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Duchenne muscular dystrophy is part of a group of inherited disorders that cause muscular debilitation. It is an X-linked recessive disease produced by mutations, most commonly deletions, in the gene responsible for encoding the protein dystrophin. The disease appears in early childhood presenting difficulties walking which progress until loss of ambulation is reached. Patients have a life expectancy of approximately 20 years with cardiac attack being the most common cause of death. There is no known cure but treatments include gene, cell, and drug therapies.
Muscular Dystrophies[edit]
Dystrophy, from the Greek dystrophe, means "defective nutrition". Muscular dystrophies are a group of inherited disorders causing muscle debilitation in varying intensities. They affect mainly males[1][2][3][4]. Major muscles than can be affected include: facial, limb, axial, respiratory, cardiac smooth muscle, muscles used for swallowing, and others. Moreover, some organs and tissues can also be attacked, for example: eyes, skin, brain, and inner ear. There are a variety of muscular dystrophies all of which affect the age at which the disorder begins, its stringency, development, prognostication, and the difficulties associated with it. Some of the most severe dystrophies can produce loss of ambulation and cardiac or respiratory failure leading to death.
Types[edit]
Muscular dystrophies are categorized by the intensity of muscle debilitation and can be classified into seven categories.
Congenital muscular dystrophy[edit]
Congenital muscular dystrophy (CMD) appears at birth, or when a baby is approximately six months old. Patients present some symptoms such as: hypotonia, joint contractures and general weakness. Other symptoms include respiratory insufficiency, rigid spine, distal joint laxity, and muscle hypertrophy. In some cases, the central nervous system (CNS) is compromised, parts that could be affected include: brain stem, cortex, and cerebellum. This can lead to mental deficiency and eventually epilepsy. Some variants of CMD can cause eye problems.
A large percent of children suffering CMD cannot walk by themselves, with the help of physical support structure some can maintain an upright position. The most common form of CMD is Fukuyama congenital muscular dystrophy and it occurs mainly in Japan. CMD is caused by a founder recessive mutation associated with the fukutin gene, the function of which remains unclear. Dr. Yukio Fukuyama was the first to describe this disease in 1960 in Tokyo.
Duchenne and Becker muscular dystrophy[edit]
Duchenne muscular dystrophy (DMD) has an incidence of 1 per 3500 in males, making it the most common out of all kinds of muscular dystrophy. Becker muscular dystrophy (BMD) has an incidence of 1 in 17500 in males, it is the least common muscular dystrophy. They are both caused by a mutation of the same gene, and have similar symptoms but BMD has a less severe prognosis.
Regarding DMD, patients present a series of symptoms: the disease appears in early childhood. The child experiments some difficulties to walk, climb stairs, and its knees and hips are weakened. There is a certain extent of mental deterioration, approximately 20% of children with DMD have an intellectual coefficient below 70. Muscle weakness progresses over the years, and around the age of 12 the child with DMD will have lost his capacity to ambulate by himself, and depends on a wheelchair. Around this time, the child will also present respiratory insufficiency and scoliosis. Children diagnosed with DMD begin suffering from cardiac problems in their adolescence and young adulthood. With regards to prognosis, persons affected with DMD die around 20 years old generally victims of cardiac attack.
Patients with BMD present similar symptoms as those with DMD, but they present at a later age and with lower intensity as compared to DMD. Some BMD patients may lose the ability to walk at age16, but some retain this ability even into their adult years. Cardiac muscle is affected in the same way as in DMD but because it occurs with a lower intensity patients have a life expectancy between 50 and 60 years of age.
The cause of both DMD and BMD is a mutation in the gene which codes the dystrophin protein, which exists in the X chromosome.
Emery-Dreifuss muscular dystrophy[edit]
Emery-Dreifuss muscular dystrophy is caused by mutations in the STA gene at Xq28 which codes emerin, a protein necessary in the nuclear membrane, which leads to the complete absence of emerin in the muscles. There are a series of symptoms in this kind of disorder: weakness of Achilles tendons, posterior cervical muscles and rigidity in elbows. After that, flexion of neck and entire spine is restricted. If the disease is advanced, limb-girdle muscles waste away and get weakened. In later stages, cardiomyopathy will present, usually around the age of 30, which can lead to sudden death.
Distal muscular dystrophy[edit]
Distal muscular dystrophy, as indicated by its name, is characterized by symptoms exhibiting in distal regions (hands and feet). The disease can be due to either autosomal dominant inheritance, patients exhibit symptoms after the age of 40, and autosomal recessive inheritance, patients exhibit symptoms before the age of 30. The cause of this disease is still unknown. The disease can be regarded as a myopathy. It first attacks hands followed by forearms, calves, and finally feet.
This dystrophy is mostly seen in people from Scandinavia. The protect defect is unknown when referring to autosomal dominant inheritance, but in autosomal recessive inheritance it is known to be a defect with dysferlin.
Facioscapulohumeral muscular dystrophy[edit]
The prevalence of facioscapulohumeral muscular dystrophy (FSHD) is 1 in 20,000, making it the third most common kind of muscular dystrophy. It is an autosomal dominant disorder. A molecular defect related to FSHD is a deletion of 3.3 kb of DNA repeat fragments in the subtelomeric region of chromosome 4q (D4Z4), but the function of genes involved in FSHD is unclear.
FSHD commonly appears around the age of 30, presenting weakness at facial muscles, shoulder, peroneal muscle, and abdominal muscles. Other symptoms include: scapular winging, hearing loss, and retinal vasculopathy. Interestingly, patients with FSHD do not present cardiac symptoms, inferring that cardiac muscle is not involved or affected by FSHD. Mental capacities and motor functions are not usually compromised, therefore there is independent ambulation after treatment. In the case of older patients a wheelchair may be required after treatment.
Oculopharyngeal muscular dystrophy[edit]
Oculopharyngeal muscular dystrophy (OPMD) is an autosomal dominant myopathy, prevalent in French Canada, that affects extraocular, facial, neck, and proximal upper limb muscles. It is characterized by dysphagia, difficulty swallowing, as well as a nasal voice. OPMD presents no cardiac problems.
OPMD is caused by a molecular defect in the 14q chromosome. The molecular defect is due to short GCG expansions of the first exon of the poly(A)-binding protein nuclear 1 gene (PABPN1).
Limb-girdle muscular dystrophy[edit]
There are fifteen genetic variants of Limb-girdle muscular dystrophy (LGMD). Therefore, it will exist with both genetic and clinical heterogeneity. Both an autosomal dominant inheritance (LGMD1) and an autosomal recessive inheritance (LGMD2). Most cases of LGMD are reported in Europe. This disease is characterized because it has genetic mutations in multiple genes. Currently, research is being conducted in order to identify more genes responsible for LGMD.
In LGMD the proximal limb-girdle muscles suffer of weakness. One of the concerns for patients with LGMD is cardiac disease, since 92% of patients older than 30 show cardiac failures (dysrhythmias). Therefore, they must be carefully treated. Some cases of mental retardation have been reported. Commonly, patients can ambulate independently.
Duchenne Muscular Dystrophy[edit]
Symptoms and Prognosis[edit]
DMD is a disease that affects males at an incidence rate of 1 in 3500. It is very rare for a woman to present symptoms of DMD because the disease is X-linked. It is estimated that 5-10% of women that suffer from DMD present muscular weakness, usually with less severity than males. They can also be susceptible to cardiomyopathy, even if they don't present muscle weakness[1][2][3][4].
