Updates on VCP Inclusion Body Myopathy Paget disease… on VCP Inclusion Body Myopathy and...
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Updates on VCP Inclusion Body Myopathy Paget disease, FTD and ALS (IBMPFD) Virginia Kimonis, MD. MRCP Professor, Dept. of Pediatrics, Division of Genetics and Genomic Medicine Univ. of California, Irvine [email protected] Jacksonville, IL Family Meeting June 11, 2016
Transcript of Updates on VCP Inclusion Body Myopathy Paget disease… on VCP Inclusion Body Myopathy and...
Updates on VCP Inclusion Body Myopathy Paget disease, FTD and ALS
(IBMPFD)
Virginia Kimonis, MD. MRCP Professor, Dept. of Pediatrics,
Division of Genetics and Genomic Medicine Univ. of California, Irvine
[email protected] Jacksonville, IL Family Meeting June 11, 2016
OBJECTIVES 1. Discuss clinical features of
VCP disease
2. Learn about mouse model and its use in developing treatments
3. New study trials available and on the horizon
1st Family from Central Illinois 1998 Kimonis et al 2000. Clinical and molecular studies in a unique family with autosomal dominant
limb-girdle muscular dystrophy and Paget disease of bone. Genet Med. 2000;2(4):232-41
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Presentation Notes
Kimonis VE, Kovach MJ, Waggoner B, Leal S, Salam A, Rimer L, Davis K, Khardori R, Gelber D. Clinical and molecular studies in a unique family with autosomal dominant limb-girdle muscular dystrophy and Paget disease of bone. Genet Med. 2000;2(4):232-41.
Limb girdle muscular dystrophy and Paget’s disease of bone. Kimonis et. al Genet Med 2000
FAMILY I: LGMD & PDB
III:5
II:2 II:3II:1
III:1 III:3III:2 III:6 III:10 III:11
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This disorder was first reported in 2000 in a family from Springield, IL with the combination of LGMD and PDB. These cousins were the probands who were evaluated by the genetic counselor Angela Mengelt who brought them and 2 more relatives for a hour consultation. This gentleman leland was diagnosed with IBM after a series of biopsies however we did not capitalize on the significance of this finding then. There were a myth that the women became demented with the disorder but not the men, We reported that several individuals had a cardiomyopathy. We recruited the entire family and performed linkage analysis and excluded all the LGMD, cardiomyopathy and Paget disease of bone
Localisation of Inclusion body myopathy, Paget’s disease of bone and fronto-temporal dementia (IBMPFD) to 9p21
in four families. Kovach et al Mol Genet Metab 2001
9p21.1 9p13 9p12
p
q
Σ=3.12cM
D9S1118
D9S304
D9S1788 D9S1845 D9S165
D9S1878
D9S1805
D9S163
D9S1804
D9S1791 D9S1859 D9S50
D9S1874
Σ=5.5Mb
58.26
61.38
60.59
59.87
59.34 AR IBM2 locus (GNE) Limb-girdle-Bone- fragility (MTAP) ALS-FTD locus (C9ORF72)
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The next landmark was the localization of the gene by a genome wide search in this original family to the 9p locus. This was also the AR IBM2 locus associated with quadriceps sparing. This locus was confirmed in 3 other families. Nature article in Sept 2001 from Argov’s group reported mutations in the GNE gene in Iranian Jews and later in other ethnic groups. Sequencing was negative in my families This region was still large
CDC48 L1 D1 L2 D2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
NLS
C-terminal
A232E R191Q
R95G R155H, P, C
Region involved in Ubiquitin binding
Mutations in the VCP gene causes the disease
Watts GD, Wymer J, Kovach MJ, Mehta SG, Mumm S, Darvish D, Pestronk A, Whyte MP,
Kimonis VE. Inclusion body myopathy associated with Paget disease of bone and frontotemporal dementia is caused by mutant valosin-containing protein. Nat Genet. 2004;36(4):377-81.
R93C
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Mutations in the maj of familiies cluster in the N terminal CDC 48 domain involved in ubiquitin bindingVCP mutations disrupt the double psi barrel (R95G in family 9), and the 4 stranded beta barrel (R155H/C/P) or the flexible linker (R191Q). A232E mutaion in family 6 affects the alpha 5 helix of a/b subdomain of the first AAA ATPase domain and may be more deleterious because of more aggressive disease in a Canadian family. We have recently reported the L198W Leu to Tryptophan, although this is a subtle mutation- both are non polar hydrophobic residues there are structural implications because of the linker region being involved Mutations in the ub binding domain may interfere with VCP interaction with the partners /cofactors Families 1, 3, 4, 7, 10, 15, 16, and 19b harbor an identical nucleotide substitution 464G>C (R155H). Families 2, 5, and 19a share a mutation with a recently discovered French family within the same codon, 463C>T (R155C). Family 11 has a third base change in codon 155 (R155P, 464G>C), which affects the four-stranded β barrel of the protein. Both family 9 and a second French family carry exon 3 mutations (R95G and R93C, respectively), which disrupt the double Ψ barrel VCP. The N-D1 linker region is are altered by the R191Q (572 G>A) mutation isolated in family 13 and the family 30 L198W mutation. Two mutations, the A232E (family 6) and N387H (family 23) affect the α and α/β subdomains of D1, which is responsible for hexameric assembly. DeLaBerre notes that only the D2 domains hydrolyze and exchange nucleotide in hexameric VCP whereas the invariant D1 α/β subdomains serve as a fulcrum for motion in the hexamer. The N-terminal CDC48 domain in which the majority of observed mutations are found is involved in ubiquitin binding.
Inclusion body myopathy seen in 90% individuals CPK muscle enzyme may be normal to slightly
elevated.
Scapular Winging
Paired helical filaments 15-20 nm in nucleus
Muscle weakness mean age onset: 35 y. Biopsy showed variation in fiber size, rimmed
vacuoles, and inclusions
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Presentation Notes
This gentleman is exhibiting the dramatic scapular winging demonstrated by his attempt at elevation of his arms. He is exhibiting marked deltoid wasting and weakness Weihl CC et. al. TDP-43 accumulation in inclusion body myopathy muscle suggests a common pathogenic mechanism with frontotemporal dementia. Neurol Neurosurg Psychiatry. 2008 EM from muscle biopsies showed abundant nuclear and cytoplasmic paired helical filaments 15-20 nm long -typical inclusions in IBM muscle B Alvarez, Z Simmons, W K Engel and V Askanas, New autosomal dominant inclusion body myopathy (AD-IBM) with many congophilic muscle nuclei that contain paired-helical filaments (PHFs) composed of phosphorylated tau. Neurology 50 (1998), p. A204
Approx. 50%- Paget disease of Bone- overactive osteoclasts Localized painful enlargement of bone
Early onset- mean age of 41 years (Range 31-61 y.) Alkaline phosphatase is elevated with PDB (mean 290 U/L, range 58-2105 U/L; normal range 30-130 U/L)
High urine pyridinoline,deoxypyridinoline
PDB of Hip and Pelvis- 55 y old male EM Osteoclast-PHF in nucleus
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This Xray of hip of a 55 y old shows coarse trabecular pattern of bone which is also sclerotic
Frontotemporal Dementia (FTD) • 30% of individuals at a mean age of 56 y
• Degenerative condition of the frontal and anterior temporal
lobes
• Reasoning, personality, social graces, language and preservation of memory.
• Many genes associated with FTD. • Tau, C9ORF72, Progranulin, TDP 43, VCP
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Presentation Notes
add
10 % subjects recruited diagnosed as ALS
• Female 48 y. with R155C and ALS • Rapid deterioration over 2-3 years to
full-blown ALS • Cranial nerve muscles and lower
extremities: Upper motor & lower motor neuron involvement
• Upper extremities: Lower motor neuron involvement
• Severe bulbar dysfunction • Severe respiratory dysfunction with
severe diaphragmatic insufficiency-13% lung capacity.
• EMG - severe motor neuropathy with widespread fibrillations, fasciculation, & neurogenic potentials. No myopathic potentials
Autopsy confirmed ALS.
Parkinsons in 4% in VCP disease
• 5 families with PD and VCP disease Case - 54 y. male with R159C • 44 y decreased driving ability in L arm
golfing • Progression over 1 y to rigidity, reduced
dexterity and resting tremor • Responsive to dopaminergics • Scapular winging 53 y. • Muscle Bx- rare rimmed vacuoles • Parkin negative • Cousin recently Dx with PD
Chan N, Le C, Shieh P, Mozaffar T, Khare M, Bronstein J, Kimonis V. Valosin-Containing Protein Mutation and Parkinson’s Disease, Parkinsonism Relat Disord. 2011 Aug 3.
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Add Spina
Other phenotypes
• Cardiomyopathy
• Anal incompetence
• Charcot Marie Tooth 2
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Add
Frequencies of phenotypes in 187 individuals
IBM only, 37%
PDB only, 5%
FTD only, 3% IBM & PDB, 27%
IBM & FTD, 16%
PDB & FTD, 1% IBMPFD, 10%
Lifetable Analysis of survival:
A B
C D
R93C, 2, 1%M158I*, 1, 1%
R95G, 5, 3%
R159H, 5, 3%
L198W, 7, 4%
R159C, 10, 5%
R191Q, 5, 3%
R155P, 9, 4%
R155C, 31, 16%
R155H, 97, 51%
A232E, 3, 2%N387H, 2, 1%
G97E, 5, 3% A160P*, 3, 2%
G128A*, 2, 1%
Frequency of VCP genotypes in UC Irvine cohort
Age of onset IBM (yrs)
Age of onset PDB (yrs)
Age of onset FTD (yrs)
CPK (U/L)
ALP (IU/L)
ALS Phenotype PD AD
Family ID Mutation
group N symptomatic N Mean N Mean N Mean Mean Mean N N N
1, 3, 4, 7, 10, 15, 16, 19b, 22, 25, 52,
56, 57 1 (R155H) 97 86 43 44 43 24 55 136 230 11 2 1 2, 5, 14, 19a, 26,
34, 54 2 (R155C ) 31 30 38 14 36 10 53 299 282 1 0 0 11, 40 3 (R155P) 9 7 43 7 38 1 52 107 351 0 0 0 13, 33 4 (R191Q) 5 5 47 2 42 2 61 119 58 0 0 0
24, 48** 5 (R159C) 10 10 57 1 NA 7 60 177 88 0 2 0 30, 43 6 (L198W) 7 7 37 4 50 1 50 193 414 0 0 0
55 7 (R159H) 5 4 59 0 NA 3 66 713 98 1 0 1 9 8 (R95G) 5 4 45 1 35 1 58 100 382 1 0 0
36 9 (R93C) 2 2 60 1 NA 1 NA 370 NA 0 0 0 6 10 (A232E) 3 3 42 3 30 0 NA 162 2105 1 0 0
23 11 (N387H) 2 2 45 0 NA 1 46 NA NA 0 0 0 50 12 (G97E) 5 4 49 1 50 1 86 406 38 0 0 1
59 13
(A160P*) 3 1 40 1 52 2 NA NA 230 1 2 0
61 14
(G128A*) 2 2 30 1 40 1 30 464 203 0 1 0
53 15
(M158I*) 1 1 36 0 NA 0 NA 277 224 0 0 0
36 15 187 168 43 80 41 55 56 183 290 16 7 3 IBM present in 89%, PDB in 43%, FTD 29%, ALS in 8.5% and Parkinsons in 3.7% CPK creatine phosphokinase (NL 22 to 198 U/L), ALP alkaline phosphatase (44 to 147 IU/L)* indicates novel mutations
Genotype-phenotype correlations Clinical and biochemical data for symptomatic
individuals in different mutation groups
Mehta S, Watts GD, Adamson JL, Hutton M, Umberger G; Xiong S; Ramdeen S, Lovell MA, Kimonis VE, Smith C. APOE is a Potential Modifier Gene in an Autosomal Dominant Form of Frontotemporal
Dementia (IBMPFD). Genet Med. 2007. 9:9-13. Analysis: Any APOE4 haplotype vs Dx
ChiSquare
P-value
Myopathy
0.09
0.77
Paget's
0.06
0.81
Dementia
9.20
0.002
Table 1 of tests (schedule subject to change if needed) Repeat testing at 1 or 2 year intervals
Day 1 Measure/ Procedure Medical History (30 min) X Medication Use/Updates (5-10 minutes) X Blood: CPK (10 min) X Alkaline phosphatase X Urine deoxy/pyridinolines X
MRI/MRS Measurements (one hour with prep) X Muscle volumetric analysis X Intramuscular Lipid (%) X Muscle T2 X IBM rating Scale (15 min) X ASA24 Diet Questionnaire X Quality of Life scale (20 min) X 6 minute walk test (20 min with prep time) X Biodex dynamometry testing (30 min) X Echocardiogram and Electrocardiogram (30 min) X
Electromyography/Nerve Conduction Velocity (60 min) X
Diffuse Optical Spectroscopy (DOS) (30 min) X
TOTAL TIME DAY 1= APPROX. 7 HOURS DAY 2
Neuropsychological testing (1 hr) X Functional Measures Muscle strength-MRC (20-30 min) X Hand held Dynamometry (30 min) X Skin biopsy (10 min) X Muscle biopsy (20 min) X
Pulmonary Function Studies (Spirometry, MEP, MIP) (15 min)
X
DEXA scan (20 min) X Bone Scan (30 min + 3 hrs wait) X XRAYs (20 min) X
TOTAL TIME DAY 2= APPROX. 3-8 HOURS
Baseline Natural History Study
Characterization of Familial Myopathy,
Paget Disease of Bone
IRB 2007-5832
MRI of thighs and Biodex measurements from twins discordant for the VCP disease
Pixel-intensity histograms of the segmented muscle group in T2-weighted histograms of (A) Control twin and (B) Affected twin. (C) Biodex measurements of twins
Surampalli A, Gold BT, Smith C, Castellani RJ, Khare M, Yu H, Nguyen C, Lan M, Wencel M, Wigal S, Caiozzo V, Kimonis V. A case report comparing clinical, imaging and Neuromuscul Disord. 2015 Feb;25(2):177-83. doi: 10.1016/j.nmd.2014.10.003. Epub 2014 Oct 22.
Presenter
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MRI of thighs and Biodex measurements from twins discordant for the VCP disease. Pixel-intensity histograms of the segmented muscle group in T2-weighted histograms of (A) Control twin and (B) Affected twin. (C) Biodex measurements of control and affected twins of VCP disease.
Summary • VCP inclusion body disease is under-recognized • Currently > 40 mutations, R155H most common • Progressive Myopathy in 89%, presents as IBM,
LGMD, FSH • Paget is present in 43% • FTD in 29% • ALS in approx. 8.5 % • Parkinson’s in 3.7% • Genotype-phenotype correlations difficult because of
heterogeneity • We need natural history studies to attract clinical trials
Preclinical Studies in VCP Disease Using
Mouse Models
Giles Watts &Kimonis designed Knock-in mouse model for IBMPFD.
I KI R155H mutation
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Figure 6. Knock-in mouse model for IBMPFD. The most common human VCP mutation R155H was introduced to the mouse genome by Cre-LoxP technology. Upper panel shows the knock-in construct and the lower panel shows the wild-type construct. Exons 1 through 5 are shown below, and restriction enzyme cutting sites (BglII, EcoRI and HindIII) are indicated above.
Progression of muscle weakness in knock-in Neo+ R155H mice.
Grip Strength Rotarod testing
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Figure 7 A & B. Progression of muscle weakness in knock-in mice. (A) Progressive impairment of muscle strength in knock-in mice measured by the grip strength test. (B) Decline of physical performance in knock-in mice measured by rotarod apparatus after a 30 second acclimation period. Ages of mice are shown in X-axis and results are indicated in Y-axis as relative values when compared to wild-type mice.
Histological analysis of the VCPR155H/+ mouse quadriceps muscles.
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(A) H&E staining of quadriceps muscle from 24-month-old wild-type and (B, C) 15- and 24-month old VCPR155H/+ knock-in mice. (B) Centrally located nuclei are shown by arrows (C) Enlarged vacuoles in the mutant quadriceps. Quadriceps muscles from (D-F) wild-type and (J) Electron microscopy image of 19-month old VCPR155H/+ knock-in mouse muscle showing extensive accumulation of abnormal mitochondria (black arrows) and vacuoles (white arrows) in the inter myofibrillar space. and (K) abnormal mitochondrial cristae structure.
Survival Curve of Homozygote VCPR155H/R155H VCP IBMPFD Mouse Model.
Animals do not survive after 21 days
Translational Studies with the R155H mouse
M M
700 1000
200
Recombination 550bp
No recombination 2000bp
VCP 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
a
6 3 2 6 3 2 5 4
Exon 6 Exon 3 Exon 2 Exon 5 Exon 4
R155H
LoxP LoxP
b
c
500
Targeted Excision of VCP R155H mutation by Cre-LoxP Technology as a Promising Therapeutic
Strategy for Inclusion Body Myopathy Nalbandian A, Llewellyn K, Nguyen C, Monuki E, Kimonis V. Hum Gene Ther Methods. 2014 Dec 29.
Wild
Ty
pe
VCP R155H/+
c
Tamoxifen
Corn Oil
b * *
Wild
Ty
pe
CRE-ERTM-VCP
R155H/+
a
100 µM
Targeted Excision of VCP R155H mutation by Cre-LoxP Technology improves myopathy
VALOSIN CONTAINING
PROTEIN
Membrane Fusion
(NSFL1C)
Nuclear Envelope Reconstruction
Ubiquitin Dependent Protein
Degradation
Endoplasmic Reticulum Associated
Degradation Transcription
Activation Cell Cycle Control
Apoptosis
Autophagy
B M
UT1
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This is an important member of the AAA ATPase family AAA standing for ATP ase associated with a variety of cellular activites. It is an enzymatic machine, catalysing ATP hydrolysis to perform various mechanical jobs around a cell There is sequence homology down to yeast and the mutated residues are conserved in higher mammals Common mechanism - disassembly of protein-protein or DNA-protein complexes All contain ATP binding and hydrolysis domains (Walker A and B) Two distinct classes - 1 or 2 AAA domains VCP has a variety of important cellular roles including Membrane fusion Nuclear envelope reconstruction Post mitotic golgi reassembly Ubiquitin dependent protein degradation- it forms a homohexamer and binds to several different adaptor proteins that enable it to target specific substrates for degradation. It plays a critical role in endoplasmic reticulum associated degradation There is evidence that it is involved in neuronal degeneration Notes majority of mutations occur in critical regions of the CDC48 and D1 domains that have been inserted in neuronally differentiated cell lines inducing cytoplasmic vacuoles, and are assoc with polyubiquitinated accumulation in nuclear and membrane fractions
Nalbandian A, Llewellyn KJ, Nguyen C, Yazdi PG
Kimonis VE. Rapamycin and Chloroquine: the in vitro and in vivo effects of autophagy-modifying drugs show
unexpected results in valosin containing protein multisystem proteinopathy. PLoS One. 2015 Apr 17;10(4)
Rapamycin-induced autophagy aggravates pathology and weakness in a mouse model of
VCP-associated myopathy. Ching JK, Weihl CC. Autophagy. 2013 May;
9(5):799-800.
• Mice treated every other day for 21 days • Mice developed weakness, increase CPK,
increase in vacuolated and atrophic fibers • Inhibition of mTOR with rapamycin resulting in
autophagosome biogenesis worsens muscle degeneration
Presenter
Presentation Notes
Manuscript
Llewellyn KJ, Nalbandian A, Jung KM, Nguyen C, Avanesian A, Mozaffar T,
Piomelli D, Kimonis VE. Lipid-enriched diet slows down progression
in a murine model of VCP-associated disease. Hum Mol Genet. 2013 Oct 24.
Survival curve for the untreated and treated homozygous VCPR155H/R155H IBMPFD mouse model. VCPR155H/R155H
animals fed an increased fat diet several survive >3 months
6 % Diet
9 % Diet
Fatty acids
Percentage difference 2020x (normal) VS 2019 (higher-fat)
diet
C16:0 Palmitic 0.3% increase
C18:0 Stearic 0.1% increase
C18:1ω9 Oleic 0.6% increase
C18:2ω6 Linoleic 1.3% increase
C18:3ω3 Linolenic 0.1% increase
Total saturated 0.4% increase
Total monounsaturated 0.6% increase
Total polysaturated 1.5% increase
Amino Acids
Phenylalanine 0.1% increase
Isoleucine 0.1% increase
Proline 0.1% decrease
A
Wild Type VCPR155H/R155H
B
C
3 weeks ND 3 weeks LED
4 months LED
9 months LED
D
E
F
G
200μm
Measurements, and histological analyses of WT and VCPR155H/R155H mice on normal and HFDs.
Presenter
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Figure 1. Measurements, survival curves, and histological analyses of WT and VCPR155H/R155H mice on normal and HFDs. (A) Weight measurements, (B) Rotarod analysis, and (C) Kaplan-Meier survival curve of WT and VCPR155H/R155H mice (p ≤ 0.001). H&E staining of quadriceps muscle from WT and VCPR155H/R155H animals at (D-E) 3 weeks of age and (F-G) 4-months and 9-months of age, respectively on normal versus HFDs (Magnification: 630X).
Lipid analyses of quadriceps and livers from VCPR155H/R155H
and WT animals on normal and lipid-enriched diets
Summary of animal studies • VCP R155H mice are excellent models of human
disease for translational studies • Uphill exercise improved grip strength/Rotarod • Cre excision of VCP mutation improved
pathology. Exon skipping or allele silencing may be a promising strategy in patients
• ?Autophagy modifying drugs as therapy. • High fat diet (soy bean oil) improves survival
and pathology in homozygotes with translational potential
Promising treatments for VCP disease
• Arimoclomol • Mitochondrial modifiers • Flavinoids
REATA RTA 408 Capsules in Patients With Mitochondrial Myopathy - MOTOR
A Phase 2 Study of the Safety, Efficacy, and Pharmacodynamics of RTA 408 in the Treatment of
Mitochondrial Myopathy (MOTOR) • Mitochondrial myopathies are caused by mtDNA mutations
and/or nuclear mutations of the electron transport chain leads to a reduced ability to produce cellular adenosine triphosphate (ATP), often resulting in muscle weakness, exercise intolerance, and fatigue
• RTA 408 is a potent activator of Nrf2 and inhibitor of NF κB (nuclear factor kappa-light-chain-enhancer of activated B cells), and thus induces an antioxidant and anti-inflammatory phenotype.
• Several lines of evidence suggest that Nrf2 activation can increase mitochondrial respiration and biogenesis.
• https://clinicaltrials.gov/ct2/show/NCT02255422?term=reata+motor&rank=1
Presenter
Presentation Notes
This is the information on the Reata study. We are enrolling and they are paying for travel. There are also sites in LA, Boston, Ohio, Pittsburgh, Philadelphia, and Dallas. MK Mary Kay Koenig, MD Endowed Chair of Mitochondrial Medicine Associate Professor, Department of Pediatrics Division of Child and Adolescent Neurology Mitochondrial Clinic Director Lysosomal Clinic Co-Director Tuberous Sclerosis Center Co-Director
A Multicenter, Dose Ranging Safety and Pharmacokinetics Study of Arimoclomol in
Amyotrophic Lateral Sclerosis (ALS) • The primary purpose of this study is to evaluate the safety and tolerability of arimoclomol in
ALS patients following 90 days of dosing. In addition, the amount of arimoclomol in blood and cerebrospinal fluid will be measured.
• Arimoclomol is a small molecule that upregulates "molecular chaperones" in cells under stress. Arimoclomol extends survival by five weeks when given both pre-symptomatically and at disease onset in a mutant superoxide dismutase (SOD1) transgenic mouse model of ALS. Furthermore, it has been demonstrated to have neuroprotective and neuroregenerative effects in other rat models of nerve damage. Molecular chaperone proteins are critical in the cellular response to stress and protein misfolding. Recent data suggest that the SOD1 mutation responsible for ALS in some patients with familial disease reduces the availability of a variety of molecular chaperones, and thus weakens their ability to respond to cellular stress. Protein misfolding and consequent aggregation may play a role in the pathogenesis of both the familial and sporadic forms of ALS. Therapeutic agents such as arimoclomol that improve cellular chaperone response to protein misfolding may be helpful in ALS.
Study of Arimoclomol in Inclusion Body Myositis (IBM)
• This study is not yet open for participant recruitment.
• Sponsor: University of Kansas Medical Center • Mazen Dimachkie, MD, University of Kansas
Medical Center • Contact: Laura Herbelin (913) 588-5095
ACKNOWLEDGEMENTS
Patients Clinical Projects Marie Wencel Abhilasha Surampalli MBBS Laboratory Angele Nalbandian, PhD Katrina Llewellyn,PhD Arianna Gomez Naomi Walker Collaborators Daniele Piomelli Kwang Jung John H. Weiss Vince Caiozzo Hong Yin Tahseen Mozaffar Annabel Wang Masashi Kitazawa Phil Schwartz
FUNDING NIH NIAMS MDA NICHD-RDCRN CHOC-IRVINE COLLABORATIVE GRANT CODY’s QUEST ICTS
