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González-Duarte A, Cotrina-Vidal M, Kaufmann H, Norcliffe-Kaufmann L. Familial dysautonomia. Clin Auton Res 2023; 33:269-280. [PMID: 37204536 DOI: 10.1007/s10286-023-00941-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 03/30/2023] [Indexed: 05/20/2023]
Abstract
Familial dysautonomia (FD) is an autosomal recessive hereditary sensory and autonomic neuropathy (HSAN, type 3) expressed at birth with profound sensory loss and early death. The FD founder mutation in the ELP1 gene arose within the Ashkenazi Jews in the sixteenth century and is present in 1:30 Jews of European ancestry. The mutation yield a tissue-specific skipping of exon 20 and a loss of function of the elongator-1 protein (ELP1), which is essential for the development and survival of neurons. Patients with FD produce variable amounts of ELP1 in different tissues, with the brain producing mostly mutant transcripts. Patients have excessive blood pressure variability due to the failure of the IXth and Xth cranial nerves to carry baroreceptor signals. Neurogenic dysphagia causes frequent aspiration leading to chronic pulmonary disease. Characteristic hyperadrenergic "autonomic crises" consisting of brisk episodes of severe hypertension, tachycardia, skin blotching, retching, and vomiting occur in all patients. Progressive features of the disease include retinal nerve fiber loss and blindness, and proprioceptive ataxia with severe gait impairment. Chemoreflex failure may explain the high frequency of sudden death in sleep. Although 99.5% of patients are homozygous for the founder mutation, phenotypic severity varies, suggesting that modifier genes impact expression. Medical management is currently symptomatic and preventive. Disease-modifying therapies are close to clinical testing. Endpoints to measure efficacy have been developed, and the ELP1 levels are a good surrogate endpoint for target engagement. Early intervention may be critical for treatment to be successful.
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Affiliation(s)
- Alejandra González-Duarte
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA.
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, CdMx, México.
| | - Maria Cotrina-Vidal
- Department of Neurology, Stroke Division. New York University School of Medicine, New York, NY, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
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Liang Y, Wang L, Zhang R, Pan J, Wu W, Huang Y, Zhang Z, Zhao R. Determination of the Metabolites and Metabolic Pathways for Three β-Receptor Agonists in Rats Based on LC-MS/MS. Animals (Basel) 2022; 12:ani12151885. [PMID: 35892535 PMCID: PMC9332168 DOI: 10.3390/ani12151885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/15/2022] [Accepted: 07/20/2022] [Indexed: 11/16/2022] Open
Abstract
This paper developed a universal detection method by high-performance liquid chromatography-tandem mass spectrometry to detect three typical clenbuterols, CLB, SAL, and RAC, and to investigate the metabolism of β-agonists in vivo. The parent ions and daughter ions of the three β-receptor agonist standards and the residues in the muscle, liver, and blood samples of rats were obtained by Total Ions Scan mode. The metabolites produced in different tissues at a specific time were qualitatively and quantitatively analyzed, and the corresponding metabolic pathways were inferred. The results showed that the three β-receptor agonists mainly existed in the form of prototype drugs in rats, with a small amount of clenbuterol methyl compound and albuterol methyl compound. There were significant differences in residual metabolism between different tissues of the same species. In addition, different β-receptor agonists have different absorption and utilization rates in rats.
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Norcliffe-Kaufmann L. Stress and the baroreflex. Auton Neurosci 2022; 238:102946. [PMID: 35086020 DOI: 10.1016/j.autneu.2022.102946] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/16/2021] [Accepted: 01/16/2022] [Indexed: 11/27/2022]
Abstract
The stress response to emotions elicits the release of glucocorticoids from the adrenal cortex, epinephrine from the adrenal medulla, and norepinephrine from the sympathetic nerves. The baroreflex adapts to buffer these responses to ensure that perfusion to the organs meets the demands while maintaining blood pressure within a within a narrow range. While stressor-evoked autonomic cardiovascular responses may be adaptive for the short-term, the recurrent exaggerated cardiovascular stress reactions can be maladaptive in the long-term. Prolonged stress or loss of the baroreflex's buffering capacity can predispose episodes of heightened sympathetic activity during stress leading to hypertension, tachycardia, and ventricular wall motion abnormalities. This review discusses 1) how the baroreflex responds to acute and chronic stressors, 2) how lesions in the neuronal pathways of the baroreflex alter the ability to respond or counteract the stress response, and 3) the techniques to assess baroreflex sensitivity and stress responses. Evidence suggests that loss of baroreflex sensitivity may predispose heightened autonomic responses to stress and at least in part explain the association between stress, mortality and cardiovascular diseases.
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Norcliffe-Kaufmann L, Millar Vernetti P, Palma JA, Balgobin BJ, Kaufmann H. Afferent Baroreflex Dysfunction: Decreased or Excessive Signaling Results in Distinct Phenotypes. Semin Neurol 2020; 40:540-549. [PMID: 32906172 DOI: 10.1055/s-0040-1713892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Head and neck tumors can affect afferent baroreceptor neurons and either interrupt or intermittently increase their signaling, causing blood pressure to become erratic. When the afferent fibers of the baroreflex are injured by surgery or radiotherapy or fail to develop as in familial dysautonomia, their sensory information is no longer present to regulate arterial blood pressure, resulting in afferent baroreflex failure. When the baroreflex afferents are abnormally activated, such as by paragangliomas in the neck, presumably by direct compression, they trigger acute hypotension and bradycardia and frequently syncope, by a mechanism similar to the carotid sinus syndrome. We describe our observations in a large series of 23 patients with afferent baroreflex dysfunction and the cardiovascular autonomic features that arise when the sensory baroreceptor neurons are injured or compressed. The management of afferent baroreceptor dysfunction is limited, but pharmacological strategies can mitigate blood pressure swings, improve symptoms, and may reduce hypertensive organ damage. Although rare, the prevalence of afferent baroreflex dysfunction appears to be increasing in middle-aged men due to human papillomavirus related oropharyngeal cancer.
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Affiliation(s)
| | | | - Jose-Alberto Palma
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Bhumika J Balgobin
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, New York
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Norcliffe-Kaufmann L, Palma JA. Blood pressure instability in head and neck cancer survivors. Clin Auton Res 2020; 30:291-293. [PMID: 32691261 PMCID: PMC7449596 DOI: 10.1007/s10286-020-00711-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/04/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Lucy Norcliffe-Kaufmann
- Department of Neurology, New York University School of Medicine, 530 First Avenue, Suite 9Q, New York, NY, 10016, USA.
| | - Jose-Alberto Palma
- Department of Neurology, New York University School of Medicine, 530 First Avenue, Suite 9Q, New York, NY, 10016, USA
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Norcliffe-Kaufmann L, Palma JA, Martinez J, Kaufmann H. Carbidopa for Afferent Baroreflex Failure in Familial Dysautonomia: A Double-Blind Randomized Crossover Clinical Trial. Hypertension 2020; 76:724-731. [PMID: 32654554 DOI: 10.1161/hypertensionaha.120.15267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Afferent lesions of the arterial baroreflex occur in familial dysautonomia. This leads to excessive blood pressure variability with falls and frequent surges that damage the organs. These hypertensive surges are the result of excess peripheral catecholamine release and have no adequate treatment. Carbidopa is a selective DOPA-decarboxylase inhibitor that suppresses catecholamines production outside the brain. To learn whether carbidopa can inhibit catecholamine-induced hypertensive surges in patients with severe afferent baroreflex failure, we conducted a double-blind randomized crossover trial in which patients with familial dysautonomia received high dose carbidopa (600 mg/day), low-dose carbidopa (300 mg/day), or matching placebo in 3 4-week treatment periods. Among the 22 patients enrolled (13 females/8 males), the median age was 26 (range, 12-59 years). At enrollment, patients had hypertensive peaks to 164/116 (range, 144/92 to 213/150 mm Hg). Twenty-four hour urinary norepinephrine excretion, a marker of peripheral catecholamine release, was significantly suppressed on both high dose and low dose carbidopa, compared with placebo (P=0.0075). The 2 co-primary end points of the trial were met. The SD of systolic BP variability was reduced at both carbidopa doses (low dose: 17±4; high dose: 18±5 mm Hg) compared with placebo (23±7 mm Hg; P=0.0013), and there was a significant reduction in the systolic BP peaks on active treatment (P=0.0015). High- and low-dose carbidopa were similarly effective and well tolerated. This study provides class Ib evidence that carbidopa can reduce blood pressure variability in patients with congenital afferent baroreflex failure. Similar beneficial effects are observed in patients with acquired baroreflex lesions.
