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González-Duarte A, Cotrina-Vidal M, Kaufmann H, Norcliffe-Kaufmann L. Familial dysautonomia. Clin Auton Res 2023; 33:269-280. [PMID: 37204536 DOI: 10.1007/s10286-023-00941-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 03/30/2023] [Indexed: 05/20/2023]
Abstract
Familial dysautonomia (FD) is an autosomal recessive hereditary sensory and autonomic neuropathy (HSAN, type 3) expressed at birth with profound sensory loss and early death. The FD founder mutation in the ELP1 gene arose within the Ashkenazi Jews in the sixteenth century and is present in 1:30 Jews of European ancestry. The mutation yield a tissue-specific skipping of exon 20 and a loss of function of the elongator-1 protein (ELP1), which is essential for the development and survival of neurons. Patients with FD produce variable amounts of ELP1 in different tissues, with the brain producing mostly mutant transcripts. Patients have excessive blood pressure variability due to the failure of the IXth and Xth cranial nerves to carry baroreceptor signals. Neurogenic dysphagia causes frequent aspiration leading to chronic pulmonary disease. Characteristic hyperadrenergic "autonomic crises" consisting of brisk episodes of severe hypertension, tachycardia, skin blotching, retching, and vomiting occur in all patients. Progressive features of the disease include retinal nerve fiber loss and blindness, and proprioceptive ataxia with severe gait impairment. Chemoreflex failure may explain the high frequency of sudden death in sleep. Although 99.5% of patients are homozygous for the founder mutation, phenotypic severity varies, suggesting that modifier genes impact expression. Medical management is currently symptomatic and preventive. Disease-modifying therapies are close to clinical testing. Endpoints to measure efficacy have been developed, and the ELP1 levels are a good surrogate endpoint for target engagement. Early intervention may be critical for treatment to be successful.
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Affiliation(s)
- Alejandra González-Duarte
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA.
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, CdMx, México.
| | - Maria Cotrina-Vidal
- Department of Neurology, Stroke Division. New York University School of Medicine, New York, NY, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
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2
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Costello SM, Cheney AM, Waldum A, Tripet B, Cotrina-Vidal M, Kaufmann H, Norcliffe-Kaufmann L, Lefcort F, Copié V. A Comprehensive NMR Analysis of Serum and Fecal Metabolites in Familial Dysautonomia Patients Reveals Significant Metabolic Perturbations. Metabolites 2023; 13:metabo13030433. [PMID: 36984872 PMCID: PMC10057143 DOI: 10.3390/metabo13030433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/06/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
Central metabolism has a profound impact on the clinical phenotypes and penetrance of neurological diseases such as Alzheimer’s (AD) and Parkinson’s (PD) diseases, Amyotrophic Lateral Sclerosis (ALS) and Autism Spectrum Disorder (ASD). In contrast to the multifactorial origin of these neurological diseases, neurodevelopmental impairment and neurodegeneration in Familial Dysautonomia (FD) results from a single point mutation in the ELP1 gene. FD patients represent a well-defined population who can help us better understand the cellular networks underlying neurodegeneration, and how disease traits are affected by metabolic dysfunction, which in turn may contribute to dysregulation of the gut–brain axis of FD. Here, 1H NMR spectroscopy was employed to characterize the serum and fecal metabolomes of FD patients, and to assess similarities and differences in the polar metabolite profiles between FD patients and healthy relative controls. Findings from this work revealed noteworthy metabolic alterations reflected in energy (ATP) production, mitochondrial function, amino acid and nucleotide catabolism, neurosignaling molecules, and gut-microbial metabolism. These results provide further evidence for a close interconnection between metabolism, neurodegeneration, and gut microbiome dysbiosis in FD, and create an opportunity to explore whether metabolic interventions targeting the gut–brain–metabolism axis of FD could be used to redress or slow down the progressive neurodegeneration observed in FD patients.
