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Dos Santos JCC, Mano GBC, da Cunha Barreto-Vianna AR, Garcia TFM, de Vasconcelos AV, Sá CSG, de Souza Santana SL, Farias AGP, Seimaru B, Lima MPP, Goes JVC, Gusmão CTP, Junior HLR. The Molecular Impact of Glucosylceramidase Beta 1 (Gba1) in Parkinson's Disease: a New Genetic State of the Art. Mol Neurobiol 2024; 61:6754-6770. [PMID: 38347286 DOI: 10.1007/s12035-024-04008-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/29/2024] [Indexed: 08/22/2024]
Abstract
Parkinson's disease (PD) is a neurodegenerative disorder affecting 2-3% of those aged over 65, characterized by motor symptoms like slow movement, tremors, and muscle rigidity, along with non-motor symptoms such as anxiety and dementia. Lewy bodies, clumps of misfolded proteins, contribute to neuron loss in PD. Mutations in the GBA1 gene are considered the primary genetic risk factor of PD. GBA1 mutations result in decreased activity of the lysosomal enzyme glucocerebrosidase (GCase) resulting in α-synuclein accumulation. We know that α-synuclein aggregation, lysosomal dysfunction, and endoplasmic reticulum disturbance are recognized factors to PD susceptibility; however, the molecular mechanisms connecting GBA1 gene mutations to increased PD risk remain partly unknown. Thus, in this narrative review conducted according to a systematic review method, we aimed to present the main contributions arising from the molecular impact of the GBA1 gene to the pathogenesis of PD providing new insights into potential impacts for advances in the clinical care of people with PD, a neurological disorder that has contributed to the substantial increase in the global burden of disease accentuated by the aging population. In summary, this narrative review highlights the multifaceted impact of GBA1 mutations in PD, exploring their role in clinical manifestations, genetic predispositions, and molecular mechanisms. The review emphasizes the importance of GBA1 mutations in both motor and non-motor symptoms of PD, suggesting broader therapeutic and management strategies. It also discusses the potential of CRISPR/Cas9 technology in advancing PD treatment and the need for future research to integrate these diverse aspects for improved diagnostics and therapies.
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Affiliation(s)
- Júlio César Claudino Dos Santos
- Christus University Center, UNICHRISTUS, Fortaleza, Ceara, Brazil.
- Center for Research and Drug Development (NPDM), Federal University of Ceara, Fortaleza, Ceara, Brazil.
- Postgraduate Program in Morphofunctional Sciences, Federal University of Ceará, Fortaleza, Ceara, Brazil.
| | | | | | - Tulia Fernanda Meira Garcia
- Multicampi School of Medical Sciences, Federal University of Rio Grande Do Norte, Caico, Rio Grande Do Norte, Brazil
| | | | | | | | - Ana Gabriela Ponte Farias
- Center for Research and Drug Development (NPDM), Federal University of Ceara, Fortaleza, Ceara, Brazil
| | - Beatriz Seimaru
- Barão de Mauá University Center, CBM, Ribeirão Preto, São Paulo, Brazil
| | | | - João Vitor Caetano Goes
- Center for Research and Drug Development (NPDM), Federal University of Ceara, Fortaleza, Ceara, Brazil
- Post-Graduate Program of Pathology, Federal University of Ceara, Fortaleza, Ceara, Brazil
| | | | - Howard Lopes Ribeiro Junior
- Center for Research and Drug Development (NPDM), Federal University of Ceara, Fortaleza, Ceara, Brazil
- Post-Graduate Program of Pathology, Federal University of Ceara, Fortaleza, Ceara, Brazil
- Post-Graduate Program in Medical Science, Federal University of Ceara, Fortaleza, Ceara, Brazil
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Sadhukhan D, Biswas A, Mishra S, Chatterjee K, Maji D, Mitra P, Mukherjee P, Podder G, Ray BK, Biswas A, Banerjee TK, Hui SP, Deb I. Genetic Variations and Altered Blood mRNA Level of Circadian Genes and BDNF as Risk Factors of Post-Stroke Cognitive Impairment Among Eastern Indians. Neuromolecular Med 2023; 25:586-595. [PMID: 37814155 DOI: 10.1007/s12017-023-08761-2] [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: 07/25/2023] [Accepted: 09/18/2023] [Indexed: 10/11/2023]
