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Zreik F, Meshulam R, Shichel I, Webb M, Shibolet O, Jacob G. Effect of ingesting a meal and orthostasis on the regulation of splanchnic and systemic hemodynamics and the responsiveness of cardiovascular α 1-adrenoceptors. Am J Physiol Gastrointest Liver Physiol 2021; 321:G513-G526. [PMID: 34523347 DOI: 10.1152/ajpgi.00142.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Postprandial orthostasis activates mechanisms of cardiovascular homeostasis to maintain normal blood pressure (BP) and adequate blood flow to vital organs. The underlying mechanisms of cardiovascular homeostasis in postprandial orthostasis still require elucidation. Fourteen healthy volunteers were recruited to investigate the effect of an orthostatic challenge (60°-head-up-tilt for 20 min) on splanchnic and systemic hemodynamics before and after ingesting an 800-kcal composite meal. The splanchnic circulation was assessed by ultrasonography of the superior mesenteric and hepatic arteries and portal vein. Systemic hemodynamics were assessed noninvasively by continuous monitoring of BP, heart rate (HR), cardiac output (CO), and the pressor response to an intravenous infusion on increasing doses of phenylephrine, an α1-adrenoceptor agonist. Neurohumoral regulation was assessed by spectral analysis of HR and BP, plasma catecholamine and aldosterone levels and plasma renin activity. Postprandial mesenteric hyperemia was associated with an increase in CO, a decrease in SVR and cardiac vagal tone, and reduction in baroreflex sensitivity with no change in sympathetic tone. Arterial α1-adrenoceptor responsiveness was preserved and reduced in hepatic sinusoids. Postprandial orthostasis was associated with a shift of 500 mL of blood from mesenteric to systemic circulation with preserved sympathetic-mediated vasoconstriction. Meal ingestion provokes cardiovascular hyperdynamism, cardiac vagolysis, and resetting of the baroreflex without activation of the sympathetic nervous system. Meal ingestion also alters α1-adrenoceptor responsiveness in the hepatic sinusoids and participates in the redistribution of blood volume from the mesenteric to the systemic circulation to maintain a normal BP during orthostasis.NEW & NOTEWORTHY A unique integrated investigation on the effect of meal on neurohumoral mechanisms and blood flow redistribution of the mesenteric circulation during orthostasis was investigated. Food ingestion results in cardiovascular hyperdynamism, reduction in cardiac vagal tone, and baroreflex sensitivity and causes a decrease in α1-adrenoceptor responsiveness only in the venous intrahepatic sinusoids. About 500-mL blood shifts from the mesenteric to the systemic circulation during orthostasis. Accordingly, the orthostatic homeostatic mechanisms are better understood.
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Affiliation(s)
- Farid Zreik
- Department of Medicine, F and J. Recanati Autonomic Dysfunction Center, Tel Aviv "Sourasky" Medical Center, Tel Aviv, Israel
| | - Reshef Meshulam
- Department of Medicine, F and J. Recanati Autonomic Dysfunction Center, Tel Aviv "Sourasky" Medical Center, Tel Aviv, Israel
| | - Ido Shichel
- Department of Medicine, F and J. Recanati Autonomic Dysfunction Center, Tel Aviv "Sourasky" Medical Center, Tel Aviv, Israel
| | - Muriel Webb
- Department of Gastroenterology at Tel Aviv "Sourasky" Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oren Shibolet
- Department of Gastroenterology at Tel Aviv "Sourasky" Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Giris Jacob
- Department of Medicine, F and J. Recanati Autonomic Dysfunction Center, Tel Aviv "Sourasky" Medical Center, Tel Aviv, Israel
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Pure autonomic failure and the differential diagnosis of autonomic peripheral neuropathies. Curr Opin Neurol 2021; 34:675-682. [PMID: 34392300 DOI: 10.1097/wco.0000000000000985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF THE REVIEW Pure autonomic failure (PAF) is a peripheral autonomic neurodegenerative disease caused by alpha-synuclein deposition that is predominantly confined to peripheral autonomic neurons. Patients present with insidious features of autonomic failure that have a chronic course.In this review, we highlight the features of PAF, the differentiating features from other autonomic