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Affiliation(s)
- Lucy Norcliffe-Kaufmann
- From the Department of Neurology, NYU Dysautonomia Center, New York University School of Medicine
| | - Jose-Alberto Palma
- From the Department of Neurology, NYU Dysautonomia Center, New York University School of Medicine
| | - Jose Martinez
- From the Department of Neurology, NYU Dysautonomia Center, New York University School of Medicine
| | - Horacio Kaufmann
- From the Department of Neurology, NYU Dysautonomia Center, New York University School of Medicine
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Solaimanzadeh I, Schlegel TT, Feiveson AH, Greco EC, DePalma JL, Starc V, Marthol H, Tutaj M, Buechner S, Axelrod FB, Hilz MJ. Advanced electrocardiographic predictors of mortality in familial dysautonomia. Auton Neurosci 2008; 144:76-82. [PMID: 18851930 DOI: 10.1016/j.autneu.2008.08.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Revised: 07/29/2008] [Accepted: 08/26/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To identify electrocardiographic predictors of mortality in patients with familial dysautonomia (FD). METHODS Ten-minute resting high-fidelity 12-lead electrocardiograms (ECGs) were obtained from 14 FD patients and 14 age/gender-matched healthy subjects. Multiple conventional and advanced ECG parameters were studied for their ability to predict mortality over a subsequent 4.5-year period, including representative parameters of heart rate variability (HRV), QT variability (QTV), T-wave complexity, signal averaged ECG, and 3-dimensional ECG. RESULTS Four of the 14 FD patients died during the follow-up period, three with concomitant pulmonary disorder. Of the ECG parameters studied, increased non-HRV-correlated QTV and decreased HRV were the most predictive of death. Compared to controls as a group, FD patients also had significantly increased ECG voltages, JTc intervals and waveform complexity, suggestive of structural heart disease. CONCLUSION Increased QTV and decreased HRV are markers for increased risk of death in FD patients. When present, both markers may reflect concurrent pathological processes, especially hypoxia due to pulmonary disorders and sleep apnea.
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Affiliation(s)
- I Solaimanzadeh
- National Space Biomedical Research Institute, Houston, Texas, USAA
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Nussinovitch N, Nussinovitch M, Peleg E, Rosenthal T. 24-hour ambulatory blood pressure monitoring in children with familial dysautonomia. Pediatr Nephrol 2005; 20:507-11. [PMID: 15714311 DOI: 10.1007/s00467-004-1743-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2004] [Revised: 10/06/2004] [Accepted: 10/07/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND Familial dysautonomia (Riley Day syndrome) is a genetic disease. The present study of 24-hour ambulatory blood pressure monitoring in children with familial dysautonomia was carried out to investigate the pattern of blood pressure in this syndrome. OBJECTIVE To the best of our knowledge, this is the only description of patients with 24-hour blood pressure monitoring. STUDY DESIGN Vasomotor instability reflected in extreme hypertension and hypotension was recorded by 24-hour ambulatory blood pressure monitoring in three patients with familial dysautonomia: a 16-year old girl, a 14-year old boy and a 3-year old boy. Recordings were taken on a routine school day in the first two patients and during hospitalization in the third. RESULTS Patients 1 and 2 displayed circadian rhythm but with significantly higher than normal blood pressure and heart rate. Patient 3 exhibited these fluctuations to a lesser degree. Postural hypotension without compensatory tachycardia was frequently seen in all three patients. Unusual variability in blood pressure was recorded during routine activities in patients 1 and 2 and during an acute attack in patient 3. CONCLUSIONS Close monitoring of antihypertensive therapy should be considered in familial dysautonomia patients in whom blood pressure reaches excessive levels.
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Affiliation(s)
- Naomi Nussinovitch
- A.J. Chorley Institute for Hypertension, Chaim Sheba Medical Center, Tel Hashomer, Israel.
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Abstract
Familial dysautonomia (FD) patients have diminished sensory C-fibers. Calcitonin gene related peptide (CGRP) is a widely distributed neuropeptide and prominent neurotransmitter in C-fibers. We show that plasma CGRP levels measured by radioimmunoassay is significantly lower in 51 FD patients compared to controls (P<0.001). In 11/51 FD patients with FD crisis and in 19/51 FD patients with pneumonia, the mean CGRP levels rose significantly as compared to their baseline (P<0.003, P<0.001, respectively). The deficiency of CGRP in FD patients is consistent with their depletion of C-fibers, and may explain some of their symptoms, either directly or via modulation of sympathetic activity.
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Affiliation(s)
- C Maayan
- Department of Pediatrics, Hadassah University Hospital, Mt. Scopus, Jerusalem, Israel
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Abstract
Familial dysautonomia, or Riley-Day syndrome, is a hereditary disturbance in the autonomic and peripheral sensory nervous systems, first described by Riley, Day, and colleagues in 1949 [1, 2]. Previous reports of myocardial infarction and avascular necrosis in bone suggest that these patients are at risk for ischemia at certain organ sites [3, 4]. We report a case of spontaneous colonic ischemia and stricture which resulted in colocutaneous fistula formation and eventual colonic resection in a child with Riley-Day syndrome.
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Affiliation(s)
- K E Applegate
- Department of Radiology, Children's Hospital, Boston, Massachusetts 02115, USA
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