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Higuchi T, Shimada Y, Takahashi Y, Kato F, Ohashi T, Kobayashi H. Restoration of peripheral neuropathy in Fabry mice via intrathecal administration of an adeno-associated virus vector encoding mGLA cDNA. Mol Genet Metab 2024; 143:108545. [PMID: 39068683 DOI: 10.1016/j.ymgme.2024.108545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 06/11/2024] [Accepted: 07/19/2024] [Indexed: 07/30/2024]
Abstract
Anderson-Fabry disease (FD) is an X-linked lysosomal storage disorder caused by a pathological variant of the α-galactosidase A (GLA) gene that results in deficient GLA activity. GLA deficiency leads to the accumulation of globotriaosylceramide (Gb3) and lyso-Gb3 in many tissues. A certain number of FD patients have burning pain or acroparesthesia in the feet and hands since childhood. Enzyme replacement therapy (ERT) is available for FD patients. However, ERT does not dramatically improve these FD-related peripheral neuropathic pain. We generated an adeno-associated virus serotype PHP.eB (AAV-PHP.eB) vector encoding mouse GLA cDNA, which was administered to FD mice intrathecally (it) or intravenously (iv). In the it-administered AAV (it-AAV) FD mice, the GLA enzyme activity in the lumbar dorsal root ganglion (DRG) was significantly greater than that in the untreated (NT) FD mice, and the level of activity was similar to that in wild-type (WT) B6 mice. However, in iv-administered AAV (iv-AAV) FD mice, GLA activity in the DRG did not increase compared to that in NT FD mice. Gb3 storage in the DRG of it-AAV FD mice was reduced compared to that in the DRG of NT FD mice. However, compared with NT FD mice, iv-AAV FD mice did not exhibit a significant reduction in the expression of the Gb3 substrate. Compared with WT mice, FD mice were thermally hyposensitive at 52 °C according to the hot plate test. The it-AAV FD mice showed significant recovery from thermal hyposensitivity. However, the iv-AAV FD mice did not exhibit significant improvement in thermal hyposensitivity. These results suggest that the intrathecal delivery of AAV-PHP.eB-mGLA may be a valuable tool for the treatment of FD-related peripheral neuropathic pain.
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Affiliation(s)
- Takashi Higuchi
- Division of Gene Therapy, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo 1058461, Japan.
| | - Yohta Shimada
- Division of Gene Therapy, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo 1058461, Japan.
| | - Yukari Takahashi
- Division of Neuroscience, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo 1058461, Japan.
| | - Fusao Kato
- Division of Neuroscience, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo 1058461, Japan.
| | - Toya Ohashi
- Division of Gene Therapy, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo 1058461, Japan; Department of Human Health Science and Therapeutics, The Jikei University School of Nursing, Tokyo 1828570, Japan.
| | - Hiroshi Kobayashi
- Division of Gene Therapy, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo 1058461, Japan.
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Bon M, Dardis A, Scarpa M, Sechi A. Relief of nocturnal neuropathic pain with the use of cannabis in a patient with Fabry disease. Mol Genet Metab Rep 2023; 37:101010. [PMID: 38053923 PMCID: PMC10694749 DOI: 10.1016/j.ymgmr.2023.101010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 12/07/2023] Open
Abstract
Neuropathic pain is one of the most invalidating symptoms in patients with Fabry disease (FD), affecting their quality of life, it is linked to small fiber neuropathy and it may not respond to available disease specific treatments. We report the case of a 32 years old man with classic FD and severe neuropathic pain who, after the failure of several standard pharmaceutical approaches, was treated with medical cannabis with relief of nocturnal pain and sleep improvement.