neuropathies, the diagnostic tests, and the predictors for conversion to a central synucleinopathy. RECENT FINDINGS Natural history studies have defined the predictors for and rate of conversion to a central alpha-synucleinopathy. Skin immunohistochemistry techniques and demonstration of length-dependent neuronal loss of both somatic and autonomic small fiber nerves, and intraneural phosphorylated synuclein deposition provide diagnostic biomarkers. In the future, diagnosis maybe supported by measuring cerebrospinal fluid alpha-synuclein oligomers using techniques, such as protein misfolding cyclic amplification assay and real-time quaking-induced conversion. SUMMARY PAF is a sporadic peripheral autonomic neurodegenerative disease that belongs to the group of disorders known as alpha-synucleinopathies. Peripheral autonomic manifestations are similar to those seen in other autonomic neuropathies, particularly, diabetic autonomic neuropathy, amyloid polyneuropathy, and autoimmune autonomic neuropathies. Novel diagnostic procedures like skin immunohistochemistry for alpha-synuclein, and protein amplification techniques are being investigated to provide an earlier and more specific diagnosis. A substantial number of PAF patients' phenoconvert to a central alpha-synucleinopathy.
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Abstract
PURPOSE OF REVIEW This article reviews the α-synucleinopathies pure autonomic failure, multiple system atrophy, dementia with Lewy bodies, and Parkinson disease with respect to autonomic failure. RECENT FINDINGS The pattern and severity of autonomic involvement in the synucleinopathies is related to differences in cellular deposition and neuronal populations affected by α-synuclein aggregation, which influences the degree and manifestation of autonomic failure. Clinical and laboratory autonomic features distinguish the different synucleinopathies based on pattern and severity. These features also determine which patients are at risk for evolution from pure autonomic failure to the synucleinopathies with prominent motor involvement, such as multiple system atrophy, dementia with Lewy bodies, or Parkinson disease. SUMMARY Autonomic failure is a key feature of the synucleinopathies, with varying type and degree of dysfunction from predominantly peripheral involvement in the Lewy body disorders to central involvement in multiple system atrophy.
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Sasaki H, Kawamura N, Dyck PJ, Dyck PJB, Kihara M, Low PA. Spectrum of diabetic neuropathies. Diabetol Int 2020; 11:87-96. [PMID: 32206478 PMCID: PMC7082443 DOI: 10.1007/s13340-019-00424-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 12/29/2019] [Indexed: 02/06/2023]
Abstract
The diabetic state results in neuropathy. The main causative mechanism is hyperglycemia, although microvascular involvement, hypertriglyceridemia, as well as genetic and immune mechanisms may be contributory. There is a growing spectrum of types of diabetic neuropathies that differ based on the type of fibers involved (e.g. myelinated, unmyelinated, autonomic, somatic), distribution of nerves involved, and mechanisms of neuropathy. The most common type is distal sensory neuropathy (DSN), which affects the distal ends of large myelinated fibers, more often sensory than motor, and is often asymptomatic. The next-most common is distal small fiber neuropathy (DSFN), which largely affects the unmyelinated fibers and carries the phenotype of burning feet syndrome. Diabetic autonomic neuropathy (DAN) occurs when widespread involvement of autonomic unmyelinated fibers occurs, and patients can be incapacitated with orthostatic hypotension as well as neurogenic bladder and bowel involvement. Radiculoplexus diabetic neuropathy causes proximal weakness and pain, usually in the lower extremity, and has a combination of immune, inflammatory, and vascular mechanisms. The nerve roots and plexus are involved. These patients present with proximal weakness of a subacute onset, often with severe pain and some autonomic failure. Finally, rapid and sustained reduction of blood glucose can result in treatment-induced diabetic neuropathy (TIND), which largely affects the sensory and autonomic fibers. This occurs if HbA1c is rapidly reduced within 3 months, and the likelihood is proportional to the original A1c and the size of the reduction.