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Affiliation(s)
- Stephanann M. Costello
- Department of Chemistry and Biochemistry, Montana State University, Bozeman, MT 59717, USA
| | - Alexandra M. Cheney
- Department of Chemistry and Biochemistry, Montana State University, Bozeman, MT 59717, USA
| | - Annie Waldum
- Department of Chemistry and Biochemistry, Montana State University, Bozeman, MT 59717, USA
| | - Brian Tripet
- Department of Chemistry and Biochemistry, Montana State University, Bozeman, MT 59717, USA
| | - Maria Cotrina-Vidal
- Department of Neurology, New York University School of Medicine, New York, NY 10017, USA
| | - Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, NY 10017, USA
| | | | - Frances Lefcort
- Department of Microbiology and Cell Biology, Montana State University, Bozeman, MT 59717, USA
| | - Valérie Copié
- Department of Chemistry and Biochemistry, Montana State University, Bozeman, MT 59717, USA
- Correspondence: ; Tel.: +1-406-994-7244
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Ramprasad C, Palma JA, Norcliffe-Kaufmann L, Levy J, Chen LA, Kaufmann H. Gastrointestinal bleeding in children with familial dysautonomia: a case-control study. Clin Auton Res 2023; 33:87-92. [PMID: 36735101 DOI: 10.1007/s10286-023-00925-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/16/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Familial dysautonomia (FD) is a rare inherited autosomal recessive disorder with abnormal somatosensory, enteric, and afferent autonomic neurons. We aimed to define the incidence of gastrointestinal bleeding and its associated risk factors in patients with FD. METHODS In this retrospective case-control study, we identified all episodes of gastrointestinal bleeding in patients with FD, occurring over four decades (January 1980-December 2017), using the New York University FD registry. RESULTS We identified 104 episodes of gastrointestinal bleeding occurring in 60 patients with FD. The estimated incidence rate of gastrointestinal bleeds in the FD population rate was 4.20 episodes per 1000 person-years. We compared the 60 cases with 94 age-matched controls. Bleeding in the upper gastrointestinal tract from gastric and duodenal ulcers occurred most frequently (64 bleeds, 75.6%). Patients were more likely to have a gastrostomy (G)-tube and a Nissen fundoplication [odds ratio (OR) 3.73, 95% confidence interval (CI) 1.303-13.565] than controls. The mean time from G-tube placement to first gastrointestinal bleed was 7.01 years. The mean time from Nissen fundoplication to bleed was 7.01 years. Cases and controls had similar frequency of intake of nonsteroidal antiinflammatory drugs (NSAID) and selective serotonin reuptake inhibitors (SSRI). CONCLUSION The incidence of gastrointestinal bleeding in the pediatric FD population was estimated to be 4.20 per 1000 person-years, 21 times higher than in the general pediatric population (0.2 per 1000 person-years). Patients with FD with a G-tube and a Nissen fundoplication had a higher risk of a subsequent gastrointestinal bleeding.
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Affiliation(s)
- Chethan Ramprasad
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York City, NY, USA
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University Grossman School of Medicine, 530 First Av, Suite 9Q, New York City, NY, 10016, USA
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University Grossman School of Medicine, 530 First Av, Suite 9Q, New York City, NY, 10016, USA
| | - Joseph Levy
- Division of Pediatric Gastroenterology, New York University Grossman School of Medicine, New York City, NY, USA
| | - Lea Ann Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York City, NY, USA
- Division of Gastroenterology and Hepatology, Rutgers University, Robert Wood Johnson School of Medicine, New Brunswick, NJ, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University Grossman School of Medicine, 530 First Av, Suite 9Q, New York City, NY, 10016, USA.
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Younger DS. Autonomic failure: Clinicopathologic, physiologic, and genetic aspects. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:55-102. [PMID: 37562886 DOI: 10.1016/b978-0-323-98818-6.00020-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Over the past century, generations of neuroscientists, pathologists, and clinicians have elucidated the underlying causes of autonomic failure found in neurodegenerative, inherited, and antibody-mediated autoimmune disorders, each with pathognomonic clinicopathologic features. Autonomic failure affects central autonomic nervous system components in the α-synucleinopathy, multiple system atrophy, characterized clinically by levodopa-unresponsive parkinsonism or cerebellar ataxia, and pathologically by argyrophilic glial cytoplasmic inclusions (GCIs). Two other central neurodegenerative disorders, pure autonomic failure characterized clinically by deficits in norepinephrine synthesis and release from peripheral sympathetic nerve terminals; and Parkinson's disease, with early and widespread autonomic deficits independent of the loss of striatal dopamine terminals, both express Lewy pathology. The rare congenital disorder, hereditary sensory, and autonomic neuropathy type III (or Riley-Day, familial dysautonomia) causes life-threatening autonomic failure due to a genetic mutation that results in loss of functioning baroreceptors, effectively separating afferent mechanosensing neurons from the brain. Autoimmune autonomic ganglionopathy caused by autoantibodies targeting ganglionic α3-acetylcholine receptors instead presents with subacute isolated autonomic failure affecting sympathetic, parasympathetic, and enteric nervous system function in various combinations. This chapter is an overview of these major autonomic disorders with an emphasis on their historical background, neuropathological features, etiopathogenesis, diagnosis, and treatment.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Tolman Z, Chaverra M, George L, Lefcort F. Elp1 is required for development of visceral sensory peripheral and central circuitry. Dis Model Mech 2022; 15:275184. [PMID: 35481599 PMCID: PMC9187870 DOI: 10.1242/dmm.049274] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 04/20/2022] [Indexed: 11/23/2022] Open