The disease appears in early childhood with symptoms including difficulty walking and climbing stairs, and knee and hip weakness. Some children may present mental deterioration, approximately 20% of children with DMD have intellectual coefficients below 70. By the age of 12 muscle weakness has progressed to such an extent that the child will most likely not be able to ambulate independently and therefore requires the use of a wheelchair. At this point in the disease's progression the patient also present respiratory insufficiency and scoliosis. Patients of DMD begin suffering from cardiac problems in the adolescence of young adulthood. Patients of DMD have a life expectancy of 20 years, with the most common cause of death being cardiac attacks[5][6][7].
Clinical Diagnosis[edit]
In addition to the symptoms of DMD there are some useful clinical matters that have been well studied in order to better identify the disease[4][8].
Creatine Kinase Levels[edit]
Creatine kinase (CK) levels are unusually elevated, 50 times the normal level, at birth and in the infantile stage. However, there is no exact correlation between CK levels and the severity of the disease. DMD diagnosis can be carried out by measuring the levels of CK, since it provides a very good indication of the existence of DMD during an asymptomatic period[9].
Transaminase Levels[edit]
Transaminase levels should be evaluated via a biochemical analysis if DMD is suspected. Transaminases produces by the liver and muscle cells are particularly relevant in this analysis and so aspartate aminotransferase and alanine aminotransferase are the transaminases that should be evaluated [10].
Electromyography[edit]
Electromyography is an invasive procedure and involves a degree of pain and discomfort and so it is a method that is not frequently employed on children, considering the experience may be frightening. Nonetheless, this technique is very important and useful on adult patients because it provides information on the myopathies being suffered, allowing the determination of cardiac muscle condition. It can also be used to discard the presence of some neurogenic disorders [1].
Muscle Histology[edit]
Muscle histology is a histological search that produces results about some variations in muscle fiber size, necrosis, and macrophages invading the fiber cells. These are important factors that play a critical role when DMD is being studied [1].
Immunohistochemistry[edit]
Immunohistochemistry allows the identification of proteins that are affected by of the presence of DMD, aiding the diagnostic procedure. When a person suffers from DMD the amount of dystrophin, a protein present in muscle cell membranes, is less than the normal value because it is absent from skeletal muscle. For example, a Western Blot analyses on a DMD patient using the dystrophin antibody, will reveal low levels to no dystrophin[9].
Pathophysiology[edit]
Pathophysiology of DMD allows the discovery of drugs and the development of treatments for patients suffering from this condition. Dystrophin is the protein affected in DMD cases, its main function is to establish a link between the internal cytoskeleton and the extracellular matrix. In the sarcolemma there is a dystrophin-associated protein complex (DAPC), and dystrophin binds to it by using its amino-terminus to stabilize DAPC. However, when dystrophin is absent, as is the case with DMD patients, DAPC is destabilized and levels of the member proteins are lowered, leading to gradual muscle fiber damage and membrane breakdown. DAPC is composed of dystroglycans, sarcoglycans, integrins and caveolin. Therefore, any mutation in any of them produces autosomally inherited muscular dystrophies. DAPC also plays a role in signaling that, when not performed, leads to pathogenesis. The process just described leads to muscle weakness, since there is a loss of muscle enzymes, including creatine kinase[11][12][13][14][15].
There is a possibility that inter-protein interactions cause increased calcium channel activity, due mainly to conformational changes in their structure. As a result, there is a mitochondrial dysfunction that could induce cell death. In fact, early stages of DMD are characterized by abnormal levels of intracellular calcium[16][17][18][19].
Treatment[edit]
At present, there is no fully effective therapy to treat DMD. Nonetheless, experimental treatment strategies have been developed in three main areas: cell, drug, and gene therapy[20].
Gene Therapy[edit]
Gene therapy is employed to replace the mutated gene. It is based on adeno-associated vectors, which have a very small size and lower immune response. These kinds of vectors are preferred over others. The adeno-associated vector has a limited capacity, and it cannot adapt to the full-size cDNA of dystrophin; however, it can be used to store genes such as sarcoglycans, which have a smaller size.
At present, there are two strategies that have been tested: exon skipping and expression of dystrophin variants of smaller size. The first one uses adeno-associated type 1 viral vectors to form small nuclear U7 RNA targeting exons 6-8, to exclude the mutation of dystrophin. The second strategy has to do with plasmids which have been administered directly by intramuscular injection. These plasmids express human dystrophin and therefore protein expression occurs in the site where the injection was administered[21].
Cell Therapy[edit]
Cell therapy is used to replace affected cells. Some experiments have demonstrated that expression of dystrophin can be achieved by myoblasts transplanted into dystrophic muscle. It is safe, although there are no apparent benefits for muscles, particularly the injected muscles, due mainly to immune response and poor survival and displacement of myoblasts. Another difficulty that arises from local administration has to do with delivering myoblasts systemically into the bloodstream.
Stem cells are being studied, since they are very promising as a treatment for DMD, because they have the ability to self-renew and differentiate into other kinds of cells. Some experiments have been carried out with stem cells from adults, they have been isolated from bone marrow blood and muscles, and used in transplantation experiments[3][20][21][22].
Drug Therapy[edit]
Drug therapy is used mainly to compensate for the absence of dystrophin. To this date, there is a variety of drugs being researched.
- Utrophin
Utrophin was one of the first proteins studied in order to replace dystrophin, because it is a homologue of dystrophin with a molecular weight of 395 kDa. It is similar to dystrophin because it shares 80% of dystrophin's sequence. Patients with DMD have an overexpression of utrophin in their muscles[1].
It has been demonstrated that utrophin expression increases with age and helps delay the age at which the patient will lose independent ambulation. Some possible drug candidates have been synthesized, and an orally ingestible compound has been developed by Tinsley and co-workers[23] which has been able to enhance levels of utrophin mRNA and the protein itself. This drug, developed by Summit PLC, is safe and has been properly tolerated by voluntary patients.
Corticosteroids are a main aspect of DMD drug therapy and have been used in anti-inflammatory treatments demonstrating the ability to delay the progress of DMD. Clinical studies have demonstrated that corticosteroids can enhance the function and strength of muscles, with little to no sever collateral effects. The corticosteroids primarily used in treatment of DMD are Prednisone/Prednisolone and Deflazacort. Side effects include: gastrointestinal symptoms, nervous system disturbance, metabolic disorders, osteoporosis, and others. However, their benefits have been well documented[20][24].
- Aminoglycosides
Gentamicin is an antibiotic drug developed to fight infections by Gram-negative bacteria It interacts with the 40S ribosomal subunit when RNA is being transcribed. Its function is to suppress the termination codons and replace them with another amino acid. Studies carried out with human subjects and mice demonstrated that dystrophin can be expressed in muscle fibers at 20% above normal levels. Nevertheless, there is a controversy about this investigation, because varying results have been obtained regarding diverse studies on DMD patients.
When aminoglycosides are used for a long time and at high dosages, patients can suffer from ototoxicity and renal toxicity. These collateral effects limit their prolonged use[24].