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Affiliation(s)
| | | | - Peter J. Dyck
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
| | - P. James B. Dyck
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
| | | | - Phillip A. Low
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
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Coon EA, Singer W, Low PA. Pure Autonomic Failure. Mayo Clin Proc 2019; 94:2087-2098. [PMID: 31515103 PMCID: PMC6826339 DOI: 10.1016/j.mayocp.2019.03.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 03/06/2019] [Accepted: 03/12/2019] [Indexed: 12/17/2022]
Abstract
Pure autonomic failure (PAF) is a neurodegenerative disorder of the autonomic nervous system clinically characterized by orthostatic hypotension. The disorder has also been known as Bradbury-Eggleston syndrome, named for the authors of the 1925 seminal description. Patients typically present in midlife or later with orthostatic hypotension or syncope. Autonomic failure may also manifest as genitourinary, bowel, and thermoregulatory dysfunction. With widespread involvement, patients may present to a variety of different specialties and require multidisciplinary treatment approaches. Pathologically, PAF is characterized by predominantly peripheral deposition of α-synuclein. However, patients with PAF may progress into other synucleinopathies with central nervous system involvement.
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Habek M, Ruška B, Crnošija L, Adamec I, Junaković A, Krbot Skorić M. Effect of Food Intake on Hemodynamic Parameters during the Tilt-Table Test in Patients with Postural Orthostatic Tachycardia Syndrome. J Clin Neurol 2019; 15:205-210. [PMID: 30877690 PMCID: PMC6444156 DOI: 10.3988/jcn.2019.15.2.205] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/26/2018] [Accepted: 11/28/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND AND PURPOSE The aim of this study was to determine the effect of food intake on the heart rate (HR) in postural orthostatic tachycardia syndrome (POTS). METHODS The following five-phase protocol was applied to 41 subjects who had a sustained HR increment of ≥30 beats/min within 10 min of standing in an initial tilt-table test: 1) 10-min supine phase, 2) 10-min 70°-tilted phase, 3) ingestion of 400 mL of Nutridrink Multi Fibre®, 4) 45-min supine phase, and 5) 10-min 70°-tilted phase. Subjects were divided into four groups: A) difference in HR for standing vs. supine (ΔHR) before the meal of ≥30 beats/min (n=13), B) ΔHR <30 beats/min before the meal but ≥30 beats/min after the meal (n=12), and C) ΔHR <30 beats/min both before and after the meal (n=16). Group D consisted of 10 healthy subjects. RESULTS Before the meal, ΔHR was significantly higher in group A than in all of the other groups, and in group B than in group D (p<0.001). After the meal, ΔHR was significantly higher in groups A and B (p<0.001 and p<0.0001, respectively). When we pooled patients (according to their symptoms) from group A and B into a POTS group and from group C and D into a non-POTS group, an increase in HR of 25 beats/min before the meal had a sensitivity of 92.0% and a specificity of 80.8%. After the meal, an increase in HR of 30 beats/min had a sensitivity of 96.0% and a specificity of 96.2%. CONCLUSIONS Food intake can significantly alter the results of the tilt-table test and so should be taken into account when diagnosing POTS.
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Affiliation(s)
- Mario Habek
- Department of Neurology, School of Medicine, University of Zagreb, Zagreb, Croatia.,Department of Neurology, University Hospital Center Zagreb, Referral Center for Autonomic Nervous System Disorders, Zagreb, Croatia.