Abstract
Cardiovascular instability and a blunted respiratory drive in hypoxic conditions are hallmark features of the genetic sensory and autonomic neuropathy, familial dysautonomia (FD). FD results from a mutation in the gene ELP1, the encoded protein of which is a scaffolding subunit of the six-subunit Elongator complex. In mice, we and others have shown that Elp1 is essential for the normal development of neural crest-derived dorsal root ganglia sensory neurons. Whether Elp1 is also required for development of ectodermal placode-derived visceral sensory receptors, which are required for normal baroreception and chemosensory responses, has not been investigated. Using mouse models for FD, we here show that the entire circuitry underlying baroreception and chemoreception is impaired due to a requirement for Elp1 in the visceral sensory neuron ganglia, as well as for normal peripheral target innervation, and in their central nervous system synaptic partners in the medulla. Thus, Elp1 is required in both placode- and neural crest-derived sensory neurons, and its reduction aborts the normal development of neuronal circuitry essential for autonomic homeostasis and interoception. This article has an associated First Person interview with the first author of the paper. Summary: Our data indicate that Elp1 is required in both placode- and neural crest-derived sensory neurons, and that it exerts comparable effects, including survival, axonal morphology and target innervation in both lineages.
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Affiliation(s)
- Zariah Tolman
- Department of Microbiology and Cell Biology, Montana State University, Bozeman, MT 59717, USA
| | - Marta Chaverra
- Department of Microbiology and Cell Biology, Montana State University, Bozeman, MT 59717, USA
| | - Lynn George
- Department of Microbiology and Cell Biology, Montana State University, Bozeman, MT 59717, USA.,Department of Biological and Physical Sciences, Montana State University Billings, Billings, MT 59101, USA
| | - Frances Lefcort
- Department of Microbiology and Cell Biology, Montana State University, Bozeman, MT 59717, USA
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6
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Rosen CL. Sleep-Disordered Breathing (SDB) in Pediatric Populations. Respir Med 2022. [DOI: 10.1007/978-3-030-93739-3_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Enner S, Pavkovic I, Kothare SV. Sudden unexpected death in children: myth or reality? Curr Opin Pediatr 2021; 33:471-479. [PMID: 34226427 DOI: 10.1097/mop.0000000000001032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Despite many years of study, sudden unexplained death remains a tenuous diagnosis of exclusion. Here, we discuss the current science behind the uncertainties of sudden death, as well as the questions that still remain. RECENT FINDINGS Failure in any part of the complex interplay between peripheral sensors and central cardiorespiratory regulation can result in sudden death. Diagnostic testing with electrocardiograms, electroencephalogram, sleep studies, or even genetic studies have increased our ability to identify patients at the highest risk. SUMMARY Advances in the understanding of sudden unexplained death in children may show common pathways leading to sudden death from multiple different diseases. Although rare, the devastating implication prioritizes the importance in educating patients about how to live with the risk of sudden death.
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Affiliation(s)
- Stephanie Enner
- Division of Pediatric Neurology, Department of Pediatrics, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, USA
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Lamotte G, Coon EA, Suarez MD, Sandroni P, Benarroch EE, Cutsforth-Gregory JK, Mauermann ML, Berini SE, Shouman K, Sletten D, Goodman BP, Low PA, Singer W. Natural History of Afferent Baroreflex Failure in Adults. Neurology 2021; 97:e136-e144. [PMID: 33947784 DOI: 10.1212/wnl.0000000000012149] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/29/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe the natural history of afferent baroreflex failure (ABF) based on systematic review of clinical and laboratory data in patients with a diagnosis of ABF at Mayo Clinic Rochester. METHODS We performed a retrospective chart review of all patients who underwent standardized autonomic reflex testing between 2000 and 2020 and had confirmation of the diagnosis of ABF by an autonomic disorders specialist. Patients were identified using a data repository of medical records. Variables included demographic, all-cause mortality, medications, ABF manifestations, comorbidities, and laboratory (autonomic testing, blood pressure monitoring, echocardiogram, brain imaging, plasma catecholamines, serum sodium level, and kidney function tests). RESULTS A total of 104 patients with ABF were identified. Head and neck radiation was the most common etiology (86.5%), followed by neck surgery (5.8%) and other causes (7.7%). The most common findings were hypertension (87.5%), fluctuating blood pressure (78.8%), orthostatic hypotension (91.3%), syncope (58.6%), headache (22.1%), and tachycardia (20.2%). Patients commonly received antihypertensives (66.3%), pressor agents (41.3%), or a combination of both (19.2%). The median latency from completion of radiation to ABF was longer compared to the latency in the surgery group (p < 0.0001). Comorbidities, including complications from neck radiation, were frequently seen and all-cause mortality was 39.4% over a 20-year period. CONCLUSIONS ABF should be suspected in patients with prior head and neck cancer treated by radiation or surgery who present with labile hypertension and orthostatic hypotension. Management may require both antihypertensive and pressor medications. The morbidity and mortality in ABF are high.
