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Monforte M, Torchia E, Bortolani S, Ravera B, Ricci E, Silvestri G, Servidei S, Primiano G, Mirabella M, Sabatelli M, Mercuri E, Franceschi F, Calabresi P, Covino M, Tasca G. Hospital admissions from the emergency department of adult patients affected by myopathies. Eur J Neurol 2024; 31:e16214. [PMID: 38226549 PMCID: PMC11236034 DOI: 10.1111/ene.16214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/23/2023] [Accepted: 01/04/2024] [Indexed: 01/17/2024]
Abstract
BACKGROUND AND PURPOSE Myopathies are associated with classic signs and symptoms, but also with possible life-threatening complications that may require assistance in an emergency setting. This phenomenon is understudied in the literature. We aimed to assess the presentation, management, and outcomes of clinical manifestations potentially related to a muscle disorder requiring referral to the adult emergency department (ED) and hospitalization. METHODS Anonymized patient data retrieved using the International Classification of Diseases, Ninth Revision codes related to muscle disorders over 4 years were retrospectively analyzed. Medical reports were evaluated to extract demographic and clinical variables, along with outcomes. Two groups were defined based on the presence (known diagnosis [KD] group) or absence (unknown diagnosis [UD] group) of a diagnosed muscle disorder at arrival. RESULTS A total of 244 patients were included, 51% of whom were affected by a known myopathy, predominantly limb-girdle muscular dystrophies and myotonic dystrophies. The main reasons for ED visits in the KD group were respiratory issues, worsening of muscle weakness, and gastrointestinal problems. Heart complications were less prevalent. In the UD group, 27 patients received a new diagnosis of a specific primary muscle disorder after the ED access, mostly an inflammatory myopathy. Death during hospitalization was recorded in 26 patients, with a higher rate in the KD group and in patients affected by mitochondrial and inflammatory myopathies. Sepsis and dyspnea were associated with increased death risk. CONCLUSIONS Respiratory complications are the most common reason for myopathic patients accessing the ED, followed by gastrointestinal issues. Infections are severe threats and, once hospitalized, these patients have relatively high mortality.
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Affiliation(s)
- Mauro Monforte
- Dipartimento di Neuroscienze, Organi di Senso e ToraceFondazione Policlinico Universitario Agostino Gemelli IRCCSRomeItaly
| | | | - Sara Bortolani
- Dipartimento di Neuroscienze, Organi di Senso e ToraceFondazione Policlinico Universitario Agostino Gemelli IRCCSRomeItaly
| | | | - Enzo Ricci
- Dipartimento di Neuroscienze, Organi di Senso e ToraceFondazione Policlinico Universitario Agostino Gemelli IRCCSRomeItaly
- Università Cattolica del Sacro CuoreRomeItaly
| | - Gabriella Silvestri
- Dipartimento di Neuroscienze, Organi di Senso e ToraceFondazione Policlinico Universitario Agostino Gemelli IRCCSRomeItaly
- Università Cattolica del Sacro CuoreRomeItaly
| | - Serenella Servidei
- Dipartimento di Neuroscienze, Organi di Senso e ToraceFondazione Policlinico Universitario Agostino Gemelli IRCCSRomeItaly
- Università Cattolica del Sacro CuoreRomeItaly
| | - Guido Primiano
- Dipartimento di Neuroscienze, Organi di Senso e ToraceFondazione Policlinico Universitario Agostino Gemelli IRCCSRomeItaly
| | - Massimiliano Mirabella
- Dipartimento di Neuroscienze, Organi di Senso e ToraceFondazione Policlinico Universitario Agostino Gemelli IRCCSRomeItaly
- Università Cattolica del Sacro CuoreRomeItaly
| | - Mario Sabatelli
- Dipartimento di Neuroscienze, Organi di Senso e ToraceFondazione Policlinico Universitario Agostino Gemelli IRCCSRomeItaly
- Università Cattolica del Sacro CuoreRomeItaly
- Centro Clinico NeMO AdultiRomeItaly
| | - Eugenio Mercuri
- Centro Clinico Nemo PediatricoFondazione Policlinico Universitario Agostino Gemelli IRCCSRomaItaly