Abstract
Post-stroke cognitive impairment (PSCI) is a clinical outcome in around 30% of post-stroke survivors. BDNF is a major gene in this regard. It is regulated by circadian rhythm. The circadian genes are correlated with stroke timings at molecular level. However, studies suggesting the role of these on susceptibility to PSCI are limited. We aim here to determine: (a) genetic risk variants in circadian clock genes, BDNF and (b) dysregulation in expression level of CLOCK, BMAL1, and BDNF that may be associated with PSCI. BDNF (rs6265G/A, rs56164415C/T), CLOCK (rs1801260T/C, rs4580704G/C), and CRY2 (rs2292912C/G) genes variants were genotyped among 119 post-stroke survivors and 292 controls from Eastern part of India. In addition, we analyzed their gene expression in Peripheral blood Mononuclear cells (PBMC) from 15 PSCI cases and 12 controls. The mRNA data for BDNF was further validated by its plasma level through ELISA (n = 38). Among the studied variants, only rs4580704/CLOCK showed an overall association with PSCI (P = 0.001) and lower Bengali Mini-Mental State Examination (BMSE) score. Its 'C' allele showed a correlation with attention deficiency. The language and memory impairments showed association with rs6265/BDNF, while the 'CC' genotype of rs2292912/CRY2 negatively influenced language and executive function. A significant decrease in gene expression for CLOCK and BDNF in PBMC (influenced by specific genotypes) of PSCI patients was observed than controls. Unlike Pro-BDNF, plasma-level mBDNF was also lower in them. Our results suggest the genetic variants in CLOCK, CRY2, and BDNF as risk factors for PSCI among eastern Indians. At the same time, a lowering expression of CLOCK and BDNF genes in PSCI patients than controls describes their transcriptional dysregulation as underlying mechanism for post-stroke cognitive decline.
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Affiliation(s)
- Dipanwita Sadhukhan
- Department of Biochemistry, University of Calcutta, 35, Ballygunge Circular Road, Kolkata, West Bengal, 700019, India.
- Molecular Biology & Clinical Neuroscience Division, National Neurosciences Centre Calcutta, Kolkata, India.
| | - Arindam Biswas
- Molecular Biology & Clinical Neuroscience Division, National Neurosciences Centre Calcutta, Kolkata, India
| | - Smriti Mishra
- Molecular Biology & Clinical Neuroscience Division, National Neurosciences Centre Calcutta, Kolkata, India
| | - Koustav Chatterjee
- Department of Neurology, Institute of Neurosciences Kolkata, Kolkata, India
| | - Daytee Maji
- Department of Biochemistry, University of Calcutta, 35, Ballygunge Circular Road, Kolkata, West Bengal, 700019, India
| | - Parama Mitra
- Molecular Biology & Clinical Neuroscience Division, National Neurosciences Centre Calcutta, Kolkata, India
| | - Priyanka Mukherjee
- Molecular Biology & Clinical Neuroscience Division, National Neurosciences Centre Calcutta, Kolkata, India
| | - Gargi Podder
- Institute of Post Graduate of Medical Education & Research and Bangur Institute of Neurosciences, Kolkata, India
| | - Biman Kanti Ray
- Institute of Post Graduate of Medical Education & Research and Bangur Institute of Neurosciences, Kolkata, India
| | - Atanu Biswas
- Institute of Post Graduate of Medical Education & Research and Bangur Institute of Neurosciences, Kolkata, India
| | - Tapas Kumar Banerjee
- Molecular Biology & Clinical Neuroscience Division, National Neurosciences Centre Calcutta, Kolkata, India
| | - Subhra Prakash Hui
- S. N. Pradhan Centre for Neurosciences, University of Calcutta, Kolkata, India
| | - Ishani Deb
- Department of Biochemistry, University of Calcutta, 35, Ballygunge Circular Road, Kolkata, West Bengal, 700019, India.
