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Lenka A, Isonaka R, Holmes C, Goldstein DS. Cardiac 18F-dopamine positron emission tomography predicts the type of phenoconversion of pure autonomic failure. Clin Auton Res 2023; 33:737-747. [PMID: 37843677 DOI: 10.1007/s10286-023-00987-1] [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: 07/10/2023] [Accepted: 09/13/2023] [Indexed: 10/17/2023]
Abstract
PURPOSE Pure autonomic failure (PAF) is a rare disease characterized by neurogenic orthostatic hypotension (nOH), no known secondary cause, and lack of a neurodegenerative movement or cognitive disorder. Clinically diagnosed PAF can evolve ("phenoconvert") to a central Lewy body disease [LBD, e.g., Parkinson's disease (PD) or dementia with Lewy bodies (DLB)] or to the non-LBD synucleinopathy multiple system atrophy (MSA). Since cardiac 18F-dopamine-derived radioactivity usually is low in LBDs and usually is normal in MSA, we hypothesized that patients with PAF with low cardiac 18F-dopamine-derived radioactivity would be more likely to phenoconvert to a central LBD than to MSA. METHODS We reviewed data from all the patients seen at the National Institutes of Health Clinical Center from 1994 to 2023 with a clinical diagnosis of PAF and data about 18F-dopamine positron emission tomography (PET). RESULTS Nineteen patients (15 with low 18F-dopamine-derived radioactivity, 4 with normal radioactivity) met the above criteria and had follow-up data. Nine (47%) phenoconverted to a central synucleinopathy over a mean of 6.6 years (range 1.5-18.8 years). All 6 patients with low cardiac 18F-dopamine-derived radioactivity who phenoconverted during follow-up developed a central LBD, whereas none of 4 patients with consistently normal 18F-dopamine PET phenoconverted to a central LBD (p = 0.0048), 3 evolving to probable MSA and 1 upon autopsy having neither a LBD nor MSA. CONCLUSION Cardiac 18F-dopamine PET can predict the type of phenoconversion of PAF. This capability could refine eligibility criteria for entry into disease-modification trials aimed at preventing evolution of PAF to symptomatic central LBDs.
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Affiliation(s)
- Abhishek Lenka
- Autonomic Medicine Section, National Institute of Neurological, Disorders and Stroke (NINDS), National Institutes of Health (NIH), CNP/DIR/NINDS/NIH, 9000 Rockville Pike MSC-1620, Building 10 Room 8N260, Bethesda, MD, 20892, USA
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Risa Isonaka
- Autonomic Medicine Section, National Institute of Neurological, Disorders and Stroke (NINDS), National Institutes of Health (NIH), CNP/DIR/NINDS/NIH, 9000 Rockville Pike MSC-1620, Building 10 Room 8N260, Bethesda, MD, 20892, USA
| | - Courtney Holmes
- Autonomic Medicine Section, National Institute of Neurological, Disorders and Stroke (NINDS), National Institutes of Health (NIH), CNP/DIR/NINDS/NIH, 9000 Rockville Pike MSC-1620, Building 10 Room 8N260, Bethesda, MD, 20892, USA
| | - David S Goldstein
- Autonomic Medicine Section, National Institute of Neurological, Disorders and Stroke (NINDS), National Institutes of Health (NIH), CNP/DIR/NINDS/NIH, 9000 Rockville Pike MSC-1620, Building 10 Room 8N260, Bethesda, MD, 20892, USA.
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Lenka A, Isonaka R, Holmes C, Goldstein DS. Cardiac 18F-Dopamine Positron Emission Tomography Predicts the Type of Phenoconversion of Pure Autonomic Failure. RESEARCH SQUARE 2023:rs.3.rs-3157807. [PMID: 37503103 PMCID: PMC10371148 DOI: 10.21203/rs.3.rs-3157807/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Background Pure autonomic failure (PAF) is a rare disease characterized clinically by neurogenic orthostatic hypotension (nOH) and biochemically by peripheral noradrenergic deficiency. Clinically diagnosed PAF can evolve ("phenoconvert") to a central Lewy body disease (LBD, e.g., Parkinson's disease (PD) or dementia with Lewy bodies (DLB)) or to the non-LBD synucleinopathy multiple system atrophy (MSA). We examined whether cardiac 18F-dopamine positron emission tomography (PET) predicts the trajectory of phenoconversion in PAF. Since cardiac 18F-dopamine-derived radioactivity always is decreased in LBDs with nOH and usually is normal in MSA, we hypothesized that PAF patients with low cardiac 18F-dopamine-derived radioactivity may phenoconvert to a central LBD but do not phenoconvert to MSA. Methods We reviewed data from all the patients seen at the National Institutes of Health Clinical Center from 1994 to 2023 with a clinical diagnosis of PAF and data about serial 18F-dopamine PET. Results Twenty patients met the above criteria. Of 15 with low cardiac 18F-dopamine-derived radioactivity, 6 (40%) phenoconverted to PD or DLB and none to MSA. Of 5 patients with consistently normal 18F-dopamine PET, 4 phenoconverted to MSA, and the other at autopsy had neither a central LBD nor MSA. Conclusion In this case series, 40% of patients with nOH and low cardiac 18F-dopamine-derived radioactivity phenoconverted to PD or DLB during follow-up; none phenoconverted to MSA. Cardiac 18F-DA PET therefore can predict the type of phenoconversion in PAF. This capability could refine eligibility criteria for entry into disease-modification trials aiming to prevent evolution of PAF to symptomatic central LBDs.