| | - Berislav Ruška
- Department of Neurology, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Luka Crnošija
- Department of Neurology, University Hospital Center Zagreb, Referral Center for Autonomic Nervous System Disorders, Zagreb, Croatia
| | - Ivan Adamec
- Department of Neurology, University Hospital Center Zagreb, Referral Center for Autonomic Nervous System Disorders, Zagreb, Croatia
| | - Anamari Junaković
- Department of Neurology, University Hospital Center Zagreb, Referral Center for Autonomic Nervous System Disorders, Zagreb, Croatia
| | - Magdalena Krbot Skorić
- Department of Neurology, University Hospital Center Zagreb, Referral Center for Autonomic Nervous System Disorders, Zagreb, Croatia
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Chelimsky G, Chelimsky T. The gastrointestinal symptoms present in patients with postural tachycardia syndrome: A review of the literature and overview of treatment. Auton Neurosci 2018; 215:70-77. [PMID: 30245098 DOI: 10.1016/j.autneu.2018.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 09/06/2018] [Accepted: 09/06/2018] [Indexed: 12/18/2022]
Abstract
Orthostatic intolerance, including postural tachycardia syndrome, is often associated with gastrointestinal symptoms. In the vast majority of the cases, the gastrointestinal symptoms are not secondary to the orthostatic disorder, but rather just a comorbid condition. This concept is critical, since treatment aimed at the orthostatic condition will not improve the gastrointestinal symptoms. Only when the gastrointestinal symptoms develop in the upright position and improve or resolve in the supine position, they may be related to the orthostatic stress. The most common symptoms associated with orthostatic intolerance include nausea, dyspepsia, bloating and constipation. The majority of subjects do not have gastroparesis. The chapter discusses available treatments of these conditions.
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Affiliation(s)
- Gisela Chelimsky
- Department of Pediatrics, Division of Pediatric Gastroenterology, Medical College of Wisconsin, United States of America.
| | - Thomas Chelimsky
- Department of Neurology; Medical College of Wisconsin, United States of America
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Mehr SE, Barbul A, Shibao CA. Gastrointestinal symptoms in postural tachycardia syndrome: a systematic review. Clin Auton Res 2018; 28:411-421. [PMID: 29549458 PMCID: PMC6314490 DOI: 10.1007/s10286-018-0519-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 03/05/2018] [Indexed: 01/06/2023]
Abstract
Gastrointestinal symptoms are among the most common complaints in patients with postural tachycardia syndrome (POTS). In some cases, they dominate the clinical presentation and cause substantial disabilities, including significant weight loss and malnutrition, that require the use of invasive treatment to support caloric intake. Multiple cross-sectional studies have reported a high prevalence of gastrointestinal symptoms in POTS patients with connective tissue diseases, such as Ehlers-Danlos, hypermobile type, and in patients with evidence of autonomic neuropathy. Previous studies that evaluated gastric motility in these patients reported a wide range of abnormalities, particularly delayed gastric emptying. The pathophysiology of gastrointestinal symptoms in POTS is likely multifactorial and probably depends on the co-morbid conditions. In patients with POTS and Ehlers-Danlos syndromes, structural and functional abnormalities in the gastrointestinal connective tissue may play a significant role, whereas in neuropathic POTS, the gastrointestinal tract motility and gut hormonal secretion may be directly impaired due to localized autonomic denervation. In patients with normal gastrointestinal motility but persistent gastrointestinal symptoms, gastrointestinal functional disorders should be considered. We performed a systematic review of the literature related to POTS and gastrointestinal symptoms have proposed possible mechanisms and discussed diagnosis and treatment approaches for delayed gastric emptying, the most common gastrointestinal abnormality reported in patients with POTS.
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Affiliation(s)
- Shahram E Mehr
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, 506 RRB, 2222 Pierce Ave, Nashville, TN, 37232, USA
| | - Adrian Barbul
- Department of Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, 506 RRB, 2222 Pierce Ave, Nashville, TN, 37232, USA.