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Koros C, Bougea A, Simitsi AM, Papagiannakis N, Angelopoulou E, Pachi I, Antonelou R, Bozi M, Stamelou M, Stefanis L. The Landscape of Monogenic Parkinson's Disease in Populations of Non-European Ancestry: A Narrative Review. Genes (Basel) 2023; 14:2097. [PMID: 38003040 PMCID: PMC10671808 DOI: 10.3390/genes14112097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/06/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
INTRODUCTION There has been a bias in the existing literature on Parkinson's disease (PD) genetics as most studies involved patients of European ancestry, mostly in Europe and North America. Our target was to review published research data on the genetic profile of PD patients of non-European or mixed ancestry. METHODS We reviewed articles published during the 2000-2023 period, focusing on the genetic status of PD patients of non-European origin (Indian, East and Central Asian, Latin American, sub-Saharan African and Pacific islands). RESULTS There were substantial differences regarding monogenic PD forms between patients of European and non-European ancestry. The G2019S Leucine Rich Repeat Kinase 2 (LRRK2) mutation was rather scarce in non-European populations. In contrast, East Asian patients carried different mutations like p.I2020T, which is common in Japan. Parkin (PRKN) variants had a global distribution, being common in early-onset PD in Indians, in East Asians, and in early-onset Mexicans. Furthermore, they were occasionally present in Black African PD patients. PTEN-induced kinase 1 (PINK1) and PD protein 7 (DJ-1) variants were described in Indian, East Asian and Pacific Islands populations. Glucocerebrosidase gene variants (GBA1), which represent an important predisposing factor for PD, were found in East and Southeast Asian and Indian populations. Different GBA1 variants have been reported in Black African populations and Latin Americans. CONCLUSIONS Existing data reveal a pronounced heterogeneity in the genetic background of PD. A number of common variants in populations of European ancestry appeared to be absent or scarce in patients of diverse ethnic backgrounds. Large-scale studies that include genetic screening in African, Asian or Latin American populations are underway. The outcomes of such efforts will facilitate further clinical studies and will possibly contribute to the identification of either new pathogenic mutations in already described genes or novel PD-related genes.
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Affiliation(s)
- Christos Koros
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (C.K.); (A.M.S.); (N.P.); (E.A.); (I.P.); (R.A.); (L.S.)
| | - Anastasia Bougea
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (C.K.); (A.M.S.); (N.P.); (E.A.); (I.P.); (R.A.); (L.S.)
| | - Athina Maria Simitsi
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (C.K.); (A.M.S.); (N.P.); (E.A.); (I.P.); (R.A.); (L.S.)
| | - Nikolaos Papagiannakis
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (C.K.); (A.M.S.); (N.P.); (E.A.); (I.P.); (R.A.); (L.S.)
| | - Efthalia Angelopoulou
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (C.K.); (A.M.S.); (N.P.); (E.A.); (I.P.); (R.A.); (L.S.)
| | - Ioanna Pachi
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (C.K.); (A.M.S.); (N.P.); (E.A.); (I.P.); (R.A.); (L.S.)
| | - Roubina Antonelou
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (C.K.); (A.M.S.); (N.P.); (E.A.); (I.P.); (R.A.); (L.S.)
| | - Maria Bozi
- Dafni Psychiatric Hospital, 12462 Athens, Greece;
- 2nd Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | | | - Leonidas Stefanis
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (C.K.); (A.M.S.); (N.P.); (E.A.); (I.P.); (R.A.); (L.S.)