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Affiliation(s)
| | - Risa Isonaka
- National Institute of Neurological Disorders and Stroke Intramural Research Program
| | - Courtney Holmes
- National Institute of Neurological Disorders and Stroke Intramural Research Program
| | - David S Goldstein
- National Institute of Neurological Disorders and Stroke Intramural Research Program
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Williams AM, Manouchehri N, Erskine E, Tauh K, So K, Shortt K, Webster M, Fisk S, Billingsley A, Munro A, Tigchelaar S, Streijger F, Kim KT, Kwon BK, West CR. Cardio-centric hemodynamic management improves spinal cord oxygenation and mitigates hemorrhage in acute spinal cord injury. Nat Commun 2020; 11:5209. [PMID: 33060602 PMCID: PMC7562705 DOI: 10.1038/s41467-020-18905-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 09/14/2020] [Indexed: 12/29/2022] Open
Abstract
Chronic high-thoracic and cervical spinal cord injury (SCI) results in a complex phenotype of cardiovascular consequences, including impaired left ventricular (LV) contractility. Here, we aim to determine whether such dysfunction manifests immediately post-injury, and if so, whether correcting impaired contractility can improve spinal cord oxygenation (SCO2), blood flow (SCBF) and metabolism. Using a porcine model of T2 SCI, we assess LV end-systolic elastance (contractility) via invasive pressure-volume catheterization, monitor intraparenchymal SCO2 and SCBF with fiberoptic oxygen sensors and laser-Doppler flowmetry, respectively, and quantify spinal cord metabolites with microdialysis. We demonstrate that high-thoracic SCI acutely impairs cardiac contractility and substantially reduces SCO2 and SCBF within the first hours post-injury. Utilizing the same model, we next show that augmenting LV contractility with the β-agonist dobutamine increases SCO2 and SCBF more effectively than vasopressor therapy, whilst also mitigating increased anaerobic metabolism and hemorrhage in the injured cord. Finally, in pigs with T2 SCI survived for 12 weeks post-injury, we confirm that acute hemodynamic management with dobutamine appears to preserve cardiac function and improve hemodynamic outcomes in the chronic setting. Our data support that cardio-centric hemodynamic management represents an advantageous alternative to the current clinical standard of vasopressor therapy for acute traumatic SCI.
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Affiliation(s)
- Alexandra M Williams
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada.,Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Neda Manouchehri
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Erin Erskine
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada.,Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Keerit Tauh
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Kitty So
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Katelyn Shortt
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Megan Webster
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Shera Fisk
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Avril Billingsley
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Alex Munro
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Seth Tigchelaar
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Femke Streijger
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Kyoung-Tae Kim
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada.,Department of Neurosurgery, School of Medicine, Kyungpook National University Hospital, Daegu, South Korea
| | - Brian K Kwon
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada.,Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - Christopher R West
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada. .,Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
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Moineau B, Brown A, Brisbois L, Zivanovic V, Miyatani M, Kapadia N, Hsieh JTC, Popovic MR. Lessons learned from the pilot study of an orthostatic hypotension intervention in the subacute phase following spinal cord injury. J Spinal Cord Med 2019; 42:176-185. [PMID: 31573450 PMCID: PMC6781467 DOI: 10.1080/10790268.2019.1638129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Context: Following spinal cord injury (SCI) at the cervical or upper-thoracic level, orthostatic hypotension (OH) is observed in 13-100% of patients. This study aimed to test the feasibility of conducting a randomized controlled trial combining a dynamic tilt-table (Erigo®) and functional electrical stimulation (FES) to mitigate OH symptoms in the subacute phase after SCI. Design: Pilot study. Setting: A tertiary rehabilitation hospital. Participants: Inpatients who had a C4-T6 SCI (AIS A-D) less than 12 weeks before recruitment, and reported symptoms of OH in their medical chart. Interventions: Screening sit-up test to determine eligibility, then 1 assessment session and 3 intervention sessions with Erigo® and FES for eligible participants. Outcome measures: Recruitment rate, duration of assessment and interventions, resources used, blood pressure, and Calgary Presyncope Form (OH symptoms). Results: Amongst the 232 admissions, 148 inpatient charts were reviewed, 11 inpatients met all inclusion criteria, 7 participated in a screening sit-up test, and 2 exhibited OH. Neither of the two participants recruited in the pilot study was able to fully complete the assessment and intervention sessions due to scheduling issues (i.e. limited available time). Conclusion: This pilot study evidenced the non-feasibility of the clinical trial as originally designed, due to the low recruitment rate and the lack of available time for research in participant's weekday schedule. OH in the subacute phase after SCI was less prevalent and less incapacitating than expected. Conventional management and spontaneous resolution of symptoms appeared sufficient to mitigate OH in most patients with subacute SCI.