- Ataluren
Ataluren was synthesized to have the same activity as gentamicin, but with a different structure and a better safety profile. It has been well tolerated by patients, must be taken orally, and has no antibiotic activity.
Research on ataluren found that it bound to the 60S ribosomal subunit, and some studies on mice have found it aids in dystrophin expression in skeletal muscles, diaphragm, and the heart. In other trials, ataluren has been shown to aid dystrophin expression in patients suffering DMD with nonsense mutation. Additionally, it can induce expression of transmembrane conductance regulator (cftr) protein in nonsense mutation to patients suffering cystic fibrosis. The European Union granted conditional marketing approval of ataluren under the trade name Translarna. This is the first drug treatment officially approved for DMD[24]
- Myostatin
Myostatin is a protein that influences regulation of muscle size. It is produced in both blood and muscles. A potential treatment for DMD is the blocking of myostatin. One research regrading clinical trials has been carried out on DMD patients using an antibody against myostatin (MYO-029). It demonstrated that, while the patients didn't suffer from adverse effects, no significant muscle strengthening was achieved[20][24]. However, myostatin inhibition is still considered a viable treatment for muscular dystrophies[25].
- Histone deacetylase inhibitors
Givinostat (ITF2357) is a histone deacetylase inhibitor, which is anti-inflammatory, antio-angiogenic, and anti-neoplastic. In mice it has demonstrated that progress of DMD is delayed by givionstat by increasing the cross-sectional area of myofibers and reducing fibrotic tissue and fatty infiltration. Research demonstrated that is has the capability of muscle regeneration [20][26]
- NO-releasing anti-inflammatory agents
Flurbiprofen is a non-steroidal anti-inflammatory compound. An NO-releasing derivative of flurbiprofen (HCT1026) has been researched and been found to improve muscle repair by slowing down the progress of DMD, and consequently reducing inflammation and avoiding muscle damage[24][27].
- Vitamin D supplements
Patients suffering from DMD tend to have little exposure to sunlight; therefore, synthesis of vitamin D is poor, and they have lower-than-normal levels. Consequences of low vitamin D levels include low bone mineral density, and osteoporosis. Hence, patients could develop pathological fractures which compromise long bones and the spine. Doctors recommend diet with physical exercise and supplements containing calcium and vitamin D for persons with DMD and deficiency of vitamin D[24][27].
- Simvastatin
Simvastatin is a drug that belongs to the statin group. In laboratory experiments using mice it was observed that simvastatin improves the muscle function and reduces damage produced by DMD. Simvastatin can also reduce inflammation and enhance the strength of the diaphragm muscle. Its effects are similar to dytrophin gene-based therapies. In short, simvastatin enhances the general health and function of muscles compromised in DMD, by reducing oxidative stress and fibrosis. Clinically, simvastatin and other statins have been approved by the FDA for drug therapy in children older than 10, who are suffering hypercholesterolemia. Therefore, simvastatin and related statins represent a potential safe treatment for DMD[28].
- Exondys 51
In September 19th, 2016, the U.S. Food and Drug Administration (FDA) approved Exondys 51 to be administered by injection. This is the first FDA approved drug for treatment of DMD. Exondys 51 is an antisense oligonucleotide recommended for patients who have a positive mutation of the dystrophin gene owed to exon 51 skipping. This mutation occurs in approximately 13% of patients with DMD.
Exondys 51 was approved by the FDA, based on an increase in dystrophin in skeletal muscle, observed in patients treated with this drug. Up to date, the clinical benefits of Exondyn 51 has not been fully established and clinical trials have been ordered by the FDA in order to confirm positively its clinical performance. Among the side effects reported by patients using this drug were balance disorders and vomiting[29].
Genetics of DMD[edit]
Duchenne muscular dystrophy was described for the first time by G.B. Duchenne in 1861. DMD is an X-linked recessive disease that is produced by mutations in the gene responsible for encoding dystrophin, that belongs to a family of dystrophin-related proteins. The protein related to DMD (Dp427m) is found at the sarcolemma in the muscle in a membrane-spanning protein complex that links the cytoskeleton to the basal lamina. The function of the dystrophin protein is not known; however, its absence induces destabilization of the membrane that leads to damage of the sarcolemma, loss of calcium homeostasis, and progressive degeneration of muscle fibers[24].
Detecting mutations in the DMD gene has proven to be difficult primarily because of its length. The reported frequency of different mutations varies widely but according to the Leiden database duplications corresponds to 7% of mutations, point mutations for 20%, and deletions for 72%. Over 1000 mutations have been identified[30]. Most of these deletions occur between exons 44 and 55, which corresponds to the protein's rod domain. These mutations can cause the dystrophin's reading frame to be altered, which leads to out of frame mutations, causing the protein to be truncated and no dystrophin is produced, this leads to development of DMD. If the mutation is "in frame", then an altered dystrophin is produced which can still function and the patient is diagnosed with BMD [24].
Gene sequence[edit]
The DMD gene is found on the X-chromosome in Xp21.2-p21.1 which is the short arm (p arm) of the X chromosome between positions 21.2 and 21.1. Its location was possible thanks to DNA markers. The function of the gene is to encode the protein dystrophin. The DMD gene, isolated in 1986, is one of the largest known genes spanning a genomic range greater than 2 million base pairs (2,241,933 bases). It consists of 89 exons and 88 introns. Duchenne muscular dystrophy is suspected to be caused by deletions, duplications, and point mutations at this gene locus. The genetic sequence can be found here.
mRNA Transcript Variants[edit]
The DMD gene produces many distinct mRNA-transcripts which encode various dystrophin proteins containing the same basic sequence but with distinct segments of varying length (isoforms). These transcript variants are due to alternative promoter usage and alternative splicing. The following table lists known transcript variants. For brevity's sake, the mRNA sequences are not included (their length can go over 14000 base pairs) but through the accession numbers both the mRNA sequence and the protein amino acid sequence can be found.
| Transcript Variant | mRNA length | Amount of Exons | Protein Size | Molecular Weight | Description | Accession Numbers |
|---|---|---|---|---|---|---|
| Dp427m | 13993 bp | 79 | 3685 aa | 427 kDa | Transcript Dp427m encodes the main dystrophin protein found in muscle. Considered to be the full length dystrophin product. | NM_004006 NP_003997 |
| Dp427c | 14069 bp | 79 | 3677 aa | 427 kDa | Transcript Dp427c is expressed predominantly in neurons of the cortex and the CA regions of the hippocampus. It uses a unique promoter located about 130 kb upstream of the Dp427m transcript promoter. | NM_000109 NP_000100 |
| Dp427p1 | 14000 bp | 79 | 3681 aa | 427 kDa | Transcript Dp427p1 initiates from a unique promoter/exon 1 located in what corresponds to the first intron of transcript Dp427m. | NM_004009 NP_004000 |
| Dp427p2 | 14083 bp | 79 | 3562 aa | 427 kDa | Transcript Dp427p2 has an additional 82 nt directly after exon 1 which introduces a translational stop codon 24 bp downstream of the same ATG codon included in the Dp427p1 transcript. This transcript has unknown coding capacity. | NM_004010 NP_004001 |
| Dp260-1 | 9771 bp | 51 | 2344 aa | 260 kDa | Transcript Dp260-1 uses exons 30-79, and originates from a promoter/exon 1 sequence located in intron 29 of the dystrophin gene. | NM_004011 NP_004002 |
| Dp260-2 | 9914 bp | 51 | 2341 aa | 260 kDa | Transcript Dp260-2 uses exons 30-79, starting from a promoter/exon 1 sequence located in intron 29 of the dystrophin gene that is alternatively spliced. | NM_004012 NP_004003 |
| Dp140 | 7410 bp | 36 | 1225 aa | 140 kDa | Dp140 transcripts use exons 45-79, starting at a promoter/exon 1 located in intron 44. | NM_004013 NP_004004 |
| Dp116 | 5623 bp | 25 | 956 aa | 116 kDa | Transcript Dp116 uses exons 56-79, starting from a promoter/exon 1 within intron 55. | NM_004014 NP_004005 |
| Dp71 | 4623 bp | 18 | 617 aa | 71 kDa | Dp71 transcripts use exons 63-79 with a novel 80- to 100-nt exon containing an ATG start site for a new coding sequence of 17 nt. | NM_004015 NP_004006 |
| Dp71b | 4591 bp | 17 | 635 aa | 71 kDa | Dp71 transcripts use exons 63-79 with a novel 80- to 100-nt exon containing an ATG start site for a new coding sequence of 17 nt. | NM_004016 NP_004007 |
| Dp71a | 4584 bp | 17 | 604 aa | 71 kDa | Dp71 transcripts use exons 63-79 with a novel 80- to 100-nt exon containing an ATG start site for a new coding sequence of 17 nt. | NM_004017 NP_004008 |
| Dp71ab | 4552 bp | 16 | 622 aa | 71 kDa | Dp71 transcripts use exons 63-79 with a novel 80- to 100-nt exon containing an ATG start site for a new coding sequence of 17 nt. | NM_004018 NP_004009 |
| Dp40 | 1571 bp | 9 | 340 aa | 40 kDa | Transcript Dp40 uses exons 63-70. The 5' UTR and encoded first 7 aa are identical to that in transcript Dp71, but the stop codon lies at the splice junction of the exon/intron 70. | NM_004019 NP_004010 |
| Dp140c | 7080 bp | 32 | 1115 aa | 140 kDa | Dp140 transcripts use exons 45-79, starting at a promoter/exon 1 located in intron 44. | NM_004020 NP_004011 |
| Dp140b | 7378 bp | 35 | 1243 aa | 140 kDa | Transcript Dp140b lacks exon 78 and encodes a protein with a unique C-terminus. | NM_004021 NP_004012 |
| Dp140ab | 7339 bp | 34 | 1230 aa | 140 kDa | Transcript Dp140ab lacks exons 71 and 78 and encodes a protein with a unique C-terminus. | NM_004022 NP_004013 |
| Dp140bc | 7048 bp | 31 | 1133 aa | 140 kDa | Transcript Dp140bc lacks exons 71-74 and 78 and encodes a protein with a unique C-terminus. | NM_004023 NP_004014 |
Dp427m Isoform[edit]
The dystrophin protein is rod-shaped, has a length of 150nm, 3685 amino acids, and a calculated molecular weight of 427 kDa. DP427m is the main dystrophin found in skeletal muscles and heart muscles. It is involved in both Duchenne and Becker muscular dystrophies and consists of 79 exons. It is coded by an mRNA with a length of 13993 base pairs (Accesion: NM_004006). This protein is found in the sarcolemma in a membrane-spanning protein complex that links the cytoskeleton and the basal lamina. Its function is unknown; but in its absence the membrane destabilizes which leads to sarcolemma damage, loss of calcium homeostasis, and progressive degeneration of muscle fibers[24].
Dp427m mRNA sequence
1 tcctggcatc agttactgtg ttgactcact cagtgttggg atcactcact ttccccctac
61 aggactcaga tctgggaggc aattaccttc ggagaaaaac gaataggaaa aactgaagtg
121 ttactttttt taaagctgct gaagtttgtt ggtttctcat tgtttttaag cctactggag
181 caataaagtt tgaagaactt ttaccaggtt ttttttatcg ctgccttgat atacactttt
241 caaaatgctt tggtgggaag aagtagagga ctgttatgaa agagaagatg ttcaaaagaa
301 aacattcaca aaatgggtaa atgcacaatt ttctaagttt gggaagcagc atattgagaa
361 cctcttcagt gacctacagg atgggaggcg cctcctagac ctcctcgaag gcctgacagg
421 gcaaaaactg ccaaaagaaa aaggatccac aagagttcat gccctgaaca atgtcaacaa
481 ggcactgcgg gttttgcaga acaataatgt tgatttagtg aatattggaa gtactgacat
541 cgtagatgga aatcataaac tgactcttgg tttgatttgg aatataatcc tccactggca
601 ggtcaaaaat gtaatgaaaa atatcatggc tggattgcaa caaaccaaca gtgaaaagat
661 tctcctgagc tgggtccgac aatcaactcg taattatcca caggttaatg taatcaactt
721 caccaccagc tggtctgatg gcctggcttt gaatgctctc atccatagtc ataggccaga
781 cctatttgac tggaatagtg tggtttgcca gcagtcagcc acacaacgac tggaacatgc
841 attcaacatc gccagatatc aattaggcat agagaaacta ctcgatcctg aagatgttga
901 taccacctat ccagataaga agtccatctt aatgtacatc acatcactct tccaagtttt
961 gcctcaacaa gtgagcattg aagccatcca ggaagtggaa atgttgccaa ggccacctaa
1021 agtgactaaa gaagaacatt ttcagttaca tcatcaaatg cactattctc aacagatcac
1081 ggtcagtcta gcacagggat atgagagaac ttcttcccct aagcctcgat tcaagagcta
1141 tgcctacaca caggctgctt atgtcaccac ctctgaccct acacggagcc catttccttc
1201 acagcatttg gaagctcctg aagacaagtc atttggcagt tcattgatgg agagtgaagt
1261 aaacctggac cgttatcaaa cagctttaga agaagtatta tcgtggcttc tttctgctga
1321 ggacacattg caagcacaag gagagatttc taatgatgtg gaagtggtga aagaccagtt
1381 tcatactcat gaggggtaca tgatggattt gacagcccat cagggccggg ttggtaatat
1441 tctacaattg ggaagtaagc tgattggaac aggaaaatta tcagaagatg aagaaactga
1501 agtacaagag cagatgaatc tcctaaattc aagatgggaa tgcctcaggg tagctagcat
1561 ggaaaaacaa agcaatttac atagagtttt aatggatctc cagaatcaga aactgaaaga
1621 gttgaatgac tggctaacaa aaacagaaga aagaacaagg aaaatggagg aagagcctct
1681 tggacctgat cttgaagacc taaaacgcca agtacaacaa cataaggtgc ttcaagaaga
1741 tctagaacaa gaacaagtca gggtcaattc tctcactcac atggtggtgg tagttgatga
1801 atctagtgga gatcacgcaa ctgctgcttt ggaagaacaa cttaaggtat tgggagatcg
1861 atgggcaaac atctgtagat ggacagaaga ccgctgggtt cttttacaag acatccttct
1921 caaatggcaa cgtcttactg aagaacagtg cctttttagt gcatggcttt cagaaaaaga
1981 agatgcagtg aacaagattc acacaactgg ctttaaagat caaaatgaaa tgttatcaag
2041 tcttcaaaaa ctggccgttt taaaagcgga tctagaaaag aaaaagcaat ccatgggcaa
2101 actgtattca ctcaaacaag atcttctttc aacactgaag aataagtcag tgacccagaa
2161 gacggaagca tggctggata actttgcccg gtgttgggat aatttagtcc aaaaacttga
2221 aaagagtaca gcacagattt cacaggctgt caccaccact cagccatcac taacacagac
2281 aactgtaatg gaaacagtaa ctacggtgac cacaagggaa cagatcctgg taaagcatgc
2341 tcaagaggaa cttccaccac cacctcccca aaagaagagg cagattactg tggattctga
2401 aattaggaaa aggttggatg ttgatataac tgaacttcac agctggatta ctcgctcaga
2461 agctgtgttg cagagtcctg aatttgcaat ctttcggaag gaaggcaact tctcagactt
2521 aaaagaaaaa gtcaatgcca tagagcgaga aaaagctgag aagttcagaa aactgcaaga
2581 tgccagcaga tcagctcagg ccctggtgga acagatggtg aatgagggtg ttaatgcaga
2641 tagcatcaaa caagcctcag aacaactgaa cagccggtgg atcgaattct gccagttgct
2701 aagtgagaga cttaactggc tggagtatca gaacaacatc atcgctttct ataatcagct
2761 acaacaattg gagcagatga caactactgc tgaaaactgg ttgaaaatcc aacccaccac
2821 cccatcagag ccaacagcaa ttaaaagtca gttaaaaatt tgtaaggatg aagtcaaccg
2881 gctatcaggt cttcaacctc aaattgaacg attaaaaatt caaagcatag ccctgaaaga
2941 gaaaggacaa ggacccatgt tcctggatgc agactttgtg gcctttacaa atcattttaa
3001 gcaagtcttt tctgatgtgc aggccagaga gaaagagcta cagacaattt ttgacacttt
3061 gccaccaatg cgctatcagg agaccatgag tgccatcagg acatgggtcc agcagtcaga
3121 aaccaaactc tccatacctc aacttagtgt caccgactat gaaatcatgg agcagagact
3181 cggggaattg caggctttac aaagttctct gcaagagcaa caaagtggcc tatactatct
3241 cagcaccact gtgaaagaga tgtcgaagaa agcgccctct gaaattagcc ggaaatatca
3301 atcagaattt gaagaaattg agggacgctg gaagaagctc tcctcccagc tggttgagca
3361 ttgtcaaaag ctagaggagc aaatgaataa actccgaaaa attcagaatc acatacaaac
3421 cctgaagaaa tggatggctg aagttgatgt ttttctgaag gaggaatggc ctgcccttgg
3481 ggattcagaa attctaaaaa agcagctgaa acagtgcaga cttttagtca gtgatattca
3541 gacaattcag cccagtctaa acagtgtcaa tgaaggtggg cagaagataa agaatgaagc
3601 agagccagag tttgcttcga gacttgagac agaactcaaa gaacttaaca ctcagtggga
3661 tcacatgtgc caacaggtct atgccagaaa ggaggccttg aagggaggtt tggagaaaac
3721 tgtaagcctc cagaaagatc tatcagagat gcacgaatgg atgacacaag ctgaagaaga
3781 gtatcttgag agagattttg aatataaaac tccagatgaa ttacagaaag cagttgaaga
3841 gatgaagaga gctaaagaag aggcccaaca aaaagaagcg aaagtgaaac tccttactga
3901 gtctgtaaat agtgtcatag ctcaagctcc acctgtagca caagaggcct taaaaaagga
3961 acttgaaact ctaaccacca actaccagtg gctctgcact aggctgaatg ggaaatgcaa
4021 gactttggaa gaagtttggg catgttggca tgagttattg tcatacttgg agaaagcaaa
4081 caagtggcta aatgaagtag aatttaaact taaaaccact gaaaacattc ctggcggagc
4141 tgaggaaatc tctgaggtgc tagattcact tgaaaatttg atgcgacatt cagaggataa
4201 cccaaatcag attcgcatat tggcacagac cctaacagat ggcggagtca tggatgagct
4261 aatcaatgag gaacttgaga catttaattc tcgttggagg gaactacatg aagaggctgt
4321 aaggaggcaa aagttgcttg aacagagcat ccagtctgcc caggagactg aaaaatcctt
4381 acacttaatc caggagtccc tcacattcat tgacaagcag ttggcagctt atattgcaga
4441 caaggtggac gcagctcaaa tgcctcagga agcccagaaa atccaatctg atttgacaag
4501 tcatgagatc agtttagaag aaatgaagaa acataatcag gggaaggagg ctgcccaaag
4561 agtcctgtct cagattgatg ttgcacagaa aaaattacaa gatgtctcca tgaagtttcg
4621 attattccag aaaccagcca attttgagca gcgtctacaa gaaagtaaga tgattttaga
4681 tgaagtgaag atgcacttgc ctgcattgga aacaaagagt gtggaacagg aagtagtaca
4741 gtcacagcta aatcattgtg tgaacttgta taaaagtctg agtgaagtga agtctgaagt
4801 ggaaatggtg ataaagactg gacgtcagat tgtacagaaa aagcagacgg aaaatcccaa
4861 agaacttgat gaaagagtaa cagctttgaa attgcattat aatgagctgg gagcaaaggt
4921 aacagaaaga aagcaacagt tggagaaatg cttgaaattg tcccgtaaga tgcgaaagga
4981 aatgaatgtc ttgacagaat ggctggcagc tacagatatg gaattgacaa agagatcagc
5041 agttgaagga atgcctagta atttggattc tgaagttgcc tggggaaagg ctactcaaaa
5101 agagattgag aaacagaagg tgcacctgaa gagtatcaca gaggtaggag aggccttgaa
5161 aacagttttg ggcaagaagg agacgttggt ggaagataaa ctcagtcttc tgaatagtaa
5221 ctggatagct gtcacctccc gagcagaaga gtggttaaat cttttgttgg aataccagaa
