1
|
Darling AM, Young BE, Skow RJ, Dominguez CM, Saunders EFH, Fadel PJ, Greaney JL. Sympathetic and blood pressure reactivity in young adults with major depressive disorder. J Affect Disord 2024; 361:322-332. [PMID: 38897296 DOI: 10.1016/j.jad.2024.06.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 06/12/2024] [Accepted: 06/15/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Sympathetic and blood pressure (BP) hyper-reactivity to stress may contribute to increased cardiovascular disease (CVD) risk in adults with major depressive disorder (MDD); however, whether this is evident in young adults with MDD without comorbid disease remains unclear. We hypothesized that acute stress-induced increases in muscle sympathetic nerve activity (MSNA) and BP would be exaggerated in young adults with MDD compared to healthy non-depressed young adults (HA) and that, in adults with MDD, greater symptom severity would be positively related to MSNA and BP reactivity. METHODS In 28 HA (17 female) and 39 young adults with MDD of mild-to-moderate severity (unmedicated; 31 female), MSNA (microneurography) and beat-to-beat BP (finger photoplethysmography) were measured at rest and during the cold pressor test (CPT) and Stroop color word test (SCWT). RESULTS There were no group differences in resting MSNA (p = 0.24). Neither MSNA nor BP reactivity to either the CPT [MSNA: ∆24 ± 10 HA vs. ∆21 ± 11 bursts/min MDD, p = 0.67; mean arterial pressure (MAP): ∆22 ± 7 HA vs. ∆21 ± 10 mmHg MDD, p = 0.46)] or the SCWT (MSNA: ∆-4 ± 6 HA vs. ∆-5 ± 8 bursts/min MDD, p = 0.99; MAP: ∆7 ± 8 HA vs ∆9 ± 5 mmHg MDD; p = 0.82) were different between groups. In adults with MDD, symptom severity predicted MAP reactivity to the CPT (β = 0.78, SE = 0.26, p = 0.006), but not MSNA (p = 0.42). LIMITATIONS The mild-to-moderate symptom severity reflects only part of the MDD spectrum. CONCLUSIONS Neither sympathetic nor BP stress reactivity are exaggerated in young adults with MDD; however, greater symptom severity may amplify BP reactivity to stress, thereby increasing CVD risk.
Collapse
Affiliation(s)
- Ashley M Darling
- Department of Kinesiology, The University of Texas at Arlington, Arlington, TX, United States of America
| | - Benjamin E Young
- Department of Kinesiology, The University of Texas at Arlington, Arlington, TX, United States of America; Department of Applied Clinical Research, The University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Rachel J Skow
- Department of Kinesiology, The University of Texas at Arlington, Arlington, TX, United States of America
| | - Cynthia M Dominguez
- Department of Bioengineering, The University of Texas at Arlington, United States of America
| | - Erika F H Saunders
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, Hershey, PA, United States of America
| | - Paul J Fadel
- Department of Kinesiology, The University of Texas at Arlington, Arlington, TX, United States of America
| | - Jody L Greaney
- Department of Kinesiology, The University of Texas at Arlington, Arlington, TX, United States of America; Department of Health Behavior and Nutrition Sciences, University of Delaware, Newark, DE, United States of America.
| |
Collapse
|
2
|
Keramidas ME, Kölegård R, Elia A, Sköldefors H, Eiken O. Repetitive high-sustained gravitoinertial stress does not modulate pressure responsiveness to peripheral sympathetic stimulation. Eur J Appl Physiol 2024; 124:1253-1258. [PMID: 37991551 PMCID: PMC10954908 DOI: 10.1007/s00421-023-05354-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/28/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE We evaluated the hypothesis that repetitive gravitoinertial stress would augment the arterial-pressure response to peripheral sympathetic stimulation. METHODS Before and after a 5-weeks G-training regimen conducted in a human-use centrifuge, twenty healthy men performed a hand cold-pressor test, and nine of them also a foot cold-pressor test (4 min; 4 °C water). Arterial pressures and total peripheral resistance were monitored. RESULTS The cold-induced elevation (P ≤ 0.002) in arterial pressures and total peripheral resistance did not vary between testing periods, either in the hand [mean arterial pressure: Before = + 16% vs. After = + 17% and total peripheral resistance: Before = + 13% vs. After = + 15%], or in the foot [mean arterial pressure: Before = + 19% vs. After = + 21% and total peripheral resistance: Before = + 16% vs. After = + 16%] cold-pressor tests (P > 0.05). CONCLUSION Present results demonstrate that 5 weeks of prolonged iterative exposure to hypergravity does not alter the responsiveness of sympathetically mediated circulatory reflexes.
Collapse
Affiliation(s)
- Michail E Keramidas
- Division of Environmental Physiology, Swedish Aerospace Physiology Center, KTH Royal Institute of Technology, Berzelius väg 13, Solna, 171 65, Stockholm, Sweden.
| | - Roger Kölegård
- Division of Environmental Physiology, Swedish Aerospace Physiology Center, KTH Royal Institute of Technology, Berzelius väg 13, Solna, 171 65, Stockholm, Sweden
| | - Antonis Elia
- Division of Environmental Physiology, Swedish Aerospace Physiology Center, KTH Royal Institute of Technology, Berzelius väg 13, Solna, 171 65, Stockholm, Sweden
| | | | - Ola Eiken
- Division of Environmental Physiology, Swedish Aerospace Physiology Center, KTH Royal Institute of Technology, Berzelius väg 13, Solna, 171 65, Stockholm, Sweden
| |
Collapse
|
3
|
Takeda R, Hissen SL, Akins JD, Washio T, Hearon CM, MacNamara JP, Sarma S, Levine BD, Fadel PJ, Fu Q. Sympathetic Neural Control at Rest and During the Cold Pressor Test in Patients With Heart Failure With Preserved Ejection Fraction. Hypertension 2024; 81:917-926. [PMID: 38385250 PMCID: PMC10954398 DOI: 10.1161/hypertensionaha.123.21918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/06/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND We tested the hypothesis that patients with heart failure with preserved ejection fraction (HFpEF) would have greater muscle sympathetic nerve activity (MSNA) at rest and sympathetic reactivity during a cold pressor test compared with non-heart failure controls. Further, given the importance of the baroreflex modulation of MSNA in the control of blood pressure (BP), we hypothesized that patients with HFpEF would exhibit a reduced sympathetic baroreflex sensitivity. METHODS Twenty-eight patients with HFpEF and 44 matched controls (mean±SD: 71±8 versus 70±7 years; 9 men/19 women versus 16 men/28 women) were studied. BP, heart rate, and MSNA (microneurography) were measured during 6 to 10 minutes of supine rest and the 2-minute cold pressor test. Spontaneous sympathetic baroreflex sensitivity was assessed during supine rest. RESULTS Patients with HFpEF had higher resting MSNA burst frequency (39±14 versus 31±12 bursts/min; P=0.020) and lower sympathetic baroreflex sensitivity (-2.83±0.76 versus -3.57±1.19 bursts/100 heartbeats/mm Hg; P=0.019) than controls, but burst incidence was not different between groups (56±19 versus 50±20 bursts/100 heartbeats; P=0.179). During the cold pressor test, increases in MSNA indices did not differ between groups (P=0.135-0.998), but patients had a smaller increase in diastolic BP (Δ4±6 versus Δ14±11 mm Hg; P<0.001) compared with controls. CONCLUSIONS Despite augmented resting MSNA burst frequency, burst incidence was not significantly different between groups, and sympathetic baroreflex sensitivity was reduced in patients with HFpEF. Furthermore, patients had preserved sympathetic reactivity but attenuated diastolic BP responses during the cold pressor test. These data suggest that, during physiological stress, sympathetic reactivity is intact, but the peripheral pathway for sympathetic vasoconstriction may be impaired in HFpEF.
Collapse
Affiliation(s)
- Ryosuke Takeda
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sarah L. Hissen
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - John D. Akins
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Takuro Washio
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christopher M. Hearon
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James P. MacNamara
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Satyam Sarma
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Benjamin D. Levine
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Paul J. Fadel
- University of Texas at Arlington, Arlington, Texas, USA
| | - Qi Fu
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
4
|
Wegeberg AM, Sejersgaard-Jacobsen TH, Brock C, Drewes AM. Prediction of pain using electrocardiographic-derived autonomic measures: A systematic review. Eur J Pain 2024; 28:199-213. [PMID: 37655709 DOI: 10.1002/ejp.2175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/08/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND AND OBJECTIVE Pain is a major clinical challenge, and understanding the pathophysiology is critical for optimal management. The autonomic nervous system reacts to pain stimuli, and autonomic dysfunction may predict pain sensation. The most used assessment of autonomic function is based on electrocardiographic measures, and the ability of such measures to predict pain was investigated. DATABASES AND DATA TREATMENT English articles indexed in PubMed and EMBASE were reviewed for eligibility and included when they reported electrocardiographic-derived measures' ability to predict pain response. The quality in prognostic studies (QUIPS) tool was used to assess the quality of the included articles. RESULTS The search revealed 15 publications, five on experimental pain, five on postoperative pain, and five on longitudinal clinical pain changes, investigating a total of 1069 patients. All studies used electrocardiographically derived parameters to predict pain assessed with pain thresholds using quantitative sensory testing or different scales. Across all study modalities, electrocardiographic measures were able to predict pain. Higher parasympathetic activity predicted decreased experimental, postoperative, and long-term pain in most cases while changes in sympathetic activity did not consistently predict pain. CONCLUSIONS Most studies demonstrated that parasympathetic activity could predict acute and chronic pain intensity. In the clinic, this may be used to identify which patients need more intensive care to prevent, for example postoperative pain and develop personalized chronic pain management. SIGNIFICANCE Pain is a debilitating problem, and the ability to predict occurrence and severity would be a useful clinical tool. Basal autonomic tone has been suggested to influence pain perception. This systematic review investigated electrocardiographic-derived autonomic tone and found that increased parasympathetic tone could predict pain reduction in different types of pain.
