneous diseases.
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Affiliation(s)
- Cheng-Yuan Mao
- a 1 Department of Neurology , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China.,b 2 Institute of Clinical Medicine , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China
| | - Jing Yang
- a 1 Department of Neurology , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China
| | - Shu-Yu Zhang
- a 1 Department of Neurology , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China.,b 2 Institute of Clinical Medicine , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China
| | - Hai-Yang Luo
- a 1 Department of Neurology , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China.,b 2 Institute of Clinical Medicine , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China
| | - Bo Song
- a 1 Department of Neurology , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China
| | - Yu-Tao Liu
- a 1 Department of Neurology , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China
| | - Jun Wu
- a 1 Department of Neurology , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China
| | - Shi-Lei Sun
- a 1 Department of Neurology , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China
| | - Zhi-Hua Yang
- a 1 Department of Neurology , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China.,b 2 Institute of Clinical Medicine , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China
| | - Pan Du
- c 3 International Joint Research Laboratory for Cell and Gene Therapy of Henan Province , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China
| | - Yao-He Wang
- c 3 International Joint Research Laboratory for Cell and Gene Therapy of Henan Province , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China
| | - Chang-He Shi
- a 1 Department of Neurology , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China.,b 2 Institute of Clinical Medicine , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China
| | - Yu-Ming Xu
- a 1 Department of Neurology , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China.,b 2 Institute of Clinical Medicine , The First Affiliated Hospital of Zhengzhou University, Zhengzhou University , Zhengzhou , China
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