5281 acacatggaa acttttgacc agaatgtgga ccacatcaca aagtggatca ttcaggctga
5341 cacacttttg gatgaatcag agaaaaagaa accccagcaa aaagaagacg tgcttaagcg
5401 tttaaaggca gaactgaatg acatacgccc aaaggtggac tctacacgtg accaagcagc
5461 aaacttgatg gcaaaccgcg gtgaccactg caggaaatta gtagagcccc aaatctcaga
5521 gctcaaccat cgatttgcag ccatttcaca cagaattaag actggaaagg cctccattcc
5581 tttgaaggaa ttggagcagt ttaactcaga tatacaaaaa ttgcttgaac cactggaggc
5641 tgaaattcag cagggggtga atctgaaaga ggaagacttc aataaagata tgaatgaaga
5701 caatgagggt actgtaaaag aattgttgca aagaggagac aacttacaac aaagaatcac
5761 agatgagaga aagcgagagg aaataaagat aaaacagcag ctgttacaga caaaacataa
5821 tgctctcaag gatttgaggt ctcaaagaag aaaaaaggct ctagaaattt ctcatcagtg
5881 gtatcagtac aagaggcagg ctgatgatct cctgaaatgc ttggatgaca ttgaaaaaaa
5941 attagccagc ctacctgagc ccagagatga aaggaaaata aaggaaattg atcgggaatt
6001 gcagaagaag aaagaggagc tgaatgcagt gcgtaggcaa gctgagggct tgtctgagga
6061 tggggccgca atggcagtgg agccaactca gatccagctc agcaagcgct ggcgggaaat
6121 tgagagcaaa tttgctcagt ttcgaagact caactttgca caaattcaca ctgtccgtga
6181 agaaacgatg atggtgatga ctgaagacat gcctttggaa atttcttatg tgccttctac
6241 ttatttgact gaaatcactc atgtctcaca agccctatta gaagtggaac aacttctcaa
6301 tgctcctgac ctctgtgcta aggactttga agatctcttt aagcaagagg agtctctgaa
6361 gaatataaaa gatagtctac aacaaagctc aggtcggatt gacattattc atagcaagaa
6421 gacagcagca ttgcaaagtg caacgcctgt ggaaagggtg aagctacagg aagctctctc
6481 ccagcttgat ttccaatggg aaaaagttaa caaaatgtac aaggaccgac aagggcgatt
6541 tgacagatct gttgagaaat ggcggcgttt tcattatgat ataaagatat ttaatcagtg
6601 gctaacagaa gctgaacagt ttctcagaaa gacacaaatt cctgagaatt gggaacatgc
6661 taaatacaaa tggtatctta aggaactcca ggatggcatt gggcagcggc aaactgttgt
6721 cagaacattg aatgcaactg gggaagaaat aattcagcaa tcctcaaaaa cagatgccag
6781 tattctacag gaaaaattgg gaagcctgaa tctgcggtgg caggaggtct gcaaacagct
6841 gtcagacaga aaaaagaggc tagaagaaca aaagaatatc ttgtcagaat ttcaaagaga
6901 tttaaatgaa tttgttttat ggttggagga agcagataac attgctagta tcccacttga
6961 acctggaaaa gagcagcaac taaaagaaaa gcttgagcaa gtcaagttac tggtggaaga
7021 gttgcccctg cgccagggaa ttctcaaaca attaaatgaa actggaggac ccgtgcttgt
7081 aagtgctccc ataagcccag aagagcaaga taaacttgaa aataagctca agcagacaaa
7141 tctccagtgg ataaaggttt ccagagcttt acctgagaaa caaggagaaa ttgaagctca
7201 aataaaagac cttgggcagc ttgaaaaaaa gcttgaagac cttgaagagc agttaaatca
7261 tctgctgctg tggttatctc ctattaggaa tcagttggaa atttataacc aaccaaacca
7321 agaaggacca tttgacgttc aggaaactga aatagcagtt caagctaaac aaccggatgt
7381 ggaagagatt ttgtctaaag ggcagcattt gtacaaggaa aaaccagcca ctcagccagt
7441 gaagaggaag ttagaagatc tgagctctga gtggaaggcg gtaaaccgtt tacttcaaga
7501 gctgagggca aagcagcctg acctagctcc tggactgacc actattggag cctctcctac
7561 tcagactgtt actctggtga cacaacctgt ggttactaag gaaactgcca tctccaaact
7621 agaaatgcca tcttccttga tgttggaggt acctgctctg gcagatttca accgggcttg
7681 gacagaactt accgactggc tttctctgct tgatcaagtt ataaaatcac agagggtgat
7741 ggtgggtgac cttgaggata tcaacgagat gatcatcaag cagaaggcaa caatgcagga
7801 tttggaacag aggcgtcccc agttggaaga actcattacc gctgcccaaa atttgaaaaa
7861 caagaccagc aatcaagagg ctagaacaat cattacggat cgaattgaaa gaattcagaa
7921 tcagtgggat gaagtacaag aacaccttca gaaccggagg caacagttga atgaaatgtt
7981 aaaggattca acacaatggc tggaagctaa ggaagaagct gagcaggtct taggacaggc
8041 cagagccaag cttgagtcat ggaaggaggg tccctataca gtagatgcaa tccaaaagaa
8101 aatcacagaa accaagcagt tggccaaaga cctccgccag tggcagacaa atgtagatgt
8161 ggcaaatgac ttggccctga aacttctccg ggattattct gcagatgata ccagaaaagt
8221 ccacatgata acagagaata tcaatgcctc ttggagaagc attcataaaa gggtgagtga
8281 gcgagaggct gctttggaag aaactcatag attactgcaa cagttccccc tggacctgga
8341 aaagtttctt gcctggctta cagaagctga aacaactgcc aatgtcctac aggatgctac
8401 ccgtaaggaa aggctcctag aagactccaa gggagtaaaa gagctgatga aacaatggca
8461 agacctccaa ggtgaaattg aagctcacac agatgtttat cacaacctgg atgaaaacag
8521 ccaaaaaatc ctgagatccc tggaaggttc cgatgatgca gtcctgttac aaagacgttt
8581 ggataacatg aacttcaagt ggagtgaact tcggaaaaag tctctcaaca ttaggtccca
8641 tttggaagcc agttctgacc agtggaagcg tctgcacctt tctctgcagg aacttctggt
8701 gtggctacag ctgaaagatg atgaattaag ccggcaggca cctattggag gcgactttcc
8761 agcagttcag aagcagaacg atgtacatag ggccttcaag agggaattga aaactaaaga
8821 acctgtaatc atgagtactc ttgagactgt acgaatattt ctgacagagc agcctttgga
8881 aggactagag aaactctacc aggagcccag agagctgcct cctgaggaga gagcccagaa
8941 tgtcactcgg cttctacgaa agcaggctga ggaggtcaat actgagtggg aaaaattgaa
9001 cctgcactcc gctgactggc agagaaaaat agatgagacc cttgaaagac tccaggaact
9061 tcaagaggcc acggatgagc tggacctcaa gctgcgccaa gctgaggtga tcaagggatc
9121 ctggcagccc gtgggcgatc tcctcattga ctctctccaa gatcacctcg agaaagtcaa
9181 ggcacttcga ggagaaattg cgcctctgaa agagaacgtg agccacgtca atgaccttgc
9241 tcgccagctt accactttgg gcattcagct ctcaccgtat aacctcagca ctctggaaga
9301 cctgaacacc agatggaagc ttctgcaggt ggccgtcgag gaccgagtca ggcagctgca
9361 tgaagcccac agggactttg gtccagcatc tcagcacttt ctttccacgt ctgtccaggg
9421 tccctgggag agagccatct cgccaaacaa agtgccctac tatatcaacc acgagactca
9481 aacaacttgc tgggaccatc ccaaaatgac agagctctac cagtctttag ctgacctgaa
9541 taatgtcaga ttctcagctt ataggactgc catgaaactc cgaagactgc agaaggccct
9601 ttgcttggat ctcttgagcc tgtcagctgc atgtgatgcc ttggaccagc acaacctcaa
9661 gcaaaatgac cagcccatgg atatcctgca gattattaat tgtttgacca ctatttatga