Collapse
Affiliation(s)
- Anne-Marie Wegeberg
- Thisted Research Unit, Aalborg University Hospital Thisted, Thisted, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Christina Brock
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Thisted Research Unit, Aalborg University Hospital Thisted, Thisted, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Aalborg, Denmark
| |
Collapse
|
5
|
Fan JF, Xiao YC, Feng YF, Niu LY, Tan X, Sun JC, Leng YQ, Li WY, Wang WZ, Wang YK. A systematic review and meta-analysis of cold exposure and cardiovascular disease outcomes. Front Cardiovasc Med 2023; 10:1084611. [PMID: 37051068 PMCID: PMC10083291 DOI: 10.3389/fcvm.2023.1084611] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 02/22/2023] [Indexed: 03/29/2023] Open
Abstract
BackgroundCold exposure has been considered an essential risk factor for the global disease burden, while its role in cardiovascular diseases is still underappreciated. The increase in frequency and duration of extreme cold weather events like cold spells makes it an urgent task to evaluate the effects of ambient cold on different types of cardiovascular disease and to understand the factors contributing to the population's vulnerability.MethodsIn the present systematic review and meta-analysis, we searched PubMed, Scopus, and Cochrane. We included original research that explored the association between cold exposure (low temperature and cold spell) and cardiovascular disease outcomes (mortality and morbidity). We did a random-effects meta-analysis to pool the relative risk (RR) of the association between a 1°C decrease in temperature or cold spells and cardiovascular disease outcomes.ResultsIn total, we included 159 studies in the meta-analysis. As a result, every 1°C decrease in temperature increased cardiovascular disease-related mortality by 1.6% (RR 1.016; [95% CI 1.015–1.018]) and morbidity by 1.2% (RR 1.012; [95% CI 1.010–1.014]). The most pronounced effects of low temperatures were observed in the mortality of coronary heart disease (RR 1.015; [95% CI 1.011–1.019]) and the morbidity of aortic aneurysm and dissection (RR 1.026; [95% CI 1.021–1.031]), while the effects were not significant in hypertensive disease outcomes. Notably, we identified climate zone, country income level and age as crucial influential factors in the impact of ambient cold exposure on cardiovascular disease. Moreover, the impact of cold spells on cardiovascular disease outcomes is significant, which increased mortality by 32.4% (RR 1.324; [95% CI 1.2341.421]) and morbidity by 13.8% (RR 1.138; [95% CI 1.015–1.276]).ConclusionCold exposure could be a critical risk factor for cardiovascular diseases, and the cold effect varies between disease types and climate zones.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO, identifier: CRD42022347247.
Collapse
|
6
|
Akins JD, Okada Y, Hendrix JM, Vongpatanasin W, Fu Q. Greater resting muscle sympathetic nerve activity reduces cold pressor autonomic reactivity in older women, but not older men. Am J Physiol Regul Integr Comp Physiol 2023; 324:R656-R665. [PMID: 36971420 PMCID: PMC10110704 DOI: 10.1152/ajpregu.00231.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 03/20/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
Previous work demonstrates augmented muscle sympathetic nerve activity (MSNA) responses to the cold pressor test (CPT) in older women. Given its interindividual variability, however, the influence of baseline MSNA on CPT reactivity in older adults remains unknown. Sixty volunteers (60-83y; 30 women) completed testing where MSNA (microneurography), blood pressure (BP), and heart rate (HR) were recorded during baseline and a 2-min CPT (~4°C). Participant data were terciled by baseline MSNA (n=10/group); comparisons were made between the high baseline men (HM) and women (HW), and low baseline men (LM) and women (LW). By design, HM and HW, vs. LM and LW, had greater baseline MSNA burst frequency (37±5 and 38±3 vs. 9±4 and 15±5 bursts/min) and burst incidence (59±14 and 60±8 vs. 16±10 and 23±7 bursts/100hbs; both P<0.001). However, baseline BP and HR were not different between the groups (all P>0.05). During the CPT, there were no differences in the increase in BP and HR (all P>0.05). Conversely, ΔMSNA burst frequency was lower in HW vs. LW (8±9 vs. 22±12 bursts/min; P=0.012) yet was similar in HM vs. LM (17±12 vs. 19±10 bursts/min, P=0.994). Further, ΔMSNA burst incidence was lower in HW vs. LW (9±13 vs. 28±16 bursts/100hbs; P=0.020), with no differences between HM vs. LM (21±17 vs. 31±17 bursts/100hbs; P=0.455). Our findings suggest that heightened baseline activity in older women attenuates the typical CPT-mediated increase in MSNA without changing cardiovascular reactivity. While the underlying mechanisms remain unknown, altered sympathetic recruitment or neurovascular transduction may contribute to these disparate responses.
Collapse
Affiliation(s)
- John D Akins
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, TX, United States
- The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Yoshiyuki Okada
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, TX, United States
- The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Joseph M Hendrix
- The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | | | - Qi Fu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, TX, United States
- The University of Texas Southwestern Medical Center, Dallas, TX, United States
| |
Collapse
|
7
|
A flexible adhesive surface electrode array capable of cervical electroneurography during a sequential autonomic stress challenge. Sci Rep 2022; 12:19467. [PMID: 36376365 PMCID: PMC9663551 DOI: 10.1038/s41598-022-21817-w] [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: 06/23/2022] [Accepted: 10/04/2022] [Indexed: 11/16/2022] Open
Abstract
This study introduces a flexible, adhesive-integrated electrode array that was developed to enable non-invasive monitoring of cervical nerve activity. The device uses silver-silver chloride as the electrode material of choice and combines it with an electrode array consisting of a customized biopotential data acquisition unit and integrated graphical user interface (GUI) for visualization of real-time monitoring. Preliminary testing demonstrated this electrode design can achieve a high signal to noise ratio during cervical neural recordings. To demonstrate the capability of the surface electrodes to detect changes in cervical neuronal activity, the cold-pressor test (CPT) and a timed respiratory challenge were employed as stressors to the autonomic nervous system. This sensor system recording, a new technique, was termed Cervical Electroneurography (CEN). By applying a custom spike sorting algorithm to the electrode measurements, neural activity was classified in two ways: (1) pre-to-post CPT, and (2) during a timed respiratory challenge. Unique to this work: (1) rostral to caudal channel position-specific (cephalad to caudal) firing patterns and (2) cross challenge biotype-specific change in average CEN firing, were observed with both CPT and the timed respiratory challenge. Future work is planned to develop an ambulatory CEN recording device that could provide immediate notification of autonomic nervous system activity changes that might indicate autonomic dysregulation in healthy subjects and clinical disease states.
Collapse
|
8
|
Stute NL, Szeghy RE, Stickford JL, Province VP, Augenreich MA, Ratchford SM, Stickford ASL. Longitudinal observations of sympathetic neural activity and hemodynamics during 6 months recovery from SARS-CoV-2 infection. Physiol Rep 2022; 10:e15423. [PMID: 36151607 PMCID: PMC9508384 DOI: 10.14814/phy2.15423] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 07/14/2022] [Accepted: 07/23/2022] [Indexed: 06/16/2023] Open
Abstract
Cross-sectional data indicate that acute SARS-CoV-2 infection increases resting muscle sympathetic nerve activity (MSNA) and alters hemodynamic responses to orthostasis in young adults. However, the longitudinal impact of contracting SARS-CoV-2 on autonomic function remains unclear. The aim of this study was to longitudinally track MSNA, sympathetic transduction to blood pressure (BP), and hemodynamics over 6 months following SARS-CoV-2 infection. Young adults positive with SARS-CoV-2 reported to the laboratory three times over 6 months (V1:41 ± 17, V2:108 ± 21, V3:173 ± 16 days post-infection). MSNA, systolic (SBP) and diastolic (DBP) blood pressure, and heart rate (HR) were measured at rest, during a cold pressor test (CPT), and at 30° head-up tilt (HUT). Basal SBP (p = 0.019) and DBP (p < 0.001) decreased throughout the 6 months, whereas basal MSNA and HR were not different. Basal sympathetic transduction to BP and estimates of baroreflex sensitivity did not change over time. SBP and DBP were lower during CPT (SBP: p = 0.016, DBP: p = 0.007) and HUT at V3 compared with V1 (SBP: p = 0.041, DBP: p = 0.017), with largely no changes in MSNA. There was a trend toward a visit-by-time interaction for burst incidence (p = 0.055) during HUT, wherein at baseline immediately prior to tilting, burst incidence was lower at V3 compared with V1 (p = 0.014), but there were no differences between visits in the 30 HUT position. These results support impairments to cardiovascular health, and potentially autonomic function, which may improve over time. However, the improvements in BP over 6 months recovery from mild SARS-CoV-2 infection are likely not a direct result of changes in sympathetic activity.
Collapse
Affiliation(s)
- Nina L. Stute
- Department of Health and Exercise ScienceAppalachian State UniversityBooneNorth CarolinaUSA
| | - Rachel E. Szeghy
- Department of Health and Exercise ScienceAppalachian State UniversityBooneNorth CarolinaUSA
| | - Jonathon L. Stickford
- Department of Health and Exercise ScienceAppalachian State UniversityBooneNorth CarolinaUSA
| | - Valesha P. Province
- Department of Health and Exercise ScienceAppalachian State UniversityBooneNorth CarolinaUSA
| | - Marc A. Augenreich
- Department of Health and Exercise ScienceAppalachian State UniversityBooneNorth CarolinaUSA
| | - Stephen M. Ratchford
- Department of Health and Exercise ScienceAppalachian State UniversityBooneNorth CarolinaUSA
| | | |
Collapse
|
9
|
Watso JC, Belval LN, Cimino Iii FA, Orth BD, Hendrix JM, Huang M, Johnson E, Foster J, Hinojosa-Laborde C, Crandall CG. Low-Dose Morphine Reduces Pain Perception and Blood Pressure, but Not Muscle Sympathetic Outflow, Responses During the Cold Pressor Test. Am J Physiol Heart Circ Physiol 2022; 323:H223-H234. [PMID: 35714174 PMCID: PMC9273278 DOI: 10.1152/ajpheart.00092.2022] [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] [Indexed: 11/22/2022]
Abstract
Our knowledge about how low-dose (analgesic) morphine affects autonomic cardiovascular regulation is primarily limited to animal experiments. Notably, it is unknown if low-dose morphine affects human autonomic cardiovascular responses during painful stimuli in conscious humans. Therefore, we tested the hypothesis that low-dose morphine reduces perceived pain and subsequent sympathetic and cardiovascular responses in humans during an experimental noxious stimulus. Twenty-nine participants (14F/15M; 29±6 y; 26±4 kg•m-2, mean ± SD) completed this randomized, crossover, placebo-controlled trial during two laboratory visits. During each visit, participants completed a cold pressor test (CPT; hand in ~0.4 °C ice bath for two minutes) before and ~35 minutes after drug/placebo administration (5 mg IV morphine or saline). We compared pain perception (100 mm visual analog scale), muscle sympathetic nerve activity (MSNA; microneurography; 14 paired recordings), and beat-to-beat blood pressure (BP; photoplethysmography) between trials (at both pre- and post-drug/placebo time points) using paired, two-tailed t-tests. Before drug/placebo infusion, perceived pain (p=0.92), Δ MSNA burst frequency (n=14, p=0.21), and Δ mean BP (p=0.39) during the CPT were not different between trials. After the drug/placebo infusion, morphine versus placebo attenuated perceived pain (morphine: 43±20 vs. placebo: 57±24 mm,p<0.001) and Δ mean BP (morphine: 10±7 vs. placebo: 13±8 mmHg,p=0.003), but not Δ MSNA burst frequency (morphine: 10±11 vs. placebo: 13±11 bursts/minute,p=0.12), during the CPT. Reductions in pain perception and Δ mean BP were only weakly related (r=0.34,p=0.07; post-morphine CPT minus post-placebo CPT). These data provide valuable information regarding how low-dose morphine affects autonomic cardiovascular responses during an experimental painful stimulus.
Collapse
Affiliation(s)
- Joseph C Watso
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, United States.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States.,Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Luke N Belval
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, United States.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Frank A Cimino Iii
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, United States
| | - Bonnie D Orth
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, United States
| | - Joseph M Hendrix
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, United States.,Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Mu Huang
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, United States.,Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Elias Johnson
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, United States
| | - Josh Foster
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, United States.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | | | - Craig G Crandall
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, United States.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States.,Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, United States
| |
Collapse
|
10
|
Dikshit MB. Cardiovascular Responses to Commonly Used Tests in and Outside of the Laboratory Settings. ANNALS OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES (INDIA) 2022. [DOI: 10.1055/s-0042-1744391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractSeveral tests are available for assessing cardiovascular response to various interventions which may be given in the laboratory, or outside of it in the field. The tests are meant to excite or deactivate cardiovascular and other sensory receptors which signal the central mechanisms. They have been found useful in generating data to study cardiovascular effects on subjects exposed to specialized physical training (e.g., athletes), in the evaluation of people engaged in special occupations such as pilots, astronauts, and other military personnel, and in training undergraduate and postgraduate students. If the response does not fit into the physiological norm, it may reflect a temporary aberration, or a more serious defect in the cardiovascular control mechanism because of disease. Interpretation of data generated may vary between various operators/observers. Here, an attempt has been made to bring out responses of the cardiovascular system to the commonly used tests, and their applicability in clinical situations.
Collapse
Affiliation(s)
- Mohan B. Dikshit
- Formerly Department of Physiology and Clinical Physiology, College of Medicine and Sultan Qaboos Hospital, Sultan Qaboos University, Muscat, Oman
- Formerly Department of Physiology, Maharashtra Institute of Medical Education and Research Medical College, Pune, Maharashtra, India
| |
Collapse
|
11
|
Watso JC, Huang M, Belval LN, Cimino FA, Jarrard CP, Hendrix JM, Hinojosa-Laborde C, Crandall CG. Low-dose fentanyl reduces pain perception, muscle sympathetic nerve activity responses, and blood pressure responses during the cold pressor test. Am J Physiol Regul Integr Comp Physiol 2022; 322:R64-R76. [PMID: 34851729 PMCID: PMC8742733 DOI: 10.1152/ajpregu.00218.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Our knowledge about how low-dose (analgesic) fentanyl affects autonomic cardiovascular regulation is primarily limited to animal experiments. Notably, it is unknown if low-dose fentanyl influences human autonomic cardiovascular responses during painful stimuli in humans. Therefore, we tested the hypothesis that low-dose fentanyl reduces perceived pain and subsequent sympathetic and cardiovascular responses in humans during an experimental noxious stimulus. Twenty-three adults (10 females/13 males; 27 ± 7 yr; 26 ± 3 kg·m-2, means ± SD) completed this randomized, crossover, placebo-controlled trial during two laboratory visits. During each visit, participants completed a cold pressor test (CPT; hand in ∼0.4°C ice bath for 2 min) before and 5 min after drug/placebo administration (75 μg fentanyl or saline). We compared pain perception (100-mm visual analog scale), muscle sympathetic nerve activity (MSNA; microneurography, 11 paired recordings), and beat-to-beat blood pressure (BP; photoplethysmography) between trials (at both pre- and postdrug/placebo timepoints) using paired, two-tailed t tests. Before drug/placebo administration, perceived pain (P = 0.8287), ΔMSNA burst frequency (P = 0.7587), and Δmean BP (P = 0.8649) during the CPT were not different between trials. After the drug/placebo administration, fentanyl attenuated perceived pain (36 vs. 66 mm, P < 0.0001), ΔMSNA burst frequency (9 vs. 17 bursts/min, P = 0.0054), and Δmean BP (7 vs. 13 mmHg, P = 0.0174) during the CPT compared with placebo. Fentanyl-induced reductions in pain perception and Δmean BP were moderately related (r = 0.40, P = 0.0641). These data provide valuable information regarding how low-dose fentanyl reduces autonomic cardiovascular responses during an experimental painful stimulus.
Collapse
Affiliation(s)
- Joseph C. Watso
- 1Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas,2Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mu Huang
- 1Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas,3Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Luke N. Belval
- 1Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas,2Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Frank A. Cimino
- 1Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
| | - Caitlin P. Jarrard
- 3Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joseph M. Hendrix
- 1Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas,4Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Carmen Hinojosa-Laborde
- 5United States Army Institute of Surgical Research, Joint
Base San Antonio, San Antonio, Texas
| | - Craig G. Crandall
- 1Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas,2Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas,3Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
12
|
Stute NL, Stickford JL, Province VM, Augenreich MA, Ratchford SM, Stickford ASL. COVID-19 is getting on our nerves: sympathetic neural activity and haemodynamics in young adults recovering from SARS-CoV-2. J Physiol 2021; 599:4269-4285. [PMID: 34174086 PMCID: PMC8447023 DOI: 10.1113/jp281888#support-information-section] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/16/2021] [Indexed: 11/10/2023] Open
Abstract
KEY POINTS The impact of SARS-CoV-2 infection on autonomic and cardiovascular function in otherwise healthy individuals is unknown. For the first time it is shown that young adults recovering from SARS-CoV-2 have elevated resting sympathetic activity, but similar heart rate and blood pressure, compared with control subjects. Survivors of SARS-CoV-2 also exhibit similar sympathetic nerve activity and haemodynamics, but decreased pain perception, during a cold pressor test compared with healthy controls. Further, these individuals display higher sympathetic nerve activity throughout an orthostatic challenge, as well as an exaggerated heart rate response to orthostasis. If similar autonomic dysregulation, like that found here in young individuals, is present in older adults following SARS-CoV-2 infection, there may be substantial adverse implications for cardiovascular health. ABSTRACT The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can elicit systemic adverse physiological effects. However, the impact of SARS-CoV-2 on autonomic and cardiovascular function in otherwise healthy individuals remains unclear. Young adults who tested positive for SARS-CoV-2 (COV+; n = 16, 8 F) visited the laboratory 35 ± 16 days following diagnosis. Muscle sympathetic nerve activity (MSNA), systolic (SBP) and diastolic (DBP) blood pressure, and heart rate (HR) were measured in participants at rest and during a 2 min cold pressor test (CPT) and 5 min each at 30° and 60° head-up tilt (HUT). Data were compared with age-matched healthy controls (CON; n = 14, 9 F). COV+ participants (18.2 ± 6.6 bursts min-1 ) had higher resting MSNA burst frequency compared with CON (12.7 ± 3.4 bursts min-1 ) (P = 0.020), as well as higher MSNA burst incidence and total activity. Resting HR, SBP and DBP were not different. During CPT, there were no differences in MSNA, HR, SBP or DBP between groups. COV+ participants reported less pain during the CPT compared with CON (5.7 ± 1.8 vs. 7.2 ± 1.9 a.u., P = 0.036). MSNA was higher in COV+ compared with CON during HUT. There was a group-by-position interaction in MSNA burst incidence, as well as HR, in response to HUT. These results indicate resting sympathetic activity, but not HR or BP, may be elevated following SARS-CoV-2 infection. Further, cardiovascular and perceptual responses to physiological stress may be altered, including both exaggerated (orthostasis) and suppressed (pain perception) responses, compared with healthy young adults.