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Singh NG, Nagaraja PS, Gopal D, Manjunath V, Nagesh KS, Manjunatha N, Patel GP, Mishra SK. Feasibility of measuring superior mesenteric artery blood flow during cardiac surgery under hypothermic cardiopulmonary bypass using transesophageal echocardiography: An observational study. Ann Card Anaesth 2017; 19:399-404. [PMID: 27397442 PMCID: PMC4971966 DOI: 10.4103/0971-9784.185518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Abdominal complications being rare but results in high mortality, commonly due to splanchnic organ hypoperfusion during the perioperative period of cardiac surgery. There are no feasible methods to monitor intraoperative superior mesenteric artery blood flow (SMABF). Hence, the aim of this study was to evaluate the feasibility and to measure SMABF using transesophageal echocardiography (TEE) during cardiac surgery under hypothermic cardiopulmonary bypass (CPB). Methodology: Thirty-five patients undergoing elective cardiac surgery under CPB were enrolled. Heart rate, mean arterial pressure (MAP), cardiac output (CO), SMABF, superior mesenteric artery (SMA) diameter, superior mesentric artery blood flow over cardiac output (SMA/CO) ratio and arterial blood lactates were recorded at three time intervals. T0: before sternotomy, T1: 30 min after initiation of CPB and T2: after sternal closure. Results: SMA was demonstrated in 32 patients. SMABF, SMA diameter, SMA/CO, MAP and CO decreased significantly (P < 0.0001) between T0 and T1, increased significantly (P ≤ 0.001) between T0 and T2. Lactates increased progressively from T0 to T2. Conclusion: Study shows that there is decrease in SMABF during CPB and returns to baseline after CPB. Hence, it is feasible to measure SMABF using TEE in patients undergoing cardiac surgery under hypothermic CPB. TEE can be a promising tool in detecting and preventing splanchnic hypoperfusion during perioperative period.
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Affiliation(s)
- Naveen G Singh
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - P S Nagaraja
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Divya Gopal
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - V Manjunath
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - K S Nagesh
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - N Manjunatha
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Guru Police Patel
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Satish Kumar Mishra
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
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Kim HA, Yi HA, Hong JH, Lee H. Detailed Relationship Between the Pattern of Blood Pressure Change During the Valsalva Maneuver and the Degree of Orthostatic Hypotension During the Head-Up Tilt Test in Patients With Orthostatic Intolerance: A Retrospective Case-Control Study. Medicine (Baltimore) 2016; 95:e3608. [PMID: 27175668 PMCID: PMC4902510 DOI: 10.1097/md.0000000000003608] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 04/06/2016] [Accepted: 04/12/2016] [Indexed: 11/25/2022] Open
Abstract
Although the head-up tilt (HUT) test and Valsalva maneuver (VM) have been widely used to identify sympathetic adrenergic impairment, the detailed relationship between the degree of orthostatic hypotension (OH) during the HUT test and the pattern of blood pressure (BP) change during the VM remains unknown. This study was performed to investigate the relationship between the degree of OH during the HUT test and the pattern of BP change during the VM. During a 4-year period, a total of 132 consecutive patients with neurogenic OH and 60 healthy controls were enrolled. The degree of OH was defined as mild (associated with a fall in systolic BP [SBP] ≥ 20 < 30 on tilting, n = 49), moderate (associated with a fall in SBP ≥ 30 < 40 on tilting, n = 43), and severe (associated with a fall in SBP ≥ 40 on tilting, n = 40). A standardized battery of autonomic tests, including the HUT test and VM using Finometer devices for recording beat-to-beat BP and heart rate response, and a quantitative sudomotor axon reflex test, was performed. Sympathetic indexes (SIs 1-6) were calculated from the VM. A composite autonomic severity score (CASS) was also obtained to evaluate the severity and distribution of autonomic dysfunction. The degree of OH was compared with the BP decline and recovery during the VM. All indexes exhibited overall significant differences among tested groups (P < 0.001). Only SI 3 differentiated all subject groups. Compared with other SIs, SI 3 was best correlated with the amount of decrease in the mean SBP (R = 0.473, P < 0.001) on tilting. The decrease in mean SBP on tilting was best correlated with CASS adrenergic subscore. SI 3 can differentiate between groups with different degrees of OH. The SI 3 obtained during VM can improve the diagnostic accuracy of autonomic dysfunction in patients with different degree of OH.
