MEDI1020A | Group-Project Research Proposal

Proposed Title: Quantifying the Intergenerational Risk of Facioscapulohumeral Muscular Dystrophy (FSHD) in
Vietnamese Families: A Case-Control Family-Based Study
Authors: Nguyen Huu Loc, Phan Ho Thanh Duc, Vu Minh Ha Duong, Bui Xuan Nhat Huy, Le Minh Chau, Le My
Duyen
Research Question: How does the presence of Facioscapulohumeral Muscular Dystrophy (FSHD) in one
family member influence the risk and manifestation of the disease in subsequent generations within
Vietnamese families?
Research Goal: To evaluate the association between the number of affected family members (ranging from
one to three) with FSHD and the subsequent risk and manifestation of FSHD in other family members within
Vietnamese families. The objective is to construct a chart illustrating the quantified risk of the disease based
on the number of affected first- and second-degree relatives.
Background
Facioscapulohumeral muscular dystrophy (FSHD) was first reported by Duchenne in 1853 and classified by
Landouzy and Dejerine in 1886 (therefore also called as Landouzy-Dejérine muscular dystrophy) (Duchenne,
G.B., 1853) (et Dejerine, L., 1886). After Myotonic Dystrophy and Duchenne Muscular Dystrophy, it is the
third most common muscular dystrophy, with an estimated prevalence of 3.2-4.6 per 100,000 population
(Theadom et al., 2014).
FSHD is a complex and heterogeneous disease secondary to insufficient epigenetic repression of D4Z4
repeats and aberrant expression of DUX4 in skeletal muscles. Type 1 FSHD is caused by contraction of D4Z4
repeats on 4q35, whereas type 2 FSHD is associated with mutations of the SMCHD1 or DNMT3B gene in the
presence of a disease-permissive 4qA haplotype(Mah & Chen, 2017). Other genes, such as CTCF, DNMT1,
DNMT3A, EZH2, SUV39H1, further contribute to the disease's heterogeneity (Strafella et al., 2023).

Clinically, FSHD manifests as a slow progression of weakness in facial and proximal upper limb muscles,
resulting in a mimic, smooth face, inability to purse the lips, and incomplete eye closure. Shoulder girdle
weakness with scapular winging is a consistent feature, extending to other muscle groups, including neck,
hip, and anterior leg muscles, potentially causing foot drop (Vincenten et al., 2021) (Giannini et al., 2007).
Because of its hereditary and severe impact on the patient's life, reconception counselling regarding the
genetic risk, possible options to prevent the inheritance of the disease in offspring and possible pregnancy
complications in affected women is advised (Tawil & Van Der Maarel, 2006).

With an estimated population of 98.51 million in 2021 (General Statistics Office., 2021), our calculations
project an approximate range of 3,155 to 4,531 individuals affected by FSHD in Vietnam. This lack of precise
local data impedes the development of targeted healthcare interventions and genetic counselling strategies
tailored to the Vietnamese context. In response to this critical research gap, our study aims to fill this void by
conducting a quantitative investigation into the prevalence and transmission patterns of FSHD in Vietnam.
This effort not only provides initial numerical insights but also contributes significantly to addressing a crucial
gap in the understanding of FSHD within diverse populations.

Study Design: Analytical observational case-control family-based studies

1
The choice of a case-control study stems from its ability, when well-executed, to provide valuable insights,
particularly by calculating the odds ratio. This ratio serves as a measure indicating the heightened or
diminished influence of an exposure on the outcome. In the context of our study, the outcome involves family
members with Facioscapulohumeral Muscular Dystrophy (FSHD) and the risk of the disease in subsequent
generations. The case-control approach is particularly advantageous for investigating rare diseases.

When a disease is rare, conducting a prospective cohort study may demand following a large group of people
over an extended period to accumulate sufficient incident cases for analysis. This could be impractical and
resource-intensive. For instance, if a disease occurs at a rate of 1 in 1,000,000 per year, recruiting enough
cases within a reasonable timeframe would require an unfeasible number of participants or an impractical
duration for follow-up. In such cases, a case-control study allows for a more pragmatic approach, identifying
current cases and evaluating historical associated factors.
Moreover, the case-control study design offers the flexibility to examine multiple risk factors simultaneously.
In the context of FSDH, we can extend our investigation beyond genetic factors to consider elements such as
the environment, potentially viewing FSDH as an epigenetic disease. This comprehensive approach enables a
more nuanced exploration of the various factors contributing to the development of the rare disease within
familial contexts.
Furthermore, we opt not to choose other study designs, such as a cross-sectional study, due to specific
limitations associated with them. Cross-sectional studies typically sample from a large and diverse
population, potentially making it challenging to identify participants with the rare condition of interest, such
as Facioscapulohumeral Muscular Dystrophy (FSHD). These studies offer a snapshot of the population at a
single point in time, which may not be suitable for capturing the temporal aspect of FSHD's intergenerational
development. Since FSHD is a genetic disorder with a focus on familial risk, examining changes over time is
essential, making cross-sectional studies less appropriate for our research objectives. They are better
suited for assessing prevalence and associations at a static moment.
Additionally, cohort studies are time-consuming, requiring extensive follow-up for individuals with the
disease. The retrospective cohort study design, which analyzes historical data to examine the relationship
between exposure and outcome, may be valuable for understanding past cases of FSHD in families. However,
challenges arise concerning the availability and accuracy of historical data. Obtaining comprehensive
information on exposures and outcomes retrospectively can be difficult, potentially limiting the robustness of
the study findings. Therefore, considering the nature of FSHD and the goals of our investigation, a
case-control study remains a more practical and effective choice.

This research adopts an analytical observational case-control family-based design to investigate the
prevalence of Facioscapulohumeral Muscular Dystrophy (FSHD) within the population. Given the rarity of this
condition, the study seeks to identify potential cases within existing FSHD communities (social media,
communities,...) which the research group has found publicly accessible.
To gather comprehensive data, a structured survey will be employed, necessitating individuals with FSHD to
recall familial symptoms among first and second degree relatives associated with FSHD or its history.
First-degree relatives, representing direct genetic relationships, include parents, siblings, and offspring.
Second-degree relatives broaden the scope to include grandparents, aunts, uncles, nieces, nephews,
half-siblings, and first cousins. Subsequently, professional physicians will be enlisted to conduct genetic
testing, thereby corroborating the gathered information. In cases where individuals have deceased, hospital
records will be utilized to supplement the data.

2
Study Population
The study population is composed of a targeted sample comprising more than 50 Vietnamese families
affected by Facioscapulohumeral Muscular Dystrophy (FSHD).
When selecting our control group for the FSHD study within Vietnamese families, we emphasize crucial
factors. Demographic matching focuses on aligning age, gender, ethnicity and geographical location between
the control and affected individuals. Additionally, we will gather genetic and family information for the
control group to confirm the absence of FSHD within their families, ensuring a clear demarcation between
the affected and control groups in terms of FSHD status.
Outcomes:
Outcome Measurement:
Presence of FSHD in Subsequent Generations: The outcome will be measured by determining the presence or
absence of FSHD in the offspring and other subsequent generations of individuals diagnosed with FSHD in the
previous generation. This will involve collecting data on the FSHD status of family members, including
parents, siblings, offspring, grandparents, aunts, uncles, nieces, nephews, half-siblings, and first cousins.
Comparison with Control Group: The FSHD status of individuals in subsequent generations of affected
families will be compared with the FSHD status of individuals in the control group, who do not have a family
history of FSHD. This comparison will provide insights into the relative risk of FSHD in subsequent generations
of affected families compared to individuals without a family history of the disease.

Exposure: Presence of FSHD in the Previous Generation

Description: The exposure will be identified through clinical diagnosis and confirmed by genetic testing of
individuals in the previous generation within Vietnamese families. Clinical data, including medical records
and structured interviews, will contribute to the diagnosis. Genetic testing will specifically confirm the
presence of FSHD and provide detailed information about the genetic markers associated with the disease.
In the assessment of an individual's FSHD status, reliance will be placed on the disease's characteristic
progression. The primary manifestation of Facioscapulohumeral Muscular Dystrophy (FSHD) involves a
gradual weakening and loss of skeletal muscles. Notably, the initial sites of weakness align with the
nomenclature of the disorder, affecting the face (facio), shoulder girdle (scapulo), and upper arms (humeral).
Distinctive early indicators include muscle weakness in the eye (pertaining to opening and closing) and the
mouth (impacting functions such as smiling, puckering, and whistling). Of particular significance in the clinical
diagnosis of FSHD is the confluence of these symptoms with weakness in the muscles responsible for
stabilizing the scapula, or shoulder blades. This combination of symptoms forms the basis for the physician's
clinical assessment and diagnosis of Facioscapulohumeral Muscular Dystrophy (General Statistics Office.,
2021).

Genetic testing is not needed for every affected person with a typical clinical presentation if the family
history is consistent with autosomal dominant inheritance and the diagnosis has been genetically confirmed
in a first-degree relative.IIn many cases, however, people with no family history are suspected of having
either FSHD or some other neuromuscular disorder. In these situations, less expensive and less specific tests
than the FSHD DNA test may be done first.

3
One test is a creatine kinase level. This test, also performed on a blood sample, measures the amount of an
enzyme known as creatine kinase in the blood. When muscle cells break down, as they do in muscular
dystrophies and some other disorders, the creatine kinase, or CK, level is elevated. CK is often elevated up to
5 times the upper limit of normal in symptomatic FSHD patients. CK is rarely elevated in patients with no
symptoms.
Another type of diagnostic test is the electromyogram, or EMG, which measures the electrical activity in the
muscles, displayed in the form of waves. EMG typically displays alterations in patients with FSHD.
Another diagnostic procedure sometimes undertaken is a muscle biopsy. In this procedure, a small piece of
muscle is taken, under local anesthesia, usually from the arm or leg. Biopsy samples reveal cellular and
molecular abnormalities that suggest certain muscle disorders and rule out others.

Data Collection Plan:

Phase 1: Ethics Approval (Month 1): Submit the proposal to the relevant ethics committee
Phase 2: Participant Recruitment and Training (Months 2-3)
Week 1-2: Identify participants
Week 3-4: Recruit identified participants, explaining the study objectives, procedures, and obtaining
informed consent.
Week 4: Train research assistants and healthcare professionals involved in data collection.
Phase 3: Data Collection (Months 4-8)
Week 1-8: Administer structured surveys to collect information
Week 9-16: Conduct genetic testing to confirm FSHD diagnosis and identify genetic markers
Week 9-16: Obtain and review hospital records to supplement data collected
Phase 4: Control Group Selection (Months 6-8)
Week 1-2: Identify potential control group participants
Week 3-4: Recruit control group participants, explaining the study objectives, procedures, and
obtaining informed consent.
Week 5-8: Collect genetic and family history information to confirm the absence of FSHD
Phase 5: Data Analysis (Months 9-10): Clean the collected data before conducting the statistical analysis
Phase 6: Reporting and Dissemination (Months 11-12): Detailing the research findings, methodology,
analysis, and implications for healthcare interventions and genetic counseling strategies.
Limitations
1. Sampling Bias: Recruitment of participants from FSHD communities may introduce sampling bias, as
individuals within these communities may not be representative of the broader population. To
mitigate, we propose using statistical techniques such as stratification and weighting to adjust for
biases, thus enhancing the representativeness of our findings.

4
 2. Limited Access to Deceased Family Records: Difficulty in accessing medical records of deceased
family members may limit the ability to confirm the disease status of these individuals, potentially
impacting the accuracy of the data collected

3. Historical Data Accuracy: Since our study relies in part on retrospective data, the accuracy of these
records is crucial.

4. Resource Intensive: Conducting genetic testing and surveys on a large number of participants can be
resource-intensive and time-consuming. This may pose challenges in terms of funding, staffing, and
logistical support.

5. Potential for Measurement Error: Despite rigorous training, there is still a potential for
measurement error in data collection, particularly in self-reported information obtained through
surveys. This could impact the validity and reliability of the study findings.
6. Challenges in Control Group Selection: Ensuring adequate matching and selection of control group
participants may be challenging, particularly in finding individuals with similar demographics and
socioeconomic status but without a family history of FSHD.
Justification for Study Design

1. Appropriateness for Rare Diseases: the low prevalence makes prospective cohort studies impractical
due to the need for large sample sizes and lengthy follow-up periods.
2. Efficiency and Cost-effectiveness: The case-control design allows us to examine multiple risk factors
and outcomes efficiently without the extensive resources and time required for longitudinal studies.
This approach is not only cost-effective but also yields quicker results.
3. Precision in Observing Generational Differences: This design is advantageous for observing and
comparing generational transmission patterns within families. It enables us to identify specific
familial risk factors and transmission mechanisms that might be diluted in broader, cross-sectional or
cohort studies.

Impact of the Research

1. Improving Genetic Counseling: By clarifying the intergenerational risk patterns of FSHD, our research
could significantly enhance genetic counseling services, especially in Vietnam, providing families with
accurate risk assessments and better informing their reproductive decisions.
2. Scientific Contribution: Contribute to the global understanding of the genetic variability and
expression of FSHD, potentially identifying unique genetic markers or pathways that could be targets
for future genetic therapies.

3. Informing Healthcare Policy: The insights from our study could be instrumental in shaping healthcare
policies, particularly by aiding in the development of targeted interventions and support programs
for families genetically predisposed to FSHD.
4. Raising Awareness: Our findings could help raise awareness about FSHD among healthcare providers
and the public, leading to earlier detection, diagnosis, and potentially more effective management of
the condition.

5
Potential Continued Research

1. Longitudinal Follow-up Studies: Following the initial case-control study, we suggest a longitudinal
cohort study to track the same families over time. This would help validate our findings and provide
insights into the long-term effects and progression of FSHD.
2. Expansion to Other Populations: To understand the broader applicability of our findings, we propose
extending this research to include other ethnic groups or geographic regions. This would help
compare genetic and environmental influences on FSHD prevalence and expression across different
populations.
3. Interventional Studies: Based on our findings, we could explore interventional studies aimed at
testing specific preventive or management strategies for FSHD in at-risk families, potentially reducing
the disease's impact.

References
1. Duchenne, G. B. (1853). Etude comparee des lesions anatomique dans látrophie musculaire
progressive et dans la paralysie generale. Union Med Prat, 7, 202.
2. et Dejerine, L. (1886). Nouvelles recherches cliniques et anatomopathologiques sur la myopathie
usw. Revue de médecine. XII.
3. General Statistics Office. (2021). Infographic Population, Labour and Employment in 2021.
https://www.gso.gov.vn/en/data-and-statistics/2022/01/infographic-population-labour-and-empl
oyment-in-2021/
4. Giannini, S., Faldini, C., Pagkrati, S., Grandi, G., Digennaro, V., Luciani, D., & Merlini, L. (2007).
Fixation of winged scapula in facioscapulohumeral muscular dystrophy. Clinical Medicine &
Research, 5(3), 155-162.
5. Huml, R. A. (Ed.). (2015). Muscular dystrophy: a concise guide. Springer.
6. Mah, J. K., & Chen, Y. (2017). A Pediatric Review of facioscapulohumeral Muscular Dystrophy.
Journal of Pediatric Neurology, 16(04), 222–231. https://doi.org/10.1055/s-0037-1604197

7. Strafella, C., Caputo, V., Bortolani, S., Torchia, E., Megalizzi, D., Trastulli, G., Monforte, M.,
Colantoni, L., Caltagirone, C., Ricci, E., Tasca, G., Cascella, R., & Giardina, E. (2023). Whole exome
sequencing highlights rare variants in CTCF, DNMT1, DNMT3A, EZH2 and SUV39H1 as associated
with FSHD. Frontiers in Genetics, 14. https://doi.org/10.3389/fgene.2023.1235589

8. Tawil, R., & Van Der Maarel, S. M. (2006). Facioscapulohumeral muscular dystrophy. Muscle &
Nerve: Official Journal of the American Association of Electrodiagnostic Medicine, 34(1), 1-15.
9. Theadom, A., Rodrigues, M., Roxburgh, R., Balalla, S., Higgins, C., Bhattacharjee, R., ... & Feigin, V.
(2015). Prevalence of muscular dystrophies: a systematic literature review. Neuroepidemiology,
43(3-4), 259-268.
10. Vincenten, S. C. C., Van Der Stoep, N., Paulussen, A., Mul, K., Badrising, U. A., Kriek, M., Van Der
Heijden, O. W., Van Engelen, B., Voermans, N. C., De Die-Smulders, C., & Lassche, S. (2021).
Facioscapulohumeral muscular dystrophy—Reproductive counseling, pregnancy, and delivery in a
complex multigenetic disease. Clinical Genetics, 101(2), 149–160.
https://doi.org/10.1111/cge.14031