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Affiliation(s)
- Bastien Moineau
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Andrea Brown
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Louise Brisbois
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Vera Zivanovic
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Masae Miyatani
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Naaz Kapadia
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Jane T. C. Hsieh
- Lawson Health Research Institute, St. Joseph’s Health Care, London
| | - Milos R. Popovic
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
- CRANIA, University Health Network, Toronto, Ontario, Canada
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Wecht JM, Bauman WA. Implication of altered autonomic control for orthostatic tolerance in SCI. Auton Neurosci 2018; 209:51-58. [DOI: 10.1016/j.autneu.2017.04.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 03/16/2017] [Accepted: 04/25/2017] [Indexed: 12/22/2022]
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Lee JS, Fang SY, Roan JN, Jou IM, Lam CF. Spinal cord injury enhances arterial expression and reactivity of α1-adrenergic receptors-mechanistic investigation into autonomic dysreflexia. Spine J 2016; 16:65-71. [PMID: 26433037 DOI: 10.1016/j.spinee.2015.09.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 07/26/2015] [Accepted: 09/03/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Autonomic dysreflexia (AD) usually presents with a significant increase in blood pressure, and uncontrollable autonomic response to stimuli below the level of spinal cord injury (SCI). PURPOSE This study analyzed the vasomotor function and molecular changes in the peripheral arteries below the lesion of SCI to characterize the mechanism of autonomic dysreflexia. STUDY DESIGN This was a randomized experimental study in rats. METHODS Contusive SCI was induced using a force-calibrated weight-drop device at the T10 level in anesthetized rats. Two weeks after severe SCI, blood flow in the femoral arteries was measured, and the vasomotor function and expression of α1-adrenergic receptors were analyzed. RESULTS Blood flow in the femoral artery was significantly reduced in rats with SCI (8.0±2 vs. 17.5±4 mL/min, SCI vs. control, respectively; p=.016). The contraction responses of femoral artery segments to cumulative addition of α1-adrenergic agonist phenylephrine were significantly enhanced in rats with SCI. Expression of α1-adrenergic receptor was upregulated in the medial layer of femoral artery vascular homogenates of these rats. CONCLUSION Our study provides evidence demonstrating that prolonged denervation below the lesion level following SCI results in a compensatory increased expression of α1-adrenergic receptors in the arterial smooth muscle layer, thereby enhancing the responsiveness to α1-adrenergic agonist and potentiating the development of AD.
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Affiliation(s)
- Jung-Shun Lee
- Divisions of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng Li Rd, Tainan 704, Taiwan
| | - Shih-Yuan Fang
- Department of Anesthesiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng Li Rd, Tainan 704, Taiwan
| | - Jun-Neng Roan
- Divisions of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng Li Rd, Tainan 704, Taiwan
| | - I-Ming Jou
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng Li Rd, Tainan 704, Taiwan
| | - Chen-Fuh Lam
- Department of Anesthesiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng Li Rd, Tainan 704, Taiwan; Department of Anesthesiology, Buddhist Tzu Chi General Hospital and Tzu Chi University School of Medicine, 707 Chung Yang Rd Section 3, Hualien 907, Taiwan.
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Abstract
Dysautonomias are conditions in which altered function of one or more components of the autonomic nervous system (ANS) adversely affects health. This review updates knowledge about dysautonomia in Parkinson disease (PD). Most PD patients have symptoms or signs of dysautonomia; occasionally, the abnormalities dominate the clinical picture. Components of the ANS include the sympathetic noradrenergic system (SNS), the parasympathetic nervous system (PNS), the sympathetic cholinergic system (SCS), the sympathetic adrenomedullary system (SAS), and the enteric nervous system (ENS). Dysfunction of each component system produces characteristic manifestations. In PD, it is cardiovascular dysautonomia that is best understood scientifically, mainly because of the variety of clinical laboratory tools available to assess functions of catecholamine systems. Most of this review focuses on this aspect of autonomic involvement in PD. PD features cardiac sympathetic denervation, which can precede the movement disorder. Loss of cardiac SNS innervation occurs independently of the loss of striatal dopaminergic innervation underlying the motor signs of PD and is associated with other nonmotor manifestations, including anosmia, REM behavior disorder, orthostatic hypotension (OH), and dementia. Autonomic dysfunction in PD is important not only in clinical management and in providing potential biomarkers but also for understanding disease mechanisms (e.g., autotoxicity exerted by catecholamine metabolites). Since Lewy bodies and Lewy neurites containing alpha-synuclein constitute neuropathologic hallmarks of the disease, and catecholamine depletion in the striatum and heart are characteristic neurochemical features, a key goal of future research is to understand better the link between alpha-synucleinopathy and loss of catecholamine neurons in PD.