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Affiliation(s)
- Hyun-Ah Kim
- From the Department of Neurology (H-AK, H-AY,J-HH, HL) and Brain Research Institute (H-AK, H-AY, J-HH, HL), Keimyung University School of Medicine, Daegu, Republic of Korea
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Low PA, Tomalia VA. Orthostatic Hypotension: Mechanisms, Causes, Management. J Clin Neurol 2015; 11:220-6. [PMID: 26174784 PMCID: PMC4507375 DOI: 10.3988/jcn.2015.11.3.220] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 01/20/2015] [Accepted: 01/20/2015] [Indexed: 12/13/2022] Open
Abstract
Orthostatic hypotension (OH) occurs when mechanisms for the regulation of orthostatic BP control fails. Such regulation depends on the baroreflexes, normal blood volume, and defenses against excessive venous pooling. OH is common in the elderly and is associated with an increase in mortality rate. There are many causes of OH. Aging coupled with diseases such as diabetes and Parkinson's disease results in a prevalence of 10-30% in the elderly. These conditions cause baroreflex failure with resulting combination of OH, supine hypertension, and loss of diurnal variation of BP. The treatment of OH is imperfect since it is impossible to normalize standing BP without generating excessive supine hypertension. The practical goal is to improve standing BP so as to minimize symptoms and to improve standing time in order to be able to undertake orthostatic activities of daily living, without excessive supine hypertension. It is possible to achieve these goals with a combination of fludrocortisone, a pressor agent (midodrine or droxidopa), supplemented with procedures to improve orthostatic defenses during periods of increased orthostatic stress. Such procedures include water bolus treatment and physical countermaneuvers. We provide a pragmatic guide on patient education and the patient-orientated approach to the moment to moment management of OH.
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Affiliation(s)
- Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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12
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Loavenbruck A, Iturrino J, Singer W, Sletten DM, Low PA, Zinsmeister AR, Bharucha AE. Disturbances of gastrointestinal transit and autonomic functions in postural orthostatic tachycardia syndrome. Neurogastroenterol Motil 2015; 27:92-8. [PMID: 25483980 PMCID: PMC4286289 DOI: 10.1111/nmo.12480] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 11/06/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastrointestinal symptoms are common in the postural orthostatic tachycardia syndrome (POTS). However, few studies have evaluated gastrointestinal transit in POTS. Our primary objectives were to evaluate gastrointestinal emptying and the relationship with autonomic dysfunctions in POTS. METHODS We reviewed the complete medical records of all patients aged 18 years and older with POTS diagnosed by a standardized autonomic reflex screen who also had a scintigraphic assessment of gastrointestinal transit at Mayo Clinic Rochester between 1998 and 2012. Associations between specific gastric emptying and autonomic (i.e., cardiovagal, adrenergic, and sudomotor) disturbances were evaluated. KEY RESULTS Among 163 patients (140 women, mean [± SEM] age 30 [± 1] years), 55 (34%) had normal, 30 (18%) had delayed, and 78 (48%) had rapid gastric emptying. Fifty-eight patients (36%) had clinical features of physical deconditioning, which was associated (p = 0.02) with rapid gastric emptying. Associations with delayed gastric emptying included vomiting, which was more common (p < 0.003), and anxiety or depression, which was less common (p = 0.02). The tilt-associated increase in heart rate and reduction in systolic BP at 1 min was associated (p < 0.05), being greater in patients with delayed gastric emptying. CONCLUSIONS & INFERENCES Two-thirds of patients with POTS and GI symptoms had abnormal, most frequently rapid gastric emptying. Except for more severe adrenergic impairment in patients with delayed gastric emptying, the pattern of autonomic dysfunction did not discriminate among gastric emptying groups. Further studies are necessary to ascertain whether extravascular volume depletion and/or deconditioning contribute to POTS in patients with gastrointestinal symptoms.
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Affiliation(s)
| | - Johanna Iturrino
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Program. Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Phillip A. Low
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Adil E. Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Program. Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Abstract
Neurogenic orthostatic hypotension (NOH) is a debilitating condition associated with many central and peripheral neurological disorders. It has a complex pathophysiology and variable clinical presentation, which makes diagnosis and treatment difficult. Neurogenic orthostatic hypotension is often confused with other disorders of orthostatic intolerance, hypovolemic states and systemic conditions. Diagnosis is usually made by an autonomic specialist following characteristic responses to head-up tilt. Symptom control can be achieved through a combination of patient education, nonpharmacologic and pharmacologic therapy. The purpose of this review is to provide the clinician with a practical approach to the diagnosis and management of NOH.