- Pediatric NeurologyUniversità Cattolica del Sacro CuoreRomaItaly
| | - Francesco Franceschi
- Università Cattolica del Sacro CuoreRomeItaly
- Emergency DepartmentFondazione Policlinico Universitario A. Gemelli, IRCCSRomeItaly
| | - Paolo Calabresi
- Dipartimento di Neuroscienze, Organi di Senso e ToraceFondazione Policlinico Universitario Agostino Gemelli IRCCSRomeItaly
- Università Cattolica del Sacro CuoreRomeItaly
| | - Marcello Covino
- Università Cattolica del Sacro CuoreRomeItaly
- Emergency DepartmentFondazione Policlinico Universitario A. Gemelli, IRCCSRomeItaly
| | - Giorgio Tasca
- John Walton Muscular Dystrophy Research Centre Newcastle University Translational and Clinical Research Institute and Newcastle Hospitals NHS Foundation TrustNewcastle upon TyneUK
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Mondesert E, Bargnoux AS, Portet F, Laoudj-Chenivesse D, Arbogast S, Badiou S, Brun JF, Kuster N, Raynaud de Mauverger E, Cristol JP. Cystatin C for kidney function assessment in patients with facioscapulohumeral muscular dystrophy. Clin Chim Acta 2023; 544:117328. [PMID: 37031784 DOI: 10.1016/j.cca.2023.117328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND AND AIMS Muscle mass (MM) impairment observed in facioscapulohumeral muscular dystrophy (FSHD) may bias estimated glomerular filtration rate (eGFR) based on creatinine (eGFRcreat). eGFR based on cystatin C (eGFRcys), produced by all nucleated cells, should be an interesting alternative. Main objectives were to compare eGFRcreat and eGRFcys for chronic kidney disease (CKD) staging and for annual eGFR evolution. Secondary objective was to analyse creatinine, cystatin C with measured MM. MATERIAL AND METHODS During 4 years, 159 FSHD patients having one or more creatinine and cystatin C measurements (total samples: n=379), with MM determination by bio-impedancemetry during their follow-up were included. eGFR were determined with CKD-Epi and EKFC equations. RESULTS On first examination samples, mean eGFRcys was significantly lower than mean eGFRcreat of 25.5 and 17.9 ml/min/1.73m2 using CKD-Epi and EKFC equations, respectively. 53.5% (CKD-Epi) and 59.1% (EKFC) of agreement were obtained when using eGFRcys instead of eGFRcreat with reclassifications occurring mainly towards more severe stages. Age was correlated with cystatin C but not with creatinine, MM was correlated with creatinine but not with cystatin C. eGFR decreases >1 ml/min/1.73m2 were more important when using eGFRcys instead of eGFRcreat (CKD-Epi: 37.5 vs 15.4%, p<0.001; EKFC: 34.6 vs 20.2%, p<0.01). CONCLUSION Cystatin C which is independent of MM appears as a promising candidate biomarker for CKD diagnosis and follow-up in FSHD patient.
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Affiliation(s)
- Etienne Mondesert
- Department of Biochemistry, University Hospital of Montpellier, Montpellier, France
| | - Anne-Sophie Bargnoux
- Department of Biochemistry, University Hospital of Montpellier, Montpellier, France; PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Florence Portet
- Department of Clinical Physiology, University Hospital of Montpellier, France
| | | | - Sandrine Arbogast
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Stéphanie Badiou
- Department of Biochemistry, University Hospital of Montpellier, Montpellier, France; PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Jean-Frédéric Brun
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France; Department of Clinical Physiology, University Hospital of Montpellier, France
| | - Nils Kuster
- Department of Biochemistry, University Hospital of Montpellier, Montpellier, France; PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Eric Raynaud de Mauverger
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France; Department of Clinical Physiology, University Hospital of Montpellier, France
| | - Jean-Paul Cristol
- Department of Biochemistry, University Hospital of Montpellier, Montpellier, France; PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France.
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Padberg GW, van Engelen BGM, Voermans NC. Facioscapulohumeral Disease as a myodevelopmental disease: Applying Ockham's razor to its various features. J Neuromuscul Dis 2023; 10:411-425. [PMID: 36872787 DOI: 10.3233/jnd-221624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Facioscapulohumeral muscular dystrophy (FSHD) is an exclusively human neuromuscular disease. In the last decades the cause of FSHD was identified: the loss of epigenetic repression of the D4Z4 repeat on chromosome 4q35 resulting in inappropriate transcription of DUX4. This is a consequence of a reduction of the array below 11 units (FSHD1) or of a mutation in methylating enzymes (FSHD2). Both require the presence of a 4qA allele and a specific centromeric SSLP haplotype. Muscles become involved in a rostro-caudally order with an extremely variable progression rate. Mild disease and non-penetrance in families with affected individuals is common. Furthermore, 2% of the Caucasian population carries the pathological haplotype without clinical features of FSHD.In order to explain the various features of FSHD we applied Ockham's Razor to all possible scenarios and removed unnecessary complexities. We postulate that early in embryogenesis a few cells escape epigenetic silencing of the D4Z4 repeat. Their number is assumed to be roughly inversely related to the residual D4Z4 repeat size. By asymmetric cell division, they produce a rostro-caudal and medio-lateral decreasing gradient of weakly D4Z4-repressed mesenchymal stem cells. The gradient tapers towards an end as each cell-division allows renewed epigenetic silencing. Over time, this spatial gradient translates into a temporal gradient based on a decreasing number of weakly silenced stem cells. These cells contribute to a mildly abnormal myofibrillar structure of the fetal muscles. They also form a downward tapering gradient of epigenetically weakly repressed satellite cells. When activated by mechanical trauma, these satellite cells de-differentiate and express DUX4. When fused to myofibrils they contribute to muscle cell death in various ways. Over time and dependent on how far the gradient reaches the FSHD phenotype becomes progressively manifest. We thus hypothesize FSHD to be a myodevelopmental disease with a lifelong attempt to restore DUX4 repression.
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Affiliation(s)
- G W Padberg
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, The Netherlands
| | - B G M van Engelen
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, The Netherlands
| | - N C Voermans
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, The Netherlands
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Ronderos-Botero DM, Dileep A, Yapor L, Singhal R. Disruption of cardio-pulmonary coupling in myopathies: Pathophysiological and mechanistic characterization with special emphasis on nemaline myopathy. Front Cardiovasc Med 2022; 9:996567. [DOI: 10.3389/fcvm.2022.996567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 09/30/2022] [Indexed: 11/09/2022] Open
Abstract
The heart and lung are in continuous reciprocal interaction that creates a functional and anatomical reserve referred to as cardiopulmonary coupling (CPC). Disruption of CPC can occur due to various cardiac or pulmonary pathologies but also can occur in patients with myopathies. Nemaline myopathy (NM) is a skeletal muscle heterogeneous disorder due to contractile proteins' gene mutations that impact lung and cardiac mechanics and thus is expected to adversely affect CPC in a complex manner. We present a case of NM and we review the literature on cardiac and pulmonary effects of myopathy-related disruption of CPC.
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ANT1 overexpression models: Some similarities with facioscapulohumeral muscular dystrophy. Redox Biol 2022; 56:102450. [PMID: 36030628 PMCID: PMC9434167 DOI: 10.1016/j.redox.2022.102450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/04/2022] [Accepted: 08/17/2022] [Indexed: 11/20/2022] Open
Abstract
Facioscapulohumeral muscular dystrophy (FSHD) is an autosomal dominant disorder characterized by progressive muscle weakness. Adenine nucleotide translocator 1 (ANT1), the only 4q35 gene involved in mitochondrial function, is strongly expressed in FSHD skeletal muscle biopsies. However, its role in FSHD is unclear. In this study, we evaluated ANT1 overexpression effects in primary myoblasts from healthy controls and during Xenopus laevis organogenesis. We also compared ANT1 overexpression effects with the phenotype of FSHD muscle cells and biopsies. Here, we report that the ANT1 overexpression-induced phenotype presents some similarities with FSHD muscle cells and biopsies. ANT1-overexpressing muscle cells showed disorganized morphology, altered cytoskeletal arrangement, enhanced mitochondrial respiration/glycolysis, ROS production, oxidative stress, mitochondrial fragmentation and ultrastructure alteration, as observed in FSHD muscle cells. ANT1 overexpression in Xenopus laevis embryos affected skeletal muscle development, impaired skeletal muscle, altered mitochondrial ultrastructure and led to oxidative stress as observed in FSHD muscle biopsies. Moreover, ANT1 overexpression in X. laevis embryos affected heart structure and mitochondrial ultrastructure leading to cardiac arrhythmia, as described in some patients with FSHD. Overall our data suggest that ANT1 could contribute to mitochondria dysfunction and oxidative stress in FSHD muscle cells by modifying their bioenergetic profile associated with ROS production. Such interplay between energy metabolism and ROS production in FSHD will be of significant interest for future prospects.
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Boxhammer E, Berezin AE, Paar V, Bacher N, Topf A, Pavlov S, Hoppe UC, Lichtenauer M. Severe Aortic Valve Stenosis and Pulmonary Hypertension: A Systematic Review of Non-Invasive Ways of Risk Stratification, Especially in Patients Undergoing Transcatheter Aortic Valve Replacement. J Pers Med 2022; 12:jpm12040603. [PMID: 35455719 PMCID: PMC9026430 DOI: 10.3390/jpm12040603] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 02/01/2023] Open
Abstract
Patients with severe aortic valve stenosis and concomitant pulmonary hypertension show a significantly reduced survival prognosis. Right heart catheterization as a preoperative diagnostic tool to determine pulmonary hypertension has been largely abandoned in recent years in favor of echocardiographic criteria. Clinically, determination of echocardiographically estimated systolic pulmonary artery pressure falls far short of invasive right heart catheterization data in terms of accuracy. The aim of the present systematic review was to highlight noninvasive possibilities for the detection of pulmonary hypertension in patients with severe aortic valve stenosis, with a special focus on cardiovascular biomarkers. A total of 525 publications regarding echocardiography, cardiovascular imaging and biomarkers related to severe aortic valve stenosis and pulmonary hypertension were analyzed in a systematic database analysis using PubMed Central®. Finally, 39 publications were included in the following review. It was shown that the current scientific data situation, especially regarding cardiovascular biomarkers as non-invasive diagnostic tools for the determination of pulmonary hypertension in severe aortic valve stenosis patients, is poor. Thus, there is a great scientific potential to combine different biomarkers (biomarker scores) in a non-invasive way to determine the presence or absence of PH.
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Affiliation(s)
- Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Alexander E. Berezin
- Internal Medicine Department, State Medical University of Zaporozhye, 69035 Zaporozhye, Ukraine;
| | - Vera Paar
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Nina Bacher
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Albert Topf
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Sergii Pavlov
- Department of Clinical Laboratory Diagnostics, State Medical University of Zaporozhye, 69035 Zaporozhye, Ukraine;
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
- Correspondence:
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Anselmo M, Coffman S, Larson M, Vera K, Lee E, McConville M, Kyba M, Keller‐Ross ML. Baroreflex sensitivity in facioscapulohumeral muscular dystrophy. Physiol Rep 2022; 10:e15277. [PMID: 35451178 PMCID: PMC9023871 DOI: 10.14814/phy2.15277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 11/24/2022] Open
Abstract
Facioscapulohumeral muscular dystrophy (FSHD), a common form of muscular dystrophy, is caused by a genetic mutation that alters DUX4 gene expression. This mutation contributes to significant skeletal muscle loss. Although it is suggested that cardiac muscle may be spared, people with FSHD have demonstrated autonomic dysregulation. It is unknown if baroreflex function, an important regulator of blood pressure (BP), is impaired in people with FSHD. We examined if baroreflex sensitivity (BRS) is blunted in patients with FSHD. Thirty minutes of resting BP, heart rate, and cardiovagal BRS were measured in 13 patients with FSHD (age: 50 ± 13 years, avg ± SD) and 17 sex- and age-matched controls (age: 47 ± 14 years, p > 0.05). People with FSHD were less active (Activity Metabolic Index, AMI) (FSHD: 24 ± 30; controls: 222 ± 175 kcal/day; p < 0.001) but had a similar body mass index compared with controls (FSHD: 27 ± 4; controls: 27 ± 4 kg/m2 ; p > 0.05). BRSup (hypertensive response), BRSdown (hypotensive response), and total BRS were similar between groups (BRSup: FSHD: 12 ± 8; controls: 12 ± 5 ms/mmHg; BRSdown: FSHD: 10 ± 4; controls: 13 ± 6 ms/mmHg; BRS: FSHD: 14 ± 9; controls: 13 ± 6 ms/mmHg; p > 0.05). Mean arterial pressure was similar between groups (FSHD: 96 ± 7; controls: 91 ± 6mmHg). Individuals with FSHD had an elevated heart rate compared with controls (FSHD: 65 ± 8; controls: 59 ± 8 BPM; p = 0.03), but when co-varied for AMI, this relationship disappeared (p = 0.39). These findings suggest that BRS is not attenuated in people with FSHD, but an elevated heart rate may be due to low physical activity levels, a potential consequence of limited mobility.
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Affiliation(s)
- Miguel Anselmo
- Division of Physical TherapyMedical SchoolUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Shandon Coffman
- Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Mia Larson
- Division of Physical TherapyMedical SchoolUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Kathryn Vera
- Division of Physical TherapyMedical SchoolUniversity of MinnesotaMinneapolisMinnesotaUSA
- Health and Human Performance DepartmentUniversity of Wisconsin–River FallsRiver FallsWisconsinUSA
| | - Emma Lee
- Division of Physical TherapyMedical SchoolUniversity of MinnesotaMinneapolisMinnesotaUSA
| | | | - Michael Kyba
- Department of Pediatrics and Lillehei Heart InstituteUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Manda L. Keller‐Ross
- Division of Physical TherapyMedical SchoolUniversity of MinnesotaMinneapolisMinnesotaUSA
- Division of Rehabilitation ScienceMedical SchoolUniversity of MinnesotaMinneapolisMinnesotaUSA
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Kelly CR, Saw JL, Thapa P, Mandrekar J, Naddaf E. Systemic Manifestations and Symptom Burden of Facioscapulohumeral Muscular Dystrophy in a Referral Cohort. Muscle Nerve 2022; 65:415-421. [PMID: 35020192 DOI: 10.1002/mus.27493] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 01/01/2022] [Accepted: 01/06/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION/AIMS The full spectrum of the clinical phenotype of facioscapulohumeral muscular dystrophy (FSHD), beyond skeletal muscle weakness, remains poorly characterized. In this study, we describe systemic manifestations and symptom burden in a large series of FSHD patients. METHODS We performed a retrospective chart review of FSHD patients seen at our institution between 2000 and 2017. We reviewed patients' responses to a comprehensive review of symptoms and the results of diagnostic testing for sensorineural hearing loss, cardiac disease, dysphagia, ocular abnormalities, and respiratory insufficiency. We assessed the association between disease manifestations and age of onset, genetic profile, and disease duration. RESULTS We identified 87 patients with FSHD. The most common reported symptoms included pain (71%), difficulty sleeping (41%), headaches (27%), and altered mood (24%). When tested, 7/16 (44%) patients had sensorineural hearing loss, 20/60 (33%) had cardiac arrhythmias or conduction defects, 17/45 (38%) had echocardiogram abnormalities, 12/25 (48%) had reduced forced vital capacity, and 4/10 (40%) had oropharyngeal dysphagia. However, patients with these abnormalities represented 8%, 23%, 20%, 14%, and 5% of total number of patients respectively, as uniform screening was lacking. Ocular pathology attributable to FSHD was not detected. DISCUSSION FSHD demonstrates a broad clinical phenotype. Increased vigilance among neurologists to screen for systemic manifestations of the disease is warranted. More uniform screening and future population-based studies are needed to compare the findings in FSHD patients to the general population.
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Affiliation(s)
- Cecilia R Kelly
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jacqui-Lyn Saw
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prabin Thapa
- Department of Internal Medicine-Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Jay Mandrekar
- Department of Internal Medicine-Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Elie Naddaf
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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