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Affiliation(s)
- Martina Bon
- Regional Coordinating Center for Rare Diseases, University Hospital of Udine, Udine, Italy
| | - Andrea Dardis
- Regional Coordinating Center for Rare Diseases, University Hospital of Udine, Udine, Italy
| | - Maurizio Scarpa
- Regional Coordinating Center for Rare Diseases, University Hospital of Udine, Udine, Italy
| | - Annalisa Sechi
- Regional Coordinating Center for Rare Diseases, University Hospital of Udine, Udine, Italy
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Stepien KM, Broomfield A, Cole D, Deegan PB, Forshaw-Hulme S, Hughes D, Jovanovic A, Morris L, Muir A, Ramaswami U. Management of pain in Fabry disease in the UK clinical setting: consensus findings from an expert Delphi panel. Orphanet J Rare Dis 2023; 18:203. [PMID: 37480023 PMCID: PMC10362568 DOI: 10.1186/s13023-023-02796-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 07/05/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Fabry disease is a rare, X-linked inherited lysosomal storage disorder, that manifests as a heterogeneous disease with renal, cardiac and nervous system involvement. The most common pain experienced by people with Fabry disease are episodes of neuropathic pain reported in up to 80% of classical hemizygous male patients and up to 65% of heterozygous female patients. No clear consensus exists within UK clinical practice for the assessment and management of pain in Fabry disease based on agreed clinical practice and clinical experience. Here we describe a modified Delphi initiative to establish expert consensus on management of pain in Fabry disease in the UK clinical setting. METHODS Delphi panel members were identified based on their demonstrated expertise in managing adult or paediatric patients with Fabry disease in the UK and recruited by an independent third-party administrator. Ten expert panellists agreed to participate in two survey rounds, during which they remained anonymous to each other. Circulation of the questionnaires, and collection and processing of the panel's responses were conducted between September 2021 and December 2021. All questions required an answer. RESULTS The Delphi panel reached a consensus on 21 out of 41 aspects of pain assessment and management of pain in Fabry disease. These encompassed steps in the care pathway from the goals of therapy through to holistic support, including the use of gabapentin and carbamazepine as first-line analgesic medications for the treatment of neuropathic pain in Fabry disease, as well as the proactive management of symptoms of anxiety and/or depression associated with Fabry pain. CONCLUSIONS The consensus panel outcomes reported here have highlighted strengths in current UK clinical practice, along with unmet needs for further research and agreement. This consensus is intended to prompt the next steps towards developing clinical guidelines.
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Affiliation(s)
- Karolina M Stepien
- The Mark Holland Metabolic Unit, Salford Royal NHS Foundation Trust, Salford, UK.
| | - Alexander Broomfield
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Duncan Cole
- Department of Medical Biochemistry and Immunology, University Hospital of Wales, Cardiff, Wales, UK
| | | | - Stuart Forshaw-Hulme
- The Mark Holland Metabolic Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Derralynn Hughes
- Lysosomal Storage Disorders Unit, Royal Free London NHS Foundation Trust, London, UK
| | - Ana Jovanovic
- The Mark Holland Metabolic Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Liz Morris
- Lysosomal Disorders Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Alison Muir
- Belfast Heart Centre, Royal Victoria Hospital, Belfast, UK
| | - Uma Ramaswami
- Lysosomal Storage Disorders Unit, Royal Free London NHS Foundation Trust, London, UK
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Choconta JL, Labi V, Dumbraveanu C, Kalpachidou T, Kummer KK, Kress M. Age-related neuroimmune signatures in dorsal root ganglia of a Fabry disease mouse model. Immun Ageing 2023; 20:22. [PMID: 37173694 PMCID: PMC10176851 DOI: 10.1186/s12979-023-00346-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023]
Abstract
Pain in Fabry disease (FD) is generally accepted to result from neuronal damage in the peripheral nervous system as a consequence of excess lipid storage caused by alpha-galactosidase A (α-Gal A) deficiency. Signatures of pain arising from nerve injuries are generally associated with changes of number, location and phenotypes of immune cells within dorsal root ganglia (DRG). However, the neuroimmune processes in the DRG linked to accumulating glycosphingolipids in Fabry disease are insufficiently understood.Therefore, using indirect immune fluorescence microscopy, transmigration assays and FACS together with transcriptomic signatures associated with immune processes, we assessed age-dependent neuroimmune alterations in DRG obtained from mice with a global depletion of α-Gal A as a valid mouse model for FD. Macrophage numbers in the DRG of FD mice were unaltered, and BV-2 cells as a model for monocytic cells did not show augmented migratory reactions to glycosphingolipids exposure suggesting that these do not act as chemoattractants in FD. However, we found pronounced alterations of lysosomal signatures in sensory neurons and of macrophage morphology and phenotypes in FD DRG. Macrophages exhibited reduced morphological complexity indicated by a smaller number of ramifications and more rounded shape, which were age dependent and indicative of premature monocytic aging together with upregulated expression of markers CD68 and CD163.In our FD mouse model, the observed phenotypic changes in myeloid cell populations of the DRG suggest enhanced phagocytic and unaltered proliferative capacity of macrophages as compared to wildtype control mice. We suggest that macrophages may participate in FD pathogenesis and targeting macrophages at an early stage of FD may offer new treatment options other than enzyme replacement therapy.