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Park KJ, Singer W, Sletten DM, Low PA, Bharucha AE. Gastric emptying in postural tachycardia syndrome: a preliminary report. Clin Auton Res 2013; 23:163-7. [PMID: 23708963 DOI: 10.1007/s10286-013-0193-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 03/25/2013] [Indexed: 12/22/2022]
Abstract
PURPOSE Autonomic neuropathy is widely recognized to be associated with upper gastrointestinal symptoms and abnormal (i.e., rapid or slow) gastric emptying. While patients with postural orthostatic tachycardia syndrome (POTS) may also have gastrointestinal symptoms, our understanding of gastric-emptying disturbances in POTS is very limited. The objectives of this study were to evaluate the relationship between gastric-emptying disturbances and gastrointestinal symptoms in patients with POTS. METHODS We retrospectively reviewed the medical records of 22 well-characterized patients with POTS and upper gastrointestinal symptoms in whom autonomic (i.e., postganglionic sudomotor, cardiovagal, and adrenergic) functions and gastric emptying were evaluated using standardized techniques and scintigraphy, respectively. Medical records were reviewed retrospectively to assess clinical features, gastric emptying, and autonomic functions. RESULTS Over 70 % of patients had nausea and/or vomiting, which was the most common GI symptom; other common symptoms were abdominal pain (59 %), bloating (55 %), and postprandial fullness/early satiety (46 %). Over one-third of patients had abnormal [i.e., rapid (27 %) or delayed (9 %)] gastric emptying. Gastric-emptying disturbances were not significantly associated with GI symptoms, autonomic symptoms or autonomic dysfunction. CONCLUSIONS Over one-third of patients with POTS and gastrointestinal symptoms have abnormal, more frequently rapid than delayed gastric emptying. These findings need to be confirmed in a larger cohort of patients.
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Affiliation(s)
- Ki-Jong Park
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
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Taubel J, Wong AH, Naseem A, Ferber G, Camm AJ. Shortening of the QT Interval After Food Can Be Used to Demonstrate Assay Sensitivity in Thorough QT Studies. J Clin Pharmacol 2013; 52:1558-65. [DOI: 10.1177/0091270011419851] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Osada T, Nagata H, Murase N, Kime R, Katsumura T. Determination of comprehensive arterial blood inflow in abdominal-pelvic organs: impact of respiration and posture on organ perfusion. Med Sci Monit 2011; 17:CR57-66. [PMID: 21278689 PMCID: PMC3524711 DOI: 10.12659/msm.881388] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Arterial blood flow (BF) to all abdominal-pelvic organs (AP) shows potential for an indicator of comprehensive splanchnic organ circulation (reservoir of blood supply for redistribution) in cardiovascular disease, hepato-gastrointestinal disease or hemodynamic disorders. Our previous assessment of splanchnic hemodynamics, as magnitude of BFAP [measuring by subtracting BF in both femoral arteries (FAs) from the upper abdominal aorta (Ao) above the celiac trunk] using Doppler ultrasound, was reported as the relationship between Ao and FAs, day-to-day variability and response to exercise. For accurate determination of BFAP, it is important to consider the various factors that potentially influence BFAP. However, little information exists regarding the influence of respiration (interplay between inspiration and expiration) and posture on BFAP. Material/Methods Ten healthy males were evaluated in sitting/supine positions following a 12 hr fast. Magnitude of BFAP was determined as measurement of Ao and FAs hemodynamics (blood velocity and vessel diameter) using pulsed Doppler with spectral analysis during spontaneous 4-sec inspiration/4-sec expiration phases. Results BF/blood velocity in the Ao and FAs showed significant lower in inspiration than expiration. BFAP showed a significant (P<0.005) reduction of ~20% in inspiratory phase (sitting, 2213±222 ml/min; supine, 2059±215 ml/min) compared with expiratory phase (sitting, 2765±303 ml/min; supine, 2539±253 ml/min), with no difference between sitting and supine. Conclusions Respiratory-related to alterations in BFAP were observed. It may be speculated that changes in intra-abdominal pressure during breathing (thoracic-abdominal movement) is possibly reflecting transient changes in blood velocity in the Ao and FAs. Respiratory effects should be taken into account for evaluation of BFAP.