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Affiliation(s)
- Guillaume Lamotte
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Elizabeth A Coon
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Mariana D Suarez
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Paola Sandroni
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Eduardo E Benarroch
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Jeremy K Cutsforth-Gregory
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Michelle L Mauermann
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Sarah E Berini
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Kamal Shouman
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - David Sletten
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Brent P Goodman
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Phillip A Low
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ
| | - Wolfgang Singer
- From the Department of Neurology (G.L., E.A.C., M.D.S., P.S., E.E.B., J.K.C.-G., M.L.M., S.E.B., K.S., D.S., P.A.L., W.S.), Mayo Clinic, Rochester, MN; and Department of Neurology (B.P.G.), Mayo Clinic, Scottsdale, AZ.
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Cheshire WP, Freeman R, Gibbons CH, Cortelli P, Wenning GK, Hilz MJ, Spies JM, Lipp A, Sandroni P, Wada N, Mano A, Ah Kim H, Kimpinski K, Iodice V, Idiáquez J, Thaisetthawatkul P, Coon EA, Low PA, Singer W. Electrodiagnostic assessment of the autonomic nervous system: A consensus statement endorsed by the American Autonomic Society, American Academy of Neurology, and the International Federation of Clinical Neurophysiology. Clin Neurophysiol 2020; 132:666-682. [PMID: 33419664 DOI: 10.1016/j.clinph.2020.11.024] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 11/02/2020] [Accepted: 11/28/2020] [Indexed: 12/17/2022]
Abstract
Evaluation of disorders of the autonomic nervous system is both an art and a science, calling upon the physician's most astute clinical skills as well as knowledge of autonomic neurology and physiology. Over the last three decades, the development of noninvasive clinical tests that assess the function of autonomic nerves, the validation and standardization of these tests, and the growth of a large body of literature characterizing test results in patients with autonomic disorders have equipped clinical practice further with a valuable set of objective tools to assist diagnosis and prognosis. This review, based on current evidence, outlines an international expert consensus set of recommendations to guide clinical electrodiagnostic autonomic testing. Grading and localization of autonomic deficits incorporates scores from sympathetic cardiovascular adrenergic, parasympathetic cardiovagal, and sudomotor testing, as no single test alone is sufficient to diagnose the degree or distribution of autonomic failure. The composite autonomic severity score (CASS) is a useful score of autonomic failure that is normalized for age and gender. Valid indications for autonomic testing include generalized autonomic failure, regional or selective system syndromes of autonomic impairment, peripheral autonomic neuropathy and ganglionopathy, small fiber neuropathy, orthostatic hypotension, orthostatic intolerance, syncope, neurodegenerative disorders, autonomic hyperactivity, and anhidrosis.
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Affiliation(s)
- William P Cheshire
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, Florida 32224, USA
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, 330 Brookline Avenue, Boston, Massachusetts 02215-5400, USA
| | - Christopher H Gibbons
- Department of Neurology, Harvard Medical School, 330 Brookline Avenue, Boston, Massachusetts 02215-5400, USA
| | - Pietro Cortelli
- DIBINEM - University of Bologna, Bologna, Italy; IRCCS Istituto di Scienze Neurologiche, Bologna, Italy
| | - Gregor K Wenning
- Section of Clinical Neurobiology, Department of Neurology, Medical University of Innsbruck, Anichstraße 35, A-6020 Innsbruck, Austria
| | - Max J Hilz
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Judith M Spies
- Department of Neurology, Level 8 East, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia
| | - Axel Lipp
- Park-Klinik Weißensee, Schönstraße 80, Berlin 13086, Germany
| | - Paola Sandroni
- Department of Neurology, Mayo Clinic, 200 First St. SW, Rochester, Minnesota 55905, USA
| | - Naoki Wada
- Department of Renal and Urologic Surgery, Asahikawa Medical University, 2-1-1-1 Midorigaoka Higashi, Asahikawa 078-8510, Japan
| | - Akiko Mano
- Department of Cardiothoracic Surgery, Tokyo Metropolitan Geriatric Hospital, 35-2 Sakae-Cho Itabashi-ku, Tokyo 173-0015, Japan
| | - Hyun Ah Kim
- Department of Neurology, Keimyung University Dongsan Hospital, 2800 Dalgubeol Daero, Dalseo-gu, Daegu, South Korea
| | - Kurt Kimpinski
- School of Kinesiology, Western University, London, Ontario, Canada; Department of Clinical Neurological Sciences, University Hospital, London Health Sciences Centre, London, Ontario, Canada; Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Valeria Iodice
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, Queen Square, Division of Clinical Neurology, Institute of Neurology, University College London, WC1N 3BG London, United Kingdom
| | - Juan Idiáquez
- Department of Neurologia, Facultad de Medicina, University of Valparaíso, 7 Norte 1122, Valparaíso, 2531094, Chile
| | - Pariwat Thaisetthawatkul
- Department of Neurological Sciences, 988435 University of Nebraska Medical Center, Omaha, Nebraska 68198-8435, USA
| | - Elizabeth A Coon
- Department of Neurology, Mayo Clinic, 200 First St. SW, Rochester, Minnesota 55905, USA
| | - Phillip A Low
- Department of Neurology, Mayo Clinic, 200 First St. SW, Rochester, Minnesota 55905, USA.
| | - Wolfgang Singer
- Department of Neurology, Mayo Clinic, 200 First St. SW, Rochester, Minnesota 55905, USA.
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10
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Affiliation(s)
- Horacio Kaufmann
- From the Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York
| | - Lucy Norcliffe-Kaufmann
- From the Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York
| | - Jose-Alberto Palma
- From the Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York
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11
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Palma JA, Gileles-Hillel A, Norcliffe-Kaufmann L, Kaufmann H. Chemoreflex failure and sleep-disordered breathing in familial dysautonomia: Implications for sudden death during sleep. Auton Neurosci 2019; 218:10-15. [PMID: 30890343 DOI: 10.1016/j.autneu.2019.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/11/2019] [Indexed: 01/04/2023]
Abstract
Familial dysautonomia (Riley-Day syndrome, hereditary sensory and autonomic neuropathy type III) is a rare autosomal recessive disease characterized by impaired development of primary sensory and autonomic neurons resulting in a severe neurological phenotype, which includes arterial baroreflex and chemoreflex failure with high frequency of sleep-disordered breathing and sudden death during sleep. Although a rare disease, familial dysautonomia represents a unique template to study the interactions between sleep-disordered breathing and abnormal chemo- and baroreflex function. In patients with familial dysautonomia, ventilatory responses to hypercapnia are reduced, and to hypoxia are almost absent. In response to hypoxia, these patients develop paradoxical hypoventilation, hypotension, bradycardia, and potentially, death. Impaired ventilatory control due to chemoreflex failure acquires special relevance during sleep when conscious control of respiration withdraws. Overall, almost all adult (85%) and pediatric (95%) patients have some degree of sleep-disordered breathing. Obstructive apnea events are more frequent in adults, whereas central apnea events are more severe and frequent in children. The annual incidence rate of sudden death during sleep in patients with familial dysautonomia is 3.4 per 1000 person-year, compared to 0.5-1 per 1000 person-year of sudden unexpected death in epilepsy. This review summarizes recent developments in the understanding of sleep-disordered breathing in patients with familial dysautonomia, the risk factors for sudden death during sleep, and the specific interventions that could prevent it.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States of America
| | - Alex Gileles-Hillel
- Departments of Pediatrics, Pediatric Pulmonology and Sleep, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States of America
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States of America.
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Kaufmann H, Norcliffe-Kaufmann L, Palma JA. Improvement of daytime hypercapnia with nocturnal non-invasive ventilation in familial dysautonomia. Clin Auton Res 2019; 29:255-256. [PMID: 30637592 DOI: 10.1007/s10286-019-00590-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 01/07/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Avenue, Suite 9Q, New York, NY, 10016, USA.