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Affiliation(s)
- David S Goldstein
- Clinical Neurocardiology Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
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Pathak A, Senard JM. Blood pressure disorders during Parkinson’s disease: epidemiology, pathophysiology and management. Expert Rev Neurother 2014; 6:1173-80. [PMID: 16893345 DOI: 10.1586/14737175.6.8.1173] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Blood pressure disorders are highly prevalent in the course of Parkinson's disease (PD). They relate to autonomic failure and are frequently associated with orthostatic hypotension, postprandial hypotension and supine hypertension. Supine hypertension, which may concern up to 50% of patients with PD and autonomic failure, is driven by residual sympathetic activity and changes in sensitivity of vascular adrenergic receptors. It can also be induced or worsened by antihypotensive drugs. Even if little data is available, a set of arguments suggests that supine hypertension sometimes requires treatment. This review will focus on recent data on the pathophysiology and the management of supine hypertension in the context of its association with orthostatic hypotension.
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Affiliation(s)
- Atul Pathak
- Laboratoire de Pharmacologie Médicale et Clinique, Inserm U586, Unité de recherche sur les Obésités, Toulouse F-31432 France.
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Wecht JM, Rosado-Rivera D, Handrakis JP, Radulovic M, Bauman WA. Effects of Midodrine Hydrochloride on Blood Pressure and Cerebral Blood Flow During Orthostasis in Persons With Chronic Tetraplegia. Arch Phys Med Rehabil 2010; 91:1429-35. [DOI: 10.1016/j.apmr.2010.06.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Revised: 06/15/2010] [Accepted: 06/23/2010] [Indexed: 12/01/2022]
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Orthostatic Responses to Nitric Oxide Synthase Inhibition in Persons With Tetraplegia. Arch Phys Med Rehabil 2009; 90:1428-34. [DOI: 10.1016/j.apmr.2009.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Revised: 01/14/2009] [Accepted: 02/03/2009] [Indexed: 11/18/2022]
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Krassioukov A, Eng JJ, Warburton DE, Teasell R. A systematic review of the management of orthostatic hypotension after spinal cord injury. Arch Phys Med Rehabil 2009; 90:876-85. [PMID: 19406310 DOI: 10.1016/j.apmr.2009.01.009] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 01/07/2009] [Accepted: 01/13/2009] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To review systematically the evidence for the management of orthostatic hypotension (OH) in patients with spinal cord injuries (SCIs). DATA SOURCES A key word literature search was conducted of original and review articles as well as practice guidelines using Medline, CINAHL, EMBASE, and PsycInfo, and manual searches of retrieved articles from 1950 to July 2008, to identify literature evaluating the effectiveness of currently used treatments for OH. STUDY SELECTION Included randomized controlled trials (RCTs), prospective cohort studies, case-control studies, pre-post studies, and case reports that assessed pharmacologic and nonpharmacologic intervention for the management of OH in patients with SCI. DATA EXTRACTION Two independent reviewers evaluated the quality of each study, using the Physiotherapy Evidence Database score for RCTs and the Downs and Black scale for all other studies. Study results were tabulated and levels of evidence assigned. DATA SYNTHESIS A total of 8 pharmacologic and 21 nonpharmacologic studies were identified that met the criteria. Of these 26 studies (some include both pharmacologic and nonpharmacologic interventions), only 1 pharmacologic RCT was identified (low-quality RCT producing level 2 evidence), in which midodrine was found to be effective in the management of OH after SCI. Functional electrical stimulation was one of the only nonpharmacologic interventions with some evidence (level 2) to support its utility. CONCLUSIONS Although a wide array of physical and pharmacologic measures are recommended for the management of OH in the general population, very few have been evaluated for use in SCI. Further research needs to quantify the efficacy of treatment for OH in subjects with SCI, especially of the many other pharmacologic interventions that have been shown to be effective in non-SCI conditions.
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Affiliation(s)
- Andrei Krassioukov
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada.
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Lipp A, Sandroni P, Low PA. Systemic postganglionic adrenergic studies do not distinguish Parkinson's disease from multiple system atrophy. J Neurol Sci 2009; 281:15-9. [PMID: 19345959 DOI: 10.1016/j.jns.2009.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 01/28/2009] [Accepted: 03/09/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND Multiple system atrophy (MSA) affects the preganglionic adrenergic neuron and Parkinson's disease (PD) involves the postganglionic counterpart. Widespread postganglionic denervation should result in denervation supersensitivity and a failure of the axon to release norepinephrine (NE). We examined if pharmacological dissection of the adrenergic neuron can distinguish between MSA and PD. METHOD We measured blood pressure, heart rate, and plasma NE responses to direct (phenylephrine) and indirect (tyramine) acting adrenergic agonists in 15 patients with probable MSA, 16 patients with idiopathic PD, and 16 age- and gender-matched controls. RESULTS Baroreflex sensitivity was impaired in MSA and intact in PD. Pressor responses to phenylephrine (direct acting) were higher in MSA (p<0.01) and PD patients (p=0.04) than in controls. Blood pressure responses to tyramine (indirect acting) were increased in MSA only (p<0.01). Tyramine increased plasma catecholamine levels in all groups with no significant differences between groups. CONCLUSION There is denervation supersensitivity in PD patients that is, however, insufficient to shift the dose-response curve to the left. The excessive pressor responses to both tyramine and phenylephrine in MSA are due to baroreflex failure. We conclude that this diagnostic approach lacks sufficient sensitivity to differentiate PD and MSA.
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Affiliation(s)
- Axel Lipp
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
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Luther MS, Krewer C, Müller F, Koenig E. Orthostatic circulatory disorders in early neurorehabilitation: a case report and management overview. Brain Inj 2008; 21:763-7. [PMID: 17653950 DOI: 10.1080/02699050701481639] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Orthostatic circulatory disorders are a common problem in the mobilization of patients with severe neurological diseases such as paraplegia, the vegetative state or the minimally conscious state. They create difficulties when mobilizing the patient out of bed. Although their incidence has not been clearly established and the severity and length of symptoms differ greatly, a relevant number of the patients in a rehabilitation unit is affected. Rehabilitation specialists should therefore be aware of these disorders and the therapeutic alternatives available. This case study reports on a 45-year-old patient who repeatedly suffered from orthostatic hypotension after a severe traumatic brain injury. The pathogenesis and predisposing factors of orthostatic dysfunction in severely disabled neurological patients as well as therapeutic efforts are subsequently reviewed.
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Jabary NS, Sarabia R, Sanchez T, Gordillo R. Midodrine treatment in the management of severe orthostatic hypotension after hemangioblastoma surgery. Acta Neurochir (Wien) 2007; 149:303-5; discussion 305-6. [PMID: 17334671 DOI: 10.1007/s00701-006-1103-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2005] [Accepted: 12/13/2006] [Indexed: 11/28/2022]
Affiliation(s)
- N S Jabary
- Hypertension Unit, Nephrology Service, Hospital Clínico Universitario, Valladolid, Spain.
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15
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Wang JS. Exercise prescription and thrombogenesis. J Biomed Sci 2006; 13:753-61. [PMID: 16933027 DOI: 10.1007/s11373-006-9105-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2005] [Accepted: 07/14/2006] [Indexed: 11/24/2022] Open
Abstract
Lifestyle habits, such as exercise, may significantly influence risk of major vascular thrombotic events. The risk of primary cardiac arrest has been shown to transiently increase during vigorous exercise, whereas regular moderate-intensity exercise is associated with an overall reduced risk of cardiovascular diseases. What are the mechanisms underlying these paradoxical effects of vigorous exercise versus exercise training on thrombotic modification? This review analyzes research regarding effects and their underlying mechanisms of acute exercise, endurance training, and deconditioning on platelets, coagulation, and fibrinolysis. Evidence suggests that (i) light, acute exercise ( < or = 49% VO(2 max)) does not affect platelet reactivity and coagulation and increases fibrinolytic activity; (ii) moderate, acute exercise (50 to approximately 74% VO(2 max)) suppresses platelet reactivity and enhances fibrinolysis, which remains unchanged in the coagulation system; and, (iii) strenuous, acute exercise ( > or = 75% VO(2 max)) enhances both platelet reactivity and coagulation, simultaneously promoting fibrinolytic activity. Therefore, moderate exercise is likely a safe and effective exercise dosage for minimizing risk of cardiovascular diseases by inducing beneficial anti-thrombotic changes. Moreover, moderate-intensity exercise training reduces platelet reactivity and enhances fibrinolysis at rest, also attenuating enhanced platelet reactivity and augmenting hyper-fibrinolytic activity during strenuous exercise. However, these favorable effects of exercise training on thrombotic modification return to a pre-training state after a period of deconditioning. These findings can aid in determining appropriate exercise regimes to prevent early thrombotic events and further hinder the cardiovascular disease progression.
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Affiliation(s)
- Jong-Shyan Wang
- Graduate Institute of Rehabilitation Science and Center for Gerontological Research, Chang Gung University, 259 Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan, 333, Taiwan.
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Young TM, Asahina M, Watson L, Mathias CJ. Hemodynamic effects of clonidine in two contrasting models of autonomic failure: Multiple system atrophy and pure autonomic failure. Mov Disord 2006; 21:609-15. [PMID: 16404729 DOI: 10.1002/mds.20755] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We assessed the effects of clonidine on blood pressure (BP) and heart rate (HR) in multiple system atrophy (MSA), where the autonomic nervous system lesion site is preganglionic, and in pure autonomic failure (PAF), where it is postganglionic. In normal subjects, intravenous infusion of the selective alpha2-adrenoceptor agonist clonidine reduces BP and plasma noradrenaline (NA) levels by means of central alpha2-adrenoceptor action, as well as inducing growth hormone (GH) release. Clonidine-induced GH release is impaired in MSA but spared in PAF. However, the hemodynamic effects of clonidine have not been studied extensively in these disorders. We examined intravenous clonidine test results (performed in our autonomic laboratories using the London Autonomic Units protocol) in 58 patients: 39 with probable MSA and 19 with PAF. Systolic BP (SBP), diastolic BP (DBP), HR, and NA levels were measured supine at baseline and for up to 60 minutes after clonidine. Clonidine resulted in a significant BP fall in MSA patients, which occurred earlier (within 15 minutes of clonidine) and to a greater extent than seen in PAF patients. MSA and PAF patients showed reduction in HR after clonidine administration, although this finding was significantly greater in MSA than in PAF patients. NA levels decreased significantly after clonidine administration in both groups. Although basal NA levels were lower in PAF than in MSA patients, there was no difference in NA reduction relative to baseline between groups. MSA patients showed significant negative correlation between basal NA levels and BP response to clonidine. Clonidine infusion reduces BP and HR in both MSA and PAF groups but to a greater extent in MSA patients. The greater vasodepressor action of clonidine in MSA patients suggests that there is partial preservation of brainstem sympathetic outflow pathways in MSA and may reflect its action at sites in the brainstem and spinal cord that were in part functionally preserved in MSA. Despite similar degrees of NA reduction after clonidine administration, the vasodepressor effect of clonidine was attenuated in PAF compared with MSA patients. This attenuation in PAF patients may reflect greater peripheral alpha2-adrenoceptor denervation supersensitivity due to the postganglionic lesion site. These BP differences, thus, may reflect the underlying lesion site in MSA and PAF, and the hemodynamic data after clonidine infusion may help differentiate these conditions.
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Affiliation(s)
- Tim M Young
- Neurovascular Medicine Unit, Faculty of Medicine, Imperial College London at St. Mary's Hospital, London, United Kingdom.
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Abstract
STUDY DESIGN Case-control. OBJECTIVE Tetraplegic patients are subject to episodes of autonomic dysreflexia and postural hypotension. It is suggested that these patients sustain, in addition, unstable baseline blood pressure (BP) that is independent of symptoms and body position. METHODS BP monitoring was conducted in 10 tetraplegic patients, motor and sensory complete (American Spinal Injury Association (ASIA) A) (Group A), and five paraplegic at T8-T10 levels, ASIA A (Group B). A SpaceLabs automatically inflating pneumatic cuff recorded arm pressures at 10-30 min intervals in the daytime, sitting position and at 30 min intervals in the night-time, recumbent position. Group mean arterial pressure (MAP) and MAP standard deviation (MAP variation) for sitting and recumbent positions were compared. RESULTS Sitting the MAP for Group A was less than that of Group B; 87+/-9 versus 108+/-7 mmHg, P<0.01. However, MAP variability for Group A was greater than for Group B; 17+/-4 (20% of MAP) versus 13+/-2 mmHg (12% of MAP), P=0.04. In the recumbent position, the MAP for Group A was similar to that for Group B; 87+/-13 versus 97+/-7 mmHg, P=0.16. However, MAP variability for Group A remained higher than for Group B; 13+/-3 (20% of MAP) versus 8+/-2 mmHg (8% of MAP), P=0.02. CONCLUSION Tetraplegic patients demonstrate unstable BP in either the sitting or recumbent position compared with low thoracic paraplegic patients.
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Affiliation(s)
- J H Frisbie
- Spinal Cord Injury and Medical Services, Department of Veterans Affairs Medical Center, 1400 Veterans of Foreign Wars Parkway, West Roxbury, MA 02132, USA
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Wang JS, Yang CF, Wong MK. Effect of strenuous arm crank exercise on platelet function in patients with spinal cord injury. Arch Phys Med Rehabil 2002; 83:210-6. [PMID: 11833024 DOI: 10.1053/apmr.2002.28033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the effects of arm crank exercise on various platelet functions and prostacyclin in individuals with spinal cord injury (SCI). DESIGN Case-control study. SETTING Research project at a hospital-based exercise physiology laboratory. PARTICIPANTS Seven men (with lesions at levels T11, n = 1; T12, n = 2; L1, n = 2; L2, n = 2) and 3 women (T12, n = 1; L1, n = 2) in the SCI group had SCI for at least 6 weeks. Ten age- and gender-matched healthy people who had not engaged in any regular physical activity for at least 1 year were selected as the control group. INTERVENTION All subjects exercised strenuously by using an arm crank engometer. MAIN OUTCOME MEASURE Platelet adhesiveness on fibrinogen-coated surface and epinephrine-induced aggregation in vitro, plasma soluble P-selectin (sP-selectin), and urinary 6-keto-prostaglandin F(1alpha) (6-keto PGF(1alpha)) levels. RESULTS The SCI group had higher platelet adhesiveness and aggregability and plasma sP-selectin level, but lower urinary 6-keto PGF(1alpha) level than the control group. Platelet adhesiveness and aggregability were enhanced by strenuous arm exercise in all subjects, but only in the SCI group was sP-selectin level increased by exercise. Strenuous exercise raised the levels of 6-keto PGF(1alpha) in control group subjects, but not in subjects with SCI. CONCLUSIONS Individuals with SCI had more extensive basal and exercise-induced platelet activation and sP-selectin release than people without SCI. Moreover, strenuous arm exercise, which enhanced the release of prostacyclin in healthy subjects, failed to do so in those with SCI.