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Affiliation(s)
- Jeiny Luna Choconta
- Institute of Physiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Verena Labi
- Institute of Developmental Immunology, Medical University of Innsbruck, Innsbruck, Austria
| | | | | | - Kai K Kummer
- Institute of Physiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michaela Kress
- Institute of Physiology, Medical University of Innsbruck, Innsbruck, Austria.
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Characterizing mechanism-based pain phenotypes in patients with chronic pancreatitis: a cross-sectional analysis of the PROspective Evaluation of Chronic Pancreatitis for EpidEmiologic and Translational StuDies. Pain 2023; 164:375-384. [PMID: 36149018 PMCID: PMC9726990 DOI: 10.1097/j.pain.0000000000002710] [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: 03/16/2022] [Accepted: 05/31/2022] [Indexed: 02/06/2023]
Abstract
ABSTRACT Pain is common in chronic pancreatitis (CP) and profoundly reduces quality of life (QoL). Multiple underlying mechanisms contribute to a heterogenous pain experience and reduce efficacy of pain management. This study was designed to characterize the distribution of mechanism-based pain phenotypes in painful CP. The data analyzed were collected as part of the PROspective Evaluation of Chronic Pancreatitis for EpidEmiologic and Translational StuDies, an NCI/NIDDK-funded longitudinal study of the natural history of CP. The PROspective Evaluation of Chronic pancreatitis for EpidEmiologic and translational stuDies includes patient-reported outcome (PRO) measures of pain, medication use, global health, and QoL. Of subjects (N = 681) with CP, 80% experienced abdominal pain within the year before enrollment. Subjects who experienced pain in the week before enrollment (N = 391) completed PROMIS Neuropathic and Nociceptive Pain Quality instruments which were then used to classify them by pain type: 40% had nociceptive, 5% had neuropathic-like, and 32% had both types of pain. The prevalence of having both types of pain was higher among women and subjects with diabetes mellitus, whereas nociceptive-only pain was more prevalent among men and those with pancreatic duct stricture. Other factors, including pain medication use and healthcare utilization, did not differ between groups based on pain type. Subjects in the Both group had significantly worse health and QoL scores relative to those with nociceptive-only pain, suggesting that using psychosocial pain surveys may be useful for understanding pain subtypes in patients with CP. Additional research is needed to identify biochemical and biophysical signatures that may associate with and predict responses to mechanism-specific interventions.
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Kaneski CR, Hanover JA, Schueler Hoffman UH. Generation of GLA-knockout human embryonic stem cell lines to model peripheral neuropathy in Fabry disease. Mol Genet Metab Rep 2022; 33:100914. [PMID: 36092250 PMCID: PMC9449667 DOI: 10.1016/j.ymgmr.2022.100914] [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: 05/31/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 11/28/2022] Open
Abstract
Fabry disease is an X-linked glycolipid storage disorder caused by mutations in the GLA gene which result in a deficiency in the lysosomal enzyme alpha galactosidase A (AGA). As a result, the glycolipid substrate Gb3 accumulates in critical tissues and organs producing a progressive debilitating disease. In Fabry disease up to 80% of patients experience life-long neuropathic pain that is difficult to treat and greatly affects their quality of life. The molecular mechanisms by which deficiency of AGA leads to neuropathic pain are not well understood, due in part to a lack of in vitro models that can be used to study the underlying pathology at the cellular level. Using CRISPR-Cas9 gene editing, we generated two clones with mutations in the GLA gene from a human embryonic stem cell line. Our clonal cell lines maintained normal stem cell morphology and markers for pluripotency, and showed the phenotypic characteristics of Fabry disease including absent AGA activity and intracellular accumulation of Gb3. Mutations in the predicted locations in exon 1 of the GLA gene were confirmed. Using established techniques for dual-SMAD inhibition/WNT activation, we were able to show that our AGA-deficient clones, as well as wild-type controls, could be differentiated to peripheral-type sensory neurons that express pain receptors. This genetically and physiologically relevant human model system offers a new and promising tool for investigating the cellular mechanisms of peripheral neuropathy in Fabry disease and may assist in the development of new therapeutic strategies to help lessen the burden of this disease.