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Avenue, Suite 9Q, New York, NY, 10016, USA
| | - Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Avenue, Suite 9Q, New York, NY, 10016, USA
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13
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Palma JA. Autonomic dysfunction in sleep disorders: introduction to the series. Clin Auton Res 2018; 28:507-508. [PMID: 30328032 DOI: 10.1007/s10286-018-0571-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA.
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14
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Kazachkov M, Palma JA, Norcliffe-Kaufmann L, Bar-Aluma BE, Spalink CL, Barnes EP, Amoroso NE, Balou SM, Bess S, Chopra A, Condos R, Efrati O, Fitzgerald K, Fridman D, Goldenberg RM, Goldhaber A, Kaufman DA, Kothare SV, Levine J, Levy J, Lubinsky AS, Maayan C, Moy LC, Rivera PJ, Rodriguez AJ, Sokol G, Sloane MF, Tan T, Kaufmann H. Respiratory care in familial dysautonomia: Systematic review and expert consensus recommendations. Respir Med 2018; 141:37-46. [PMID: 30053970 PMCID: PMC6084453 DOI: 10.1016/j.rmed.2018.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 05/14/2018] [Accepted: 06/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Familial dysautonomia (Riley-Day syndrome, hereditary sensory autonomic neuropathy type-III) is a rare genetic disease caused by impaired development of sensory and afferent autonomic nerves. As a consequence, patients develop neurogenic dysphagia with frequent aspiration, chronic lung disease, and chemoreflex failure leading to severe sleep disordered breathing. The purpose of these guidelines is to provide recommendations for the diagnosis and treatment of respiratory disorders in familial dysautonomia. METHODS We performed a systematic review to summarize the evidence related to our questions. When evidence was not sufficient, we used data from the New York University Familial Dysautonomia Patient Registry, a database containing ongoing prospective comprehensive clinical data from 670 cases. The evidence was summarized and discussed by a multidisciplinary panel of experts. Evidence-based and expert recommendations were then formulated, written, and graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS Recommendations were formulated for or against specific diagnostic tests and clinical interventions. Diagnostic tests reviewed included radiological evaluation, dysphagia evaluation, gastroesophageal evaluation, bronchoscopy and bronchoalveolar lavage, pulmonary function tests, laryngoscopy and polysomnography. Clinical interventions and therapies reviewed included prevention and management of aspiration, airway mucus clearance and chest physical therapy, viral respiratory infections, precautions during high altitude or air-flight travel, non-invasive ventilation during sleep, antibiotic therapy, steroid therapy, oxygen therapy, gastrostomy tube placement, Nissen fundoplication surgery, scoliosis surgery, tracheostomy and lung lobectomy. CONCLUSIONS Expert recommendations for the diagnosis and management of respiratory disease in patients with familial dysautonomia are provided. Frequent reassessment and updating will be needed.
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Affiliation(s)
- Mikhail Kazachkov
- Department of Pediatric Pulmonology, New York University School of Medicine, New York, NY, United States; Gastroesophageal, Upper Airway and Respiratory Diseases Center, New York University School of Medicine, New York, NY, United States
| | - Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States
| | - Bat-El Bar-Aluma
- Pediatric Pulmonary Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Israel
| | - Christy L Spalink
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States
| | - Erin P Barnes
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States
| | - Nancy E Amoroso
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Stamatela M Balou
- Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, NY, United States
| | - Shay Bess
- Department of Orthopedic Surgery, New York University School of Medicine, New York, NY, United States
| | - Arun Chopra
- Department of Pediatrics, Division of Pediatric Critical Care, New York University School of Medicine, New York, NY, United States
| | - Rany Condos
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Ori Efrati
- Pediatric Pulmonary Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Israel
| | - Kathryn Fitzgerald
- Department of Pediatric Pulmonology, New York University School of Medicine, New York, NY, United States
| | - David Fridman
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Ronald M Goldenberg
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Ayelet Goldhaber
- Department of Pediatrics, Pediatric Gastroenterology Unit, New York University School of Medicine, New York, NY, United States
| | - David A Kaufman
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Sanjeev V Kothare
- Department of Neurology, Pediatric Sleep Medicine Unit, New York University School of Medicine, New York, NY, United States
| | - Jeremiah Levine
- Department of Pediatrics, Pediatric Gastroenterology Unit, New York University School of Medicine, New York, NY, United States
| | - Joseph Levy
- Department of Pediatrics, Pediatric Gastroenterology Unit, New York University School of Medicine, New York, NY, United States
| | - Anthony S Lubinsky
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Channa Maayan
- Department of Pediatrics. Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Libia C Moy
- Department of Pediatrics, Pediatric Gastroenterology Unit, New York University School of Medicine, New York, NY, United States
| | - Pedro J Rivera
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Alcibiades J Rodriguez
- Department of Neurology, Sleep Laboratory, New York University School of Medicine, New York, NY, United States
| | - Gil Sokol
- Pediatric Pulmonary Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Israel
| | - Mark F Sloane
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Tina Tan
- Gastroesophageal, Upper Airway and Respiratory Diseases Center, New York University School of Medicine, New York, NY, United States
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States.