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Affiliation(s)
- Jong-Shyan Wang
- Department of Physical Therapy, Chang Gung University, Kwei-Shan, Tao-Yuan, Taiwan, ROC.
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Mukand J, Karlin L, Barrs K, Lublin P. Midodrine for the management of orthostatic hypotension in patients with spinal cord injury: A case report. Arch Phys Med Rehabil 2001; 82:694-6. [PMID: 11346851 DOI: 10.1053/apmr.2001.22350] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 21-year-old man sustained anterior displacement and a burst fracture of C7 in a motor vehicle crash. He underwent anterior corpectomy, decompression, fusion of C6-T1 vertebrae, and halo placement. The American Spinal Injury Association grade of his spinal cord injury (SCI) was C6 C tetraplegia. Severe orthostatic hypotension in the upright position complicated the patient's rehabilitation program. Midodrine was prescribed, and other medications with possible adverse effects were adjusted. Significant improvement after taking midodrine was reflected in the orthostatic vital signs and symptoms, as well as in FIM instrument scores. Staff noted improvements with therapy participation and functional status. The patient tolerated the midodrine well and had no significant side effects.
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Affiliation(s)
- J Mukand
- Southern New England Rehabilitation Center, Department of Orthopedics and Rehabilitation, Brown University, Providence, RI, USA
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Sampson EE, Burnham RS, Andrews BJ. Functional electrical stimulation effect on orthostatic hypotension after spinal cord injury. Arch Phys Med Rehabil 2000; 81:139-43. [PMID: 10668765 DOI: 10.1016/s0003-9993(00)90131-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the possibility of using functional electrical stimulation (FES) to control orthostatic hypotension in patients with spinal cord injury (SCI) and to clarify the mechanism of the response. DESIGN Subjects were tilted by 10 degree increments with varying intensities of lower-extremity FES. Stimulation over muscles was compared to stimulation over noncontractile sites. SETTING Physical therapy department of a major rehabilitation center. PATIENTS Six patients with SCI above T6 (3 with recent injury recruited consecutively from an inpatient spinal cord rehabilitation unit, and 3 from the community with longstanding injury, recruited as volunteers). MAIN OUTCOME MEASURES Blood pressure, heart rate, and perceived presyncope score recorded at each tilt angle and analyzed using a multivariate analysis of variance statistical methodology. RESULTS Systolic and diastolic blood pressure increased with increasing stimulation intensities (systolic, p = .001; diastolic, p = .0019) and decreased with increasing angle of tilt (p < .001) regardless of the site of stimulation. Subjects tolerated higher angles of incline with electrical stimulation than without (p = .03). CONCLUSIONS FES causes a dose-dependent increase in blood pressure independent of stimulation site that may be useful in treating orthostatic hypotension.
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Affiliation(s)
- E E Sampson
- Division of Physical Medicine & Rehabilitation, Faculty of Medicine, University of Alberta, Edmonton, Canada
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Roche WJ, Nwofia C, Gittler M, Patel R, Yarkony G. Catecholamine-induced hypertension in lumbosacral paraplegia: five case reports. Arch Phys Med Rehabil 2000; 81:222-5. [PMID: 10668779 DOI: 10.1016/s0003-9993(00)90145-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Hypertension in the patient with SCI is relatively rare and generally restricted to patients with high-level injuries where autonomic dysreflexia can occur. Resting blood pressure in individuals with SCI has been described as lower than that in the normal population. This report describes five previously normotensive teenagers with subsequent paraplegia as a result of gunshot wounds who presented with hypertension secondary to idiopathic elevation of plasma or urinary catecholamine levels. A clonidine suppression test was used as a neuroprobe to inhibit centrally mediated sympathetic outflow, excluding the probability of an extra-axial autonomous catecholamine-secreting tumor as the possible source of hypertension. Positive suppression was achieved in four patients (41%, 37.2%, 4.8%, and 37.2% decreases). One patient had values corresponding to orthostatic changes (an increase of 63%) because of poor compliance with the test. This patient was lost to follow-up; in the remaining four, hypertension resolved at 12, 8, 9, and 6 weeks postinjury. The increased circulating catecholamine level appears to be promoted by a centrally mediated response to the SCI. Elevated blood pressure probably results from an upgraded receptor regulation or an increased receptor sensitivity on the affected cells in the absence of restraining spinal reflexes. The pathophysiology of such hypertension seems to be secondary to autonomic dysfunction and, although it may be transient, it should be treated promptly and reevaluated periodically until stabilization is achieved.