9721 ccgcctggag caagagcaca acaatttggt caacgtccct ctctgcgtgg atatgtgtct
9781 gaactggctg ctgaatgttt atgatacggg acgaacaggg aggatccgtg tcctgtcttt
9841 taaaactggc atcatttccc tgtgtaaagc acatttggaa gacaagtaca gatacctttt
9901 caagcaagtg gcaagttcaa caggattttg tgaccagcgc aggctgggcc tccttctgca
9961 tgattctatc caaattccaa gacagttggg tgaagttgca tcctttgggg gcagtaacat
10021 tgagccaagt gtccggagct gcttccaatt tgctaataat aagccagaga tcgaagcggc
10081 cctcttccta gactggatga gactggaacc ccagtccatg gtgtggctgc ccgtcctgca
10141 cagagtggct gctgcagaaa ctgccaagca tcaggccaaa tgtaacatct gcaaagagtg
10201 tccaatcatt ggattcaggt acaggagtct aaagcacttt aattatgaca tctgccaaag
10261 ctgctttttt tctggtcgag ttgcaaaagg ccataaaatg cactatccca tggtggaata
10321 ttgcactccg actacatcag gagaagatgt tcgagacttt gccaaggtac taaaaaacaa
10381 atttcgaacc aaaaggtatt ttgcgaagca tccccgaatg ggctacctgc cagtgcagac
10441 tgtcttagag ggggacaaca tggaaactcc cgttactctg atcaacttct ggccagtaga
10501 ttctgcgcct gcctcgtccc ctcagctttc acacgatgat actcattcac gcattgaaca
10561 ttatgctagc aggctagcag aaatggaaaa cagcaatgga tcttatctaa atgatagcat
10621 ctctcctaat gagagcatag atgatgaaca tttgttaatc cagcattact gccaaagttt
10681 gaaccaggac tcccccctga gccagcctcg tagtcctgcc cagatcttga tttccttaga
10741 gagtgaggaa agaggggagc tagagagaat cctagcagat cttgaggaag aaaacaggaa
10801 tctgcaagca gaatatgacc gtctaaagca gcagcacgaa cataaaggcc tgtccccact
10861 gccgtcccct cctgaaatga tgcccacctc tccccagagt ccccgggatg ctgagctcat
10921 tgctgaggcc aagctactgc gtcaacacaa aggccgcctg gaagccagga tgcaaatcct
10981 ggaagaccac aataaacagc tggagtcaca gttacacagg ctaaggcagc tgctggagca
11041 accccaggca gaggccaaag tgaatggcac aacggtgtcc tctccttcta cctctctaca
11101 gaggtccgac agcagtcagc ctatgctgct ccgagtggtt ggcagtcaaa cttcggactc
11161 catgggtgag gaagatcttc tcagtcctcc ccaggacaca agcacagggt tagaggaggt
11221 gatggagcaa ctcaacaact ccttccctag ttcaagagga agaaataccc ctggaaagcc
11281 aatgagagag gacacaatgt aggaagtctt ttccacatgg cagatgattt gggcagagcg
11341 atggagtcct tagtatcagt catgacagat gaagaaggag cagaataaat gttttacaac
11401 tcctgattcc cgcatggttt ttataatatt catacaacaa agaggattag acagtaagag
11461 tttacaagaa ataaatctat atttttgtga agggtagtgg tattatactg tagatttcag
11521 tagtttctaa gtctgttatt gttttgttaa caatggcagg ttttacacgt ctatgcaatt
11581 gtacaaaaaa gttataagaa aactacatgt aaaatcttga tagctaaata acttgccatt
11641 tctttatatg gaacgcattt tgggttgttt aaaaatttat aacagttata aagaaagatt
11701 gtaaactaaa gtgtgcttta taaaaaaaag ttgtttataa aaacccctaa aaacaaaaca
11761 aacacacaca cacacacata cacacacaca cacaaaactt tgaggcagcg cattgttttg
11821 catccttttg gcgtgatatc catatgaaat tcatggcttt ttcttttttt gcatattaaa
11881 gataagactt cctctaccac cacaccaaat gactactaca cactgctcat ttgagaactg
11941 tcagctgagt ggggcaggct tgagttttca tttcatatat ctatatgtct ataagtatat
12001 aaatactata gttatataga taaagagata cgaatttcta tagactgact ttttccattt
12061 tttaaatgtt catgtcacat cctaatagaa agaaattact tctagtcagt catccaggct
12121 tacctgcttg gtctagaatg gatttttccc ggagccggaa gccaggagga aactacacca
12181 cactaaaaca ttgtctacag ctccagatgt ttctcatttt aaacaacttt ccactgacaa
12241 cgaaagtaaa gtaaagtatt ggattttttt aaagggaaca tgtgaatgaa tacacaggac
12301 ttattatatc agagtgagta atcggttggt tggttgattg attgattgat tgatacattc
12361 agcttcctgc tgctagcaat gccacgattt agatttaatg atgcttcagt ggaaatcaat
12421 cagaaggtat tctgaccttg tgaacatcag aaggtatttt ttaactccca agcagtagca
12481 ggacgatgat agggctggag ggctatggat tcccagccca tccctgtgaa ggagtaggcc
12541 actctttaag tgaaggattg gatgattgtt cataatacat aaagttctct gtaattacaa
12601 ctaaattatt atgccctctt ctcacagtca aaaggaactg ggtggtttgg tttttgttgc
12661 ttttttagat ttattgtccc atgtgggatg agtttttaaa tgccacaaga cataatttaa
12721 aataaataaa ctttgggaaa aggtgtaaaa cagtagcccc atcacatttg tgatactgac
12781 aggtatcaac ccagaagccc atgaactgtg tttccatcct ttgcatttct ctgcgagtag
12841 ttccacacag gtttgtaagt aagtaagaaa gaaggcaaat tgattcaaat gttacaaaaa
12901 aacccttctt ggtggattag acaggttaaa tatataaaca aacaaacaaa aattgctcaa
12961 aaaagaggag aaaagctcaa gaggaaaagc taaggactgg taggaaaaag ctttactctt
13021 tcatgccatt ttatttcttt ttgattttta aatcattcat tcaatagata ccaccgtgtg
13081 acctataatt ttgcaaatct gttacctctg acatcaagtg taattagctt ttggagagtg
13141 ggctgacatc aagtgtaatt agcttttgga gagtgggttt tgtccattat taataattaa
13201 ttaattaaca tcaaacacgg cttctcatgc tatttctacc tcactttggt tttggggtgt
13261 tcctgataat tgtgcacacc tgagttcaca gcttcaccac ttgtccattg cgttattttc
13321 tttttccttt ataattcttt ctttttcctt cataattttc aaaagaaaac ccaaagctct
13381 aaggtaacaa attaccaaat tacatgaaga tttggttttt gtcttgcatt tttttccttt
13441 atgtgacgct ggaccttttc tttacccaag gatttttaaa actcagattt aaaacaaggg
13501 gttactttac atcctactaa gaagtttaag taagtaagtt tcattctaaa atcagaggta
13561 aatagagtgc ataaataatt ttgttttaat ctttttgttt ttcttttaga cacattagct
13621 ctggagtgag tctgtcataa tatttgaaca aaaattgaga gctttattgc tgcattttaa
13681 gcataattaa tttggacatt atttcgtgtt gtgttcttta taaccaccaa gtattaaact
13741 gtaaatcata atgtaactga agcataaaca tcacatggca tgttttgtca ttgttttcag
13801 gtactgagtt cttacttgag tatcataata tattgtgttt taacaccaac actgtaacat
13861 ttacgaatta tttttttaaa cttcagtttt actgcatttt cacaacatat cagacttcac
13921 caaatatatg ccttactatt gtattatagt actgctttac tgtgtatctc aataaagcac
13981 gcagttatgt tac
References[edit]
- ^ a b c d e A. E. Emery, “The muscular dystrophies,” Lancet, vol. 359, no. 9307, pp. 687–695, 2002.
- ^ a b E. Mercuri and F. Muntoni, “Muscular dystrophies,” Lancet, vol. 381, no. 9869, pp. 845–860, 2013.
- ^ a b c S. Benedetti, G. Cossu, and F. Tedesco, “Gene and Cell Therapies for Muscular Dystrophies,” in Gene and Cell Therapy, CRC Press, 2015, pp. 993–1016.
- ^ a b c C. Sewry, C. Jimenez-Mallebrera, S. Brown, and F. Muntoni, “Diseases of muscle,” in Greenfield’s Neuropathology Eighth Edition. 2 Volume Set and DVD, CRC Press, 2008, pp. 1725–1820.
- ^ P. J. Vignos, “Physical models of rehabilitation in neuromuscular disease,” Muscle Nerve, vol. 6, no. 5, pp. 323–338, 1983.
- ^ S. IM and W. LA, “Postural substitution in Duchenne’s muscular dystrophy,” JAMA, vol. 247, no. 5, p. 584, 1982.
- ^ P. J. VIGNOS, M. B. WAGNER, B. KARLINCHAK, and B. KATIRJI, “Evaluation of a Program for Long-Term Treatment of Duchenne Muscular Dystrophy. Experience at the University Hospitals of Cleveland*,” J. Bone & Jt. Surg., vol. 78, no. 12, p. 1844 LP-52, Dec. 1996.
- ^ E. Sekul, “Muscle Disorders in Childhood, 2nd Ed.,” Neurol. , vol. 47, no. 1, p. 314, Jul. 1996.
- ^ a b S. a Bustin, “Real-Time Reverse Transcription PCR,” Encycl. Diagnostic Genomics Proteomics, no. Dmd, pp. 718–726, 2005.
- ^ M. A. Kurian et al., “Clinical and molecular characterisation of hereditary dopamine transporter deficiency syndrome: An observational cohort and experimental study,” Lancet Neurol., vol. 10, no. 1, pp. 54–62, 2011.
- ^ D. J. Blake, A. Weir, S. E. Newey, and K. E. Davies, “Function and Genetics of Dystrophin and Dystrophin-Related Proteins in Muscle,” Physiol Rev, vol. 82, no. 2, pp. 291–329, 2002.
- ^ I. Dalkilic and L. M. Kunkel, “Muscular dystrophies: Genes to pathogenesis,” Curr. Opin. Genet. Dev., vol. 13, no. 3, pp. 231–238, 2003.
- ^ V. Straub and K. P. Campbell, “Muscular dystrophies and the dystrophin-glycoprotein complex.,” Curr. Opin. Neurol., vol. 10, no. 2, pp. 168–75, 1997.
- ^ K. M. Flanigan, “Dystrophin: Gene, protein, and cell biology,” Am. J. Med. Genet., vol. 79, no. 5, p. 412, 1998.
- ^ E. A. Burton and K. E. Davies, “The Pathogenesis of Duchenne Muscular Dystrophy BT - Pathogenesis of Neurodegenerative Disorders,” M. P. Mattson, Ed. Totowa, NJ: Humana Press, 2001, pp. 239–284.
- ^ A. E. H. Emery, “Muscular dystrophy into the new millennium,” Neuromuscul. Disord., vol. 12, no. 4, pp. 343–349, 2002.
- ^ C. G. Carlson, “The Dystrophinopathies: An Alternative to the Structural Hypothesis,” Neurobiol. Dis., vol. 5, no. 1, pp. 3–15, Jul. 1998.
- ^ T. E. Bertorini et al., “Calcium and magnesium content in fetuses at risk and prenecrotic Duchenne muscular dystrophy,” Neurol. , vol. 34, no. 11, p. 1436, Nov. 1984.
- ^ K. Arahata et al., “Immunostaining of skeletal and cardiac muscle surface membrane with antibody against Duchenne muscular dystrophy peptide,” Nature, vol. 333, no. 6176, pp. 861–863, Jun. 1988.
- ^ a b c d e G. Cossu and M. Sampaolesi, “New therapies for Duchenne muscular dystrophy: challenges, prospects and clinical trials,” Trends Mol. Med., vol. 13, no. 12, pp. 520–526, 2007.
- ^ a b K. J. Nowak and K. E. Davies, “Duchenne muscular dystrophy and dystrophin: pathogenesis and opportunities for treatment,” EMBO Rep., vol. 5, no. 9, pp. 872–876, 2004.
- ^ F. D. Price, K. Kuroda, and M. A. Rudnicki, “Stem cell based therapies to treat muscular dystrophy,” Biochim. Biophys. Acta - Mol. Basis Dis., vol. 1772, no. 2, pp. 272–283, 2007.
- ^ J. Tinsley , N. Deconinck , R. Fisher , D. Kahn , S. Phelps , J.M. Gillis , K. Davies , Nature Med., 4, (1998), 1441– 1444.
- ^ a b c d e f g h i M. de los A. Beytía, J. Vry, J. Kirschner, M. De Los Angeles Beytía, J. Vry, and J. Kirschner, “Drug treatment of Duchenne muscular dystrophy: Available evidence and perspectives,” Acta Myol., vol. 31, no. 1, pp. 4–8, 2012.
- ^ Smith, Rosamund C., and Boris K. Lin. “Myostatin Inhibitors as Therapies for Muscle Wasting Associated with Cancer and Other Disorders.” Current Opinion in Supportive and Palliative Care 7.4 (2013): 352–360. PMC. Web. 11 Dec. 2016.
- ^ M. S. Falzarano, C. Scotton, C. Passarelli, and A. Ferlini, “Duchenne muscular dystrophy: From diagnosis to therapy,” Molecules, vol. 20, no. 10, pp. 18168–18184, 2015.
- ^ a b Z. E. Davidson and H. Truby, “A review of nutrition in Duchenne muscular dystrophy,” J. Hum. Nutr. Diet., vol. 22, no. 5, pp. 383–393, 2009.
- ^ N. P. Whitehead, M. J. Kim, K. L. Bible, M. E. Adams, and S. C. Froehner, “A new therapeutic effect of simvastatin revealed by functional improvement in muscular dystrophy,” Proc. Natl. Acad. Sci. U. S. A., vol. 112, no. 41, pp. 12864–12869, 2015.
- ^ U.S. Food and Drug Administration, “FDA grants accelerated approval to first drug for Duchenne muscular dystrophy,” FDA News Release, pp. 10–13, 2016.
- ^ Flanigan KM, Dunn D, von Niederhausern A, et al. Mutational Spectrum of DMD Mutations in Dystrophinopathy Patients: Application of Modern Diagnostic Techniques to a Large Cohort. Human Mutation. 2009;30(12):1657-1666. doi:10.1002/humu.21114.