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Ueki Y, Shchepetkina V, Lefcort F. Retina-specific loss of Ikbkap/Elp1 causes mitochondrial dysfunction that leads to selective retinal ganglion cell degeneration in a mouse model of familial dysautonomia. Dis Model Mech 2018; 11:dmm.033746. [PMID: 29929962 PMCID: PMC6078410 DOI: 10.1242/dmm.033746] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 06/12/2018] [Indexed: 12/26/2022] Open
Abstract
Familial dysautonomia (FD) is an autosomal recessive disorder marked by developmental and progressive neuropathies. It is caused by an intronic point-mutation in the IKBKAP/ELP1 gene, which encodes the inhibitor of κB kinase complex-associated protein (IKAP, also called ELP1), a component of the elongator complex. Owing to variation in tissue-specific splicing, the mutation primarily affects the nervous system. One of the most debilitating hallmarks of FD that affects patients' quality of life is progressive blindness. To determine the pathophysiological mechanisms that are triggered by the absence of IKAP in the retina, we generated retina-specific Ikbkap conditional knockout (CKO) mice using Pax6-Cre, which abolished Ikbkap expression in all cell types of the retina. Although sensory and autonomic neuropathies in FD are known to be developmental in origin, the loss of IKAP in the retina did not affect its development, demonstrating that IKAP is not required for retinal development. The loss of IKAP caused progressive degeneration of retinal ganglion cells (RGCs) by 1 month of age. Mitochondrial membrane integrity was breached in RGCs, and later in other retinal neurons. In Ikbkap CKO retinas, mitochondria were depolarized, and complex I function and ATP were significantly reduced. Although mitochondrial impairment was detected in all Ikbkap-deficient retinal neurons, RGCs were the only cell type to degenerate; the survival of other retinal neurons was unaffected. This retina-specific FD model is a useful in vivo model for testing potential therapeutics for mitigating blindness in FD. Moreover, our data indicate that RGCs and mitochondria are promising targets. Summary: The elongator subunit IKBKAP/ELP1 is not required for development, but is essential for maintaining mitochondrial function and retina morphology. Loss of this subunit causes progressive, selective degeneration of retinal ganglion cells.
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Affiliation(s)
- Yumi Ueki
- Department of Cell Biology and Neuroscience, Montana State University, Bozeman, MT 59717, USA
| | - Veronika Shchepetkina
- Department of Cell Biology and Neuroscience, Montana State University, Bozeman, MT 59717, USA
| | - Frances Lefcort
- Department of Cell Biology and Neuroscience, Montana State University, Bozeman, MT 59717, USA
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Miglis MG, Muppidi S. Orthostatic hypotension: does the heart rate matter? And other updates on recent autonomic research. Clin Auton Res 2018; 28:269-271. [PMID: 29779066 DOI: 10.1007/s10286-018-0532-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 05/10/2018] [Indexed: 01/23/2023]
Affiliation(s)
| | - Srikanth Muppidi
- Stanford Medical Center, Palo Alto, CA, USA.
- Stanford Neurosciences Health Center, 213 Quarry Road, 2nd Floor, Palo Alto, CA, 94304, USA.
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Singh K, Palma JA, Kaufmann H, Tkachenko N, Norcliffe-Kaufmann L, Spalink C, Kazachkov M, Kothare SV. Prevalence and characteristics of sleep-disordered breathing in familial dysautonomia. Sleep Med 2018; 45:33-38. [PMID: 29680425 PMCID: PMC5918267 DOI: 10.1016/j.sleep.2017.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 12/30/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Familial dysautonomia (FD) is an autosomal recessive disorder characterized by impaired development of sensory and afferent autonomic nerves. Untreated sleep-disordered breathing (SDB) has been reported to increase the risk of sudden unexpected death in FD. We aimed to describe the prevalence and characteristics of SDB in FD. PATIENTS/METHODS Seventy-five patients with FD (20 adults and 55 children) underwent in-lab polysomnography, including peripheral capillary oxygen saturation (SpO2) and end-tidal capnography (EtCO2) measurements. A t-test and Spearman's correlation analysis were performed to evaluate the impact of age on sleep, occurrence of apneas, SpO2 and EtCO2 levels; and to determine the relationship between apneas and SpO2/EtCO2 measurements during different sleep stages. RESULTS Overall, 85% of adults and 91% of pediatric patients had some degree of SDB. Obstructive sleep apneas were more severe in adults (8.5 events/h in adults vs. 3.5 events/h in children, p = 0.04), whereas central apneas were more severe (10.8 vs. 2.8 events/h, p = 0.04) and frequent (61.8% vs. 45%, p = 0.017) in children. Overall, a higher apnea-hypopnea index was associated with increased severity of hypoxia and hypoventilation, although in a significant fraction of patients (67% and 46%), hypoxemia and hypoventilation occurred independent of apneas. CONCLUSION Most adult and pediatric patients with FD suffer from some degree of SDB. There was a differential effect of age in the pattern of SDB observed. In some FD patients, hypoventilation and hypoxia occurred independently of apneas. Therefore, we recommend including EtCO2 monitoring during polysomnography in all patients with FD to detect SDB.
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Affiliation(s)
- Kanwaljit Singh
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Nataliya Tkachenko
- Department of Pediatrics, New York University Langone Medical Center, New York, NY, USA
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Christy Spalink
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Mikhail Kazachkov
- Department of Pediatrics, New York University Langone Medical Center, New York, NY, USA
| | - Sanjeev V Kothare
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA.
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Rubin BY, Anderson SL. IKBKAP/ELP1 gene mutations: mechanisms of familial dysautonomia and gene-targeting therapies. APPLICATION OF CLINICAL GENETICS 2017; 10:95-103. [PMID: 29290691 PMCID: PMC5735983 DOI: 10.2147/tacg.s129638] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The successful completion of the Human Genome Project led to the discovery of the molecular basis of thousands of genetic disorders. The identification of the mutations that cause familial dysautonomia (FD), an autosomal recessive disorder that impacts sensory and autonomic neurons, was aided by the release of the human DNA sequence. The identification and characterization of the genetic cause of FD have changed the natural history of this disease. Genetic testing programs, which were established shortly after the disease-causing mutations were identified, have almost completely eliminated the birth of children with this disorder. Characterization of the principal disease-causing mutation has led to the development of therapeutic modalities that ameliorate its effect, while the development of mouse models that recapitulate the impact of the mutation has allowed for the in-depth characterization of its impact on neuronal development and survival. The intense research focus on this disorder, while clearly benefiting the FD patient population, also serves as a model for the positive impact focused research efforts can have on the future of other genetic diseases. Here, we present the research advances and scientific breakthroughs that have changed and will continue to change the natural history of this centuries-old genetic disease.
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Affiliation(s)
- Berish Y Rubin
- Department of Biological Sciences, Fordham University, Bronx, NY, USA
| | - Sylvia L Anderson
- Department of Biological Sciences, Fordham University, Bronx, NY, USA
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A Controlled Trial of Inhaled Bronchodilators in Familial Dysautonomia. Lung 2017; 196:93-101. [PMID: 29234869 DOI: 10.1007/s00408-017-0073-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 10/06/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic lung disease is a leading cause of premature death in patients with familial dysautonomia (FD). A significant number of patients have obstructive airway disease, yet it is not known whether this is pharmacologically reversible. METHODS We conducted a double-blind, placebo-controlled, randomized clinical trial comparing the beta 2 agonist albuterol with the muscarinic blocker ipratropium bromide in patients homozygous for the IKBKAP founder mutation. Albuterol, ipratropium bromide, and placebo were administered on 3 separate days via nebulizer in the seated position. Airway responsiveness was evaluated using spirometry and impulse oscillometry 30 min post dose. Cardiovascular effects were evaluated by continuous monitoring of blood pressure, RR intervals, cardiac output, and systemic vascular resistance. RESULTS A total of 14 patients completed the trial. Neither active agent had significant detrimental effects on heart rate or rhythm or blood pressure. Albuterol and ipratropium were similar in their bronchodilator effectiveness causing significant improvement in forced expiratory volume in 1-s (FEV1, p = 0.002 and p = 0.030). Impulse oscillometry measures were consistent with a reduction in total airway resistance post nebulization (resistance at 5 Hz p < 0.006). CONCLUSION Airway obstruction is pharmacologically reversible in a number of patients with FD. In the short term, both albuterol and ipratropium were well tolerated and not associated with major cardiovascular adverse events.
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