Collapse
Affiliation(s)
- Nina L. Stute
- Department of Health & Exercise ScienceAppalachian State UniversityBooneNCUSA
| | | | - Valesha M. Province
- Department of Health & Exercise ScienceAppalachian State UniversityBooneNCUSA
| | - Marc A. Augenreich
- Department of Health & Exercise ScienceAppalachian State UniversityBooneNCUSA
| | | | | |
Collapse
|
13
|
Jacob DW, Harper JL, Ivie CL, Ott EP, Limberg JK. Sex differences in the vascular response to sympathetic activation during acute hypoxaemia. Exp Physiol 2021; 106:1689-1698. [PMID: 34187092 DOI: 10.1113/ep089461] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/23/2021] [Indexed: 12/22/2022]
Abstract
NEW FINDINGS What is the central question of this study? Sympathetically mediated vasoconstriction is preserved during hypoxaemia in humans, but our understanding of vascular control comes from predominantly male cohorts. We tested the hypothesis that young women attenuate sympathetically mediated vasoconstriction during steady-state hypoxaemia, whereas men do not? What is the main finding and its importance? Sympathetically mediated vasoconstriction is preserved or even enhanced during steady-state hypoxia in young men, and the peripheral vascular response to sympathetic activation during hypoxaemia is attenuated in young women. These data advance our understanding of sex-related differences in hypoxic vascular control. ABSTRACT Activation of the sympathetic nervous system causes vasoconstriction and a reduction in peripheral blood flow. Sympathetically mediated vasoconstriction may be attenuated during systemic hypoxia to maintain oxygen delivery; however, in predominantly male participants sympathetically mediated vasoconstriction is preserved or even enhanced during hypoxaemia. Given the potential for sex-specific differences in hypoxic vascular control, prior results are limited in application. We tested the hypothesis that young women attenuate sympathetically mediated vasoconstriction during steady-state hypoxaemia, whereas men do not. Healthy young men (n = 13, 25 ± 4 years) and women (n = 11, 24 ± 4 years) completed two trials consisting of a 2-min cold pressor test (CPT, a well-established sympathoexcitatory stimulus) during baseline normoxia and steady-state hypoxaemia. Beat-to-beat blood pressure (finger photoplethysmography) and forearm blood flow (venous occlusion plethysmography) were measured continuously. Total and forearm vascular conductance (TVC and FVC, respectfully) were calculated. A change (Δ) in TVC and FVC from steady-state during the last 1 min of CPT was calculated and differences between normoxia and systemic hypoxia were assessed. In men, the reduction in TVC during CPT was greater during hypoxia compared to normoxia (ΔTVC, P = 0.02), whereas ΔTVC did not differ between conditions in women (P = 0.49). In men, ΔFVC did not differ between normoxia and hypoxia (P = 0.92). In women, the reduction in FVC during CPT was attenuated during hypoxia (ΔFVC, P < 0.01). We confirm sympathetically mediated vasoconstriction is preserved or enhanced during hypoxaemia in young men, whereas peripheral vascular responsiveness to sympathetic activation during hypoxaemia is attenuated in young women. The results advance our understanding of sex-related differences in hypoxic vascular control.
Collapse
Affiliation(s)
- Dain W Jacob
- Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, MO, USA
| | - Jennifer L Harper
- Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, MO, USA
| | - Clayton L Ivie
- Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, MO, USA
| | - Elizabeth P Ott
- Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, MO, USA
| | - Jacqueline K Limberg
- Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, MO, USA
| |
Collapse
|
14
|
Stute NL, Stickford JL, Province VM, Augenreich MA, Ratchford SM, Stickford ASL. COVID-19 is getting on our nerves: sympathetic neural activity and haemodynamics in young adults recovering from SARS-CoV-2. J Physiol 2021; 599:4269-4285. [PMID: 34174086 PMCID: PMC8447023 DOI: 10.1113/jp281888] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/16/2021] [Indexed: 12/19/2022] Open
Abstract
Key points The impact of SARS‐CoV‐2 infection on autonomic and cardiovascular function in otherwise healthy individuals is unknown. For the first time it is shown that young adults recovering from SARS‐CoV‐2 have elevated resting sympathetic activity, but similar heart rate and blood pressure, compared with control subjects. Survivors of SARS‐CoV‐2 also exhibit similar sympathetic nerve activity and haemodynamics, but decreased pain perception, during a cold pressor test compared with healthy controls. Further, these individuals display higher sympathetic nerve activity throughout an orthostatic challenge, as well as an exaggerated heart rate response to orthostasis. If similar autonomic dysregulation, like that found here in young individuals, is present in older adults following SARS‐CoV‐2 infection, there may be substantial adverse implications for cardiovascular health.
Abstract The novel severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) can elicit systemic adverse physiological effects. However, the impact of SARS‐CoV‐2 on autonomic and cardiovascular function in otherwise healthy individuals remains unclear. Young adults who tested positive for SARS‐CoV‐2 (COV+; n = 16, 8 F) visited the laboratory 35 ± 16 days following diagnosis. Muscle sympathetic nerve activity (MSNA), systolic (SBP) and diastolic (DBP) blood pressure, and heart rate (HR) were measured in participants at rest and during a 2 min cold pressor test (CPT) and 5 min each at 30° and 60° head‐up tilt (HUT). Data were compared with age‐matched healthy controls (CON; n = 14, 9 F). COV+ participants (18.2 ± 6.6 bursts min−1) had higher resting MSNA burst frequency compared with CON (12.7 ± 3.4 bursts min−1) (P = 0.020), as well as higher MSNA burst incidence and total activity. Resting HR, SBP and DBP were not different. During CPT, there were no differences in MSNA, HR, SBP or DBP between groups. COV+ participants reported less pain during the CPT compared with CON (5.7 ± 1.8 vs. 7.2 ± 1.9 a.u., P = 0.036). MSNA was higher in COV+ compared with CON during HUT. There was a group‐by‐position interaction in MSNA burst incidence, as well as HR, in response to HUT. These results indicate resting sympathetic activity, but not HR or BP, may be elevated following SARS‐CoV‐2 infection. Further, cardiovascular and perceptual responses to physiological stress may be altered, including both exaggerated (orthostasis) and suppressed (pain perception) responses, compared with healthy young adults. The impact of SARS‐CoV‐2 infection on autonomic and cardiovascular function in otherwise healthy individuals is unknown. For the first time it is shown that young adults recovering from SARS‐CoV‐2 have elevated resting sympathetic activity, but similar heart rate and blood pressure, compared with control subjects. Survivors of SARS‐CoV‐2 also exhibit similar sympathetic nerve activity and haemodynamics, but decreased pain perception, during a cold pressor test compared with healthy controls. Further, these individuals display higher sympathetic nerve activity throughout an orthostatic challenge, as well as an exaggerated heart rate response to orthostasis. If similar autonomic dysregulation, like that found here in young individuals, is present in older adults following SARS‐CoV‐2 infection, there may be substantial adverse implications for cardiovascular health.
Collapse
Affiliation(s)
- Nina L Stute
- Department of Health & Exercise Science, Appalachian State University, Boone, NC, USA
| | - Jonathon L Stickford
- Department of Health & Exercise Science, Appalachian State University, Boone, NC, USA
| | - Valesha M Province
- Department of Health & Exercise Science, Appalachian State University, Boone, NC, USA
| | - Marc A Augenreich
- Department of Health & Exercise Science, Appalachian State University, Boone, NC, USA
| | - Stephen M Ratchford
- Department of Health & Exercise Science, Appalachian State University, Boone, NC, USA
| | - Abigail S L Stickford
- Department of Health & Exercise Science, Appalachian State University, Boone, NC, USA
| |
Collapse
|
15
|
Takeda R, Stickford ASL, Best SA, Yoo JK, Liu YL, Fu Q. Effects of salt intake on sympathetic neural and pressor responses to cold pressor test in premenopausal women with a history of normal pregnancy. Am J Physiol Regul Integr Comp Physiol 2021; 320:R307-R316. [PMID: 33438516 DOI: 10.1152/ajpregu.00297.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Excessive salt intake is considered a risk factor for the development of hypertension. Additionally, aberrant neurocirculatory responses to a cold stimulus are associated with an increased risk of hypertension. This study aimed to determine whether salt loading versus salt reduction would impact hemodynamic and sympathetic neural responses during the cold pressor test (CPT) in premenopausal women with a history of normal pregnancy. Nine healthy premenopausal women [42 ± 3 (SD) yr] were given a standardized isocaloric high-salt (HS; 250 mEq sodium/day) or low-salt (LS; 50 mEq sodium/day) diet for 1-wk each (∼2 mo apart with the order randomized), while water intake was ad libitum. Laboratory testing was performed following each HS and LS period in the mid-luteal phase of the menstrual cycle. Subjects were in the supine position and beat-by-beat blood pressure (BP), heart rate (HR), and muscle sympathetic nerve activity (MSNA) were continuously measured during 1-min baseline followed by 2-min CPT, and 3-min recovery. BP and HR increased during the CPT (both P < 0.001); the responses were similar between HS and LS. MSNA increased during the CPT, but the increment (Δ) was greater during HS than LS (29 ± 6 vs. 15 ± 4 bursts/min; P < 0.001). The transduction of MSNA for vasoconstriction during the CPT was lower in HS (P < 0.05). Thus, salt loading augments sympathetic neural reactivity to the cold stimulus with similar pressor responses compared with salt reduction, which may be attributed to the blunted neurovascular transduction-a compensatory mechanism for hemodynamic homeostasis in premenopausal women with a history of normal pregnancy.
Collapse
Affiliation(s)
- Ryosuke Takeda
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Abigail S L Stickford
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Stuart A Best
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jeung-Ki Yoo
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yu-Lun Liu
- Department of Population and Data Sciences, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Qi Fu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|