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Affiliation(s)
- W J Roche
- Schwab Rehabilitation Hospital and Care Network, University of Chicago Hospitals, IL, USA
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22
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Mohr T, Van Soeren M, Graham TE, Kjaer M. Caffeine ingestion and metabolic responses of tetraplegic humans during electrical cycling. J Appl Physiol (1985) 1998; 85:979-85. [PMID: 9729573 DOI: 10.1152/jappl.1998.85.3.979] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Normally, caffeine ingestion results in a wide spectrum of neural and hormonal responses, making it difficult to evaluate which are critical regulatory factors. We examined the responses to caffeine (6 mg/kg) ingestion in a group of spinal cord-injured subjects [7 tetraplegic (C5-7) and 2 paraplegic (T4) subjects] at rest and during functional electrical stimulation of their paralyzed limbs to the point of fatigue. Plasma insulin did not change, caffeine had no effect on plasma epinephrine, and there was a slight increase (P < 0. 05) in norepinephrine after 15 min of exercise. Nevertheless, serum free fatty acids were increased (P < 0.05) after caffeine ingestion after 60 min of rest and throughout the first 15 min of exercise, but the respiratory exchange ratio was not affected. The exercise time was increased (P < 0.05) by 6% or 1.26 +/- 0.57 min. These data suggest that caffeine had direct effects on both the adipose tissue and the active muscle. It is proposed that the ergogenic action of caffeine is occurring, at least in part, by a direct action of the drug on muscle.
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Affiliation(s)
- T Mohr
- The Copenhagen Muscle Research Centre, Department H, Bispebjerg Hospital, University of Copenhagen, Copenhagen DK-2200, Denmark
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23
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Abstract
This review focuses on the actual limits of the clinical pharmacology of drugs used for the treatment of orthostatic hypotension. The evidences for heterogeneity of the pathophysiological mechanisms of primary orthostatic hypotension and autonomic failure are discussed. The available data on the efficacy of some drugs used in orthostatic hypotension are also discussed.
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Affiliation(s)
- J M Senard
- Laboratoire de Pharmacologie Médicale et Clinique, INSERM U317, Faculté de Médecine, Toulouse, France
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Senard JM, Montastruc JL. Adrenoceptor regulation in orthostatic hypotension during autonomic failure. Trends Pharmacol Sci 1993; 14:349-51. [PMID: 8296389 DOI: 10.1016/0165-6147(93)90091-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- J M Senard
- Department of Medical and Clinical Pharmacology, Inserm U317, Faculty of Medicine, Toulouse, France
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Tavernier G, Sénard JM, Montastruc JL, Montastruc P. A study of alpha 1- and alpha 2-adrenoceptor responsiveness in diabetic insipidus dogs. Fundam Clin Pharmacol 1993; 7:275-80. [PMID: 8406291 DOI: 10.1111/j.1472-8206.1993.tb00241.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The present study was performed to investigate the participation of circulating vasopressin in alpha-adrenoceptor responsiveness. Thus, we compared the pressor responses induced by selective alpha 1-or alpha 2-adrenoceptor stimulation in two groups of conscious dogs: a) normal animals and b) animals with surgically-induced diabetes insipidus. In addition, platelet alpha 2-adrenoceptors labelled with (3H)RX821002 were compared in the two groups. The pressor response to alpha 1-adrenoceptor stimulation [ie successive doses of noradrenaline (0.5, 1, 2, 4 micrograms/kg i.v.) after propranolol (1 mg/kg i.v.) plus yohimbine (0.5 mg/kg i.v.)] was significantly (P < 0.05) less pronounced in diabetic insipidus than in normal dogs. In contrast, the magnitude of the pressor effects of alpha 2-adrenoceptor stimulation [ie noradrenaline after propranolol plus prazosin (1 mg/kg i.v.)] was the same in the two groups of animals. Bmax and Kd values for (3H)RX821002 binding on platelets were similar in diabetic insipidus and normal dogs. This study shows that alpha 1- (but not alpha 2-) adrenoceptor responsiveness is decreased in diabetic insipidus suggesting the involvement of vasopressin in the mechanisms of the vascular alpha 1-adrenoceptor pressor response.
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Affiliation(s)
- G Tavernier
- Laboratoire de Pharmacologie Médicale et Clinique, INSERM U317, Faculté de Médecine, Toulouse, France
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Mécanismes physiologiques d'adaptation à l'orthostatisme. Rev Med Interne 1992. [DOI: 10.1016/s0248-8663(05)80961-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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