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Affiliation(s)
- Takuya Osada
- Department of Sports Medicine for Health Promotion, Tokyo Medical University, Tokyo, Japan.
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Cui J, Shibasaki M, Low DA, Keller DM, Davis SL, Crandall CG. Heat stress attenuates the increase in arterial blood pressure during the cold pressor test. J Appl Physiol (1985) 2010; 109:1354-9. [PMID: 20798269 DOI: 10.1152/japplphysiol.00292.2010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The mechanisms by which heat stress impairs the control of blood pressure leading to compromised orthostatic tolerance are not thoroughly understood. A possible mechanism may be an attenuated blood pressure response to a given increase in sympathetic activity. This study tested the hypothesis that whole body heating attenuates the blood pressure response to a non-baroreflex-mediated sympathoexcitatory stimulus. Ten healthy subjects were instrumented for the measurement of integrated muscle sympathetic nerve activity (MSNA), mean arterial blood pressure (MAP), heart rate, sweat rate, and forearm skin blood flow. Subjects were exposed to a cold pressor test (CPT) by immersing a hand in an ice water slurry for 3 min while otherwise normothermic and while heat stressed (i.e., increase core temperature ~0.7°C via water-perfused suit). Mean responses from the final minute of the CPT were evaluated. In both thermal conditions CPT induced significant increases in MSNA and MAP without altering heart rate. Although the increase in MSNA to the CPT was similar between thermal conditions (normothermia: Δ14.0 ± 2.6; heat stress: Δ19.1 ± 2.6 bursts/min; P = 0.09), the accompanying increase in MAP was attenuated when subjects were heat stressed (normothermia: Δ25.6 ± 2.3, heat stress: Δ13.4 ± 3.0 mmHg; P < 0.001). The results demonstrate that heat stress can attenuate the pressor response to a sympathoexcitatory stimulus.
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Affiliation(s)
- Jian Cui
- Institute for Exercise and Environmental Medicine, Presbyterian Hospital of Dallas, TX 75231, USA
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On non-invasive measurement of gastric motility from finger photoplethysmographic signal. Ann Biomed Eng 2010; 38:3744-55. [PMID: 20614246 DOI: 10.1007/s10439-010-0113-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 06/22/2010] [Indexed: 10/19/2022]
Abstract
This article investigates the possibility of extracting gastric motility (GM) information from finger photoplethysmographic (PPG) signals non-invasively. Now-a-days measuring GM is a challenging task because of invasive and complicated clinical procedures involved. It is well-known that the PPG signal acquired from finger consists of information related to heart rate and respiratory rate. This thread is taken further and effort has been put here to find whether it is possible to extract GM information from finger PPG in an easier way and without discomfort to the patients. Finger PPG and GM (measured using Electrogastrogram, EGG) signals were acquired simultaneously at the rate of 100 Hz from eight healthy subjects for 30 min duration in fasting and postprandial states. In this study, we process the finger PPG signal and extract a slow wave that is analogous to actual EGG signal. To this end, we chose two advanced signal processing approaches: first, we perform discrete wavelet transform (DWT) to separate the different components, since PPG and EGG signals are non-stationary in nature. Second, in the frequency domain, we perform cross-spectral and coherence analysis using autoregressive (AR) spectral estimation method in order to compare the spectral details of recorded PPG and EGG signals. In DWT, a lower frequency oscillation (≈0.05 Hz) called slow wave was extracted from PPG signal which looks similar to the slow wave of GM in both shape and frequency in the range (0-0.1953) Hz. Comparison of these two slow wave signals was done by normalized cross-correlation technique. Cross-correlation values are found to be high (range 0.68-0.82, SD 0.12, R = 1.0 indicates exact agreement, p < 0.05) for all subjects and there is no significant difference in cross-correlation between fasting and postprandial states. The coherence analysis results demonstrate that a moderate coherence (range 0.5-0.7, SD 0.13, p < 0.05) exists between EGG and PPG signal in the "slow wave" frequency band, