However, chromosomal rearrangements can occur between 4q and 10q repeat arrays, and involvement in disease is possible if a 4q D4Z4 repeat and polyadenylation signal are transferred onto 10q, or if rearrangement causes FSHD1. DUX4 consists of three exons. Exons 1 and 2 are in each repeat. Exon 3 is in the pLAM region telomeric to the last partial repeat. Multiple RNA transcripts are produced from the D4Z4 repeat array, both sense and antisense. Some transcripts might be degraded in areas to produce si-like small RNAs. Some transcripts that originate centromeric to the D4Z4 repeat array at the non-deleted element (NDE), termed D4Z4 regulatory element transcripts (DBE-T), could play a role in DUX4 derepression. One proposed mechanism is that DBE-T leads to the recruitment of the trithorax-group protein Ash1L, an increase in H3K36me2-methylation, and ultimately de-repression of 4q35 genes. FSHD1
FSHD involving deletion of D4Z4 repeats (termed D4Z4 contraction) on 4q is classified as FSHD1, which accounts for 95% of FSHD cases. Typically, chromosome 4 includes between 11 and 150 D4Z4 repeats. In FSHD1, there are 1–10 D4Z4 repeats. The number of repeats is roughly inversely related to disease severity. Namely, those with 8 - 10 repeats tend to have the mildest presentations, sometimes with no symptoms; those with 4 - 7 repeats have moderate disease that is highly variable; and those with 1 - 3 repeats are more likely to have severe, atypical, and early-onset disease.
Prevention
Inhalants
Disease caused by exposure to industrial inhalants and burn pits can be prevented with the use of engineering controls (e.g., exhaust hoods or closed systems), personal protective equipment, monitoring of potentially affected personnel, worker education and training. Transplant
The primary prevention of bronchiolitis obliterans in people who have received either lung transplant or HSCT therapy is immunosuppression. In regards to post lung transplantation, the combination of calcineurin inhibitor combined with a purine synthesis inhibitor and a glucocorticoid is the general regimen used. People also have a baseline post-transplant lung function testing done in order to determine if their lung function is declining over time. People who are post-HSCT their immunosuppressive regimen typically includes methotrexate in combination with a calcineurin inhibitor to prevent GVHD, a risk factor for developing bronchiolitis obliterans. Treatment
While the disease is not reversible, treatments can slow further worsening. This may include the use of corticosteroids or immunosuppressive medication which may have an effect on the ability to receive a lung transplant if offered. If patients have difficulty breathing (hypoxemia) oxygen can be supplemented. Routine vaccinations are recommended for patients with chronic lung disease to prevent complications from secondary infections due to pneumonia and influenza.Transplant recipients are at risk for re-developing the disease, as bronchiolitis obliterans is a form of chronic rejection. Evaluation of interventions for its prevention relies on early detection of abnormal spirometry results or unusual decreases in repeated measurements.