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Key Words
- 4-MU, 4-methylumbelliferone
- AGA, alpha-galactosidase A
- Alpha-galactosidase
- BDNF, brain-derived neurotrophic factor
- BRN3A, brain-specific homeobox/POU domain protein 3A
- CRISPR-Cas9
- DAPI, 4′,6-diamidino-2-phenylindole
- DRG, dorsal root ganglion
- EDTA, ethylene diamine tetracetic acid
- ERT, enzyme replacement therapy
- Fabry disease
- GAPDH, glyceraldehyde-3-phosphate dehydrogenase
- GDNF, glia-derived neurotrophic factor
- GLA, alpha-galactosidase A gene
- Gb3, globotriaosylceramide
- HEX, beta-hexosaminidase
- Human embryonic stem cells
- NGF, nerve growth factor
- Neuropathy
- PAM, protospacer adjacent motif
- PBS, phosphate buffered saline
- RNP, ribonucleoprotein
- Sensory neurons
- SgRNA, single guide RNA
- TNA-alpha, Tumor Necrosis Factor- alpha
- TRPV1, transient receptor potential vanilloid family-1
- eGFP, green fluorescent protein
- hESC, human embryonic stem cell
- iPSC, induced pluripotent stem cell
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Affiliation(s)
- Christine R. Kaneski
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - John A. Hanover
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Ulrike H. Schueler Hoffman
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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Miyabayashi T, Sato R, Okubo Y, Endo W, Inui T, Togashi N, Yanagisawa H, Eto Y, Haginoya K. Water intoxication: A clue to the presence of classical Fabry disease. Brain Dev 2022; 44:592-593. [PMID: 35864002 DOI: 10.1016/j.braindev.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/28/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Takuya Miyabayashi
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai 989-3126, Japan
| | - Ryo Sato
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai 989-3126, Japan
| | - Yukimune Okubo
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai 989-3126, Japan
| | - Wakaba Endo
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai 989-3126, Japan
| | - Takehiko Inui
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai 989-3126, Japan
| | - Noriko Togashi
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai 989-3126, Japan
| | - Hiroko Yanagisawa
- Advanced Clinical Research Center, Southern Tohoku Research Center for Neuroscience, Kanagawa, Japan
| | - Yoshikatsu Eto
- Advanced Clinical Research Center, Southern Tohoku Research Center for Neuroscience, Kanagawa, Japan
| | - Kazuhiro Haginoya
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai 989-3126, Japan.