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Di Biasio F, Lazzeri G, Monfrini E, Mandich P, Trevisan L, Morbelli S, Markushi TB, Avanzino L, Di Fonzo A. The unexpected finding of CNS autoantibodies in GBA1 mutation carriers with atypical parkinsonism. J Neuropathol Exp Neurol 2023; 82:818-820. [PMID: 37428899 DOI: 10.1093/jnen/nlad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Affiliation(s)
| | - Giulia Lazzeri
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurology Unit, Milan, Italy
- Dino Ferrari Center, Neuroscience Section, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Edoardo Monfrini
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurology Unit, Milan, Italy
- Dino Ferrari Center, Neuroscience Section, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Paola Mandich
- Neurology Unit, IRCCS Policlinico San Martino, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
- Medical Genetics Unit, IRCCS San Martino Hospital, Genoa, Italy
| | - Lucia Trevisan
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
- Medical Genetics Unit, IRCCS San Martino Hospital, Genoa, Italy
| | - Silvia Morbelli
- Neurology Unit, IRCCS Policlinico San Martino, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Tiziana Benzi Markushi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Laura Avanzino
- Neurology Unit, IRCCS Policlinico San Martino, Genoa, Italy
- Section of Human Physiology, Department of Experimental Medicine, University of Genoa, Genoa, Italy
| | - Alessio Di Fonzo
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurology Unit, Milan, Italy
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Chatterjee D, Krainc D. Mechanisms of Glucocerebrosidase Dysfunction in Parkinson's Disease. J Mol Biol 2023; 435:168023. [PMID: 36828270 PMCID: PMC10247409 DOI: 10.1016/j.jmb.2023.168023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
Beta-glucocerebrosidase is a lysosomal hydrolase, encoded by GBA1 that represents the most common risk gene associated with Parkinson's disease (PD) and Lewy Body Dementia. Glucocerebrosidase dysfunction has been also observed in the absence of GBA1 mutations across different genetic and sporadic forms of PD and related disorders, suggesting a broader role of glucocerebrosidase in neurodegeneration. In this review, we highlight recent advances in mechanistic characterization of glucocerebrosidase function as the foundation for development of novel therapeutics targeting glucocerebrosidase in PD and related disorders.
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Affiliation(s)
- Diptaman Chatterjee
- Ken and Ruth Davee Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA. https://twitter.com/NeilChatterBox
| | - Dimitri Krainc
- Ken and Ruth Davee Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA; Simpson Querrey Center for Neurogenetics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
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Lysosomal functions and dysfunctions: Molecular and cellular mechanisms underlying Gaucher disease and its association with Parkinson disease. Adv Drug Deliv Rev 2022; 187:114402. [DOI: 10.1016/j.addr.2022.114402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 04/28/2022] [Accepted: 06/17/2022] [Indexed: 01/18/2023]
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Liu L, Li J, Quan W, Qin Y, Zhang Q, Pei X, Su H, Xu J, Chen J. Effect of GBA gene variants on clinical characteristics of dementia with Lewy bodies: a review and meta-analyses. Neurol Sci 2022; 43:3541-3550. [DOI: 10.1007/s10072-022-06031-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/19/2022] [Indexed: 12/01/2022]
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8
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Cognitive Impairment in Genetic Parkinson's Disease. PARKINSON'S DISEASE 2022; 2021:8610285. [PMID: 35003622 PMCID: PMC8739522 DOI: 10.1155/2021/8610285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 12/08/2021] [Indexed: 11/24/2022]
Abstract
Cognitive impairment is common in idiopathic Parkinson's disease (PD). Knowledge of the contribution of genetics to cognition in PD is increasing in the last decades. Monogenic forms of genetic PD show distinct cognitive profiles and rate of cognitive decline progression. Cognitive impairment is higher in GBA- and SNCA-associated PD, lower in Parkin- and PINK1-PD, and possibly milder in LRRK2-PD. In this review, we summarize data regarding cognitive function on clinical studies, neuroimaging, and biological markers of cognitive decline in autosomal dominant PD linked to mutations in LRRK2 and SNCA, autosomal recessive PD linked to Parkin and PINK1, and also PD linked to GBA mutations.
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Lim JL, Lohmann K, Tan AH, Tay YW, Ibrahim KA, Abdul Aziz Z, Mawardi AS, Puvanarajah SD, Lim TT, Looi I, Ooi JCE, Chia YK, Muthusamy KA, Bauer P, Rolfs A, Klein C, Ahmad-Annuar A, Lim SY. Glucocerebrosidase (GBA) gene variants in a multi-ethnic Asian cohort with Parkinson's disease: mutational spectrum and clinical features. J Neural Transm (Vienna) 2021; 129:37-48. [PMID: 34779914 DOI: 10.1007/s00702-021-02421-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 09/17/2021] [Indexed: 02/07/2023]
Abstract
GBA variants are associated with increased risk and earlier onset of Parkinson's disease (PD), and more rapid disease progression especially with "severe" variants typified by p.L483P. GBA mutation screening studies from South-East Asia, with > 650 million inhabitants of diverse ancestries, are very limited. We investigated the spectrum of GBA variants, and associated clinico-demographic features, in a multi-ethnic PD cohort in Malaysia. Patients (n = 496) were recruited from seven centres, primarily of Chinese (45%), Malay (37%), and Indian (13%) ethnicities. All GBA coding exons were screened using a next-generation sequencing-based PD gene panel and verified with Sanger sequencing. We identified 14 heterozygous GBA alleles consisting of altogether 17 missense variants (8 classified as pathogenic or likely pathogenic for PD) in 25 (5.0%) patients, with a substantially higher yield among early (< 50 years) vs. late-onset patients across all three ethnicities (9.1-13.2% vs. 1.0-3.2%). The most common variant was p.L483P (including RecNciI, n = 11, 2.2%), detected in all three ethnicities. Three novel variants/recombinant alleles of uncertain significance were found; p.P71L, p.L411P, and p.L15S(;)S16G(;)I20V. The common European risk variants, p.E365K, p.T408M, and p.N409S, were not detected. A severe disease course was noted in the majority of GBA-variant carriers, across a range of detected variants. We report a potentially novel observation of spine posture abnormalities in GBA-variant carriers. This represents the largest study on GBA variation from South-East Asia, and highlights that these populations, especially those with EOPD, would be relevant for studies including clinical trials targeting GBA pathways.
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Affiliation(s)
- Jia Lun Lim
- Department of Biomedical Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,The Mah Pooi Soo and Tan Chin Nam Centre for Parkinson's and Related Disorders, University of Malaya, Kuala Lumpur, Malaysia
| | - Katja Lohmann
- Institute of Neurogenetics, University of Luebeck, Luebeck, Germany
| | - Ai Huey Tan
- The Mah Pooi Soo and Tan Chin Nam Centre for Parkinson's and Related Disorders, University of Malaya, Kuala Lumpur, Malaysia.,Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yi Wen Tay
- Department of Biomedical Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,The Mah Pooi Soo and Tan Chin Nam Centre for Parkinson's and Related Disorders, University of Malaya, Kuala Lumpur, Malaysia
| | - Khairul Azmi Ibrahim
- Department of Medicine, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Malaysia
| | - Zariah Abdul Aziz
- Department of Medicine, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Malaysia
| | | | | | - Thien Thien Lim
- Island Hospital, Penang, Malaysia.,Penang General Hospital, Penang, Malaysia
| | - Irene Looi
- Department of Medicine and Clinical Research Centre, Hospital Seberang Jaya, Penang, Malaysia
| | - Joshua Chin Ern Ooi
- Department of Neurology, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Yuen Kang Chia
- Department of Neurology, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Kalai Arasu Muthusamy
- Division of Neurosurgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Peter Bauer
- Centogene AG, Am Strande 7, 18057, Rostock, Germany
| | - Arndt Rolfs
- Centogene AG, Am Strande 7, 18057, Rostock, Germany
| | - Christine Klein
- Institute of Neurogenetics, University of Luebeck, Luebeck, Germany
| | - Azlina Ahmad-Annuar
- Department of Biomedical Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Shen-Yang Lim
- The Mah Pooi Soo and Tan Chin Nam Centre for Parkinson's and Related Disorders, University of Malaya, Kuala Lumpur, Malaysia. .,Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
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