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Al‑Obaide M, Al‑Obaidi I, Vasylyeva T. The potential consequences of bidirectional promoter methylation on GLA and HNRNPH2 expression in Fabry disease phenotypes in a family of patients carrying a GLA deletion variant. Biomed Rep 2022; 17:71. [PMID: 35910704 PMCID: PMC9326966 DOI: 10.3892/br.2022.1554] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/10/2022] [Indexed: 11/11/2022] Open
Abstract
Fabry disease (FD) is a rare inherited disease characterized by a wide range of symptoms attributed to GLA mutations resulting in defective α-galactosidase A (α-Gal A) and accumulation of glycosphingolipids. The GLA locus is paired in a divergent manner with the heterogeneous nuclear ribonucleoprotein HNRNPH2 locus mapped in the RPL36A-HNRNPH2 readthrough locus. As a follow-up to our recent finding of the co-regulation of GLA and HNRNPH2 via a bidirectional promoter (BDP) in normal kidney and skin cells, the potential accumulative influence of BDP methylation and GLA mutation on the severity of FD in patients from the same family, two males and two females carrying a GLA deletion mutation, c.1033_1034delTC (p.Ser345Argfs) was addressed in the present study. The molecular analyses of the FD patients compared with the control revealed that the expression of GLA was significantly low (P<0.05), and HNRNPH2 showed a tendency of low expression (P=0.1) when BDP methylation was elevated in FD patients, compared with low BDP methylation and high GLA expression (P<0.05), and a high trend of HNRNPH2 expression in normal individuals. The accumulative effects of the mutation and BDP methylation with the severity of the disease were observed in three patients. One male FD patient, a member of the FD family diagnosed with progressive loss of kidney function, hypertension, and eventually a stroke, and the lowest level of α-Gal A enzyme activity showed the highest BDP DNA methylation level. It is concluded that the DNA methylation of GLA-HNRNPH2 BDP may serve a role in diagnosing and treating FD.
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Affiliation(s)
- Mohammed Al‑Obaide
- Department of Pediatrics, School of Medicine, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
| | - Ibtisam Al‑Obaidi
- Department of Pediatrics, School of Medicine, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
| | - Tetyana Vasylyeva
- Department of Pediatrics, School of Medicine, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
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Ponsiglione A, Gambardella M, Green R, Cantoni V, Nappi C, Ascione R, De Giorgi M, Cuocolo R, Pisani A, Petretta M, Cuocolo A, Imbriaco M. Cardiovascular magnetic resonance native T1 mapping in Anderson-Fabry disease: a systematic review and meta-analysis. J Cardiovasc Magn Reson 2022; 24:31. [PMID: 35606874 PMCID: PMC9125845 DOI: 10.1186/s12968-022-00859-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/24/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND T1 mapping is an established cardiovascular magnetic resonance (CMR) technique that can characterize myocardial tissue. We aimed to determine the weighted mean native T1 values of Anderson-Fabry disease (AFD) patients and the standardized mean differences (SMD) as compared to healthy control subjects. METHODS A comprehensive literature search of the PubMed, Scopus and Web of Science databases was conducted according to the PRISMA statement to retrieve original studies reporting myocardial native T1 values in AFD patients and healthy controls. A random effects model was used to calculate SMD, and meta-regression analysis was conducted to explore heterogeneity sources. Subgroup analysis was also performed according to scanner field strength and sequence type. RESULTS From a total of 151 items, 14 articles were included in the final analysis accounting for a total population of 982 subjects. Overall, the weighted mean native T1 values was 984 ± 47 ms in AFD patients and 1016 ± 26 ms in controls (P < 0.0001) with a pooled SMD of - 2.38. In AFD patients there was an inverse correlation between native T1 values and male gender (P = 0.002) and left ventricular hypertrophy (LVH) (P < 0.001). Subgroup analyses confirmed lower T1 values in AFD patients compared to controls with a pooled SMD of - 2.54, - 2.28, - 2.46 for studies performed on 1.5T with modified Look-Locker inversion recovery (MOLLI), shortened MOLLI and saturation-recovery single-shot acquisition, respectively and of - 2.41 for studies conducted on 3T. CONCLUSIONS Our findings confirm a reduction of native T1 values in AFD patients compared to healthy controls and point out that the degree of T1 shortening in AFD is influenced by gender and LVH. Although T1 mapping is useful in proving cardiac involvement in AFD patients, there is need to standardize shreshold values according to imaging equipment and protocols.
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Affiliation(s)
- Andrea Ponsiglione
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy.
| | - Michele Gambardella
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Roberta Green
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Valeria Cantoni
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Carmela Nappi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Raffaele Ascione
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Marco De Giorgi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Renato Cuocolo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
- Interdepartmental Research Center on Management and Innovation in Healthcare (CIRMIS), University of Naples Federico II, Naples, Italy
| | - Antonio Pisani
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | | | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
- Interdepartmental Research Center on Management and Innovation in Healthcare (CIRMIS), University of Naples Federico II, Naples, Italy
| | - Massimo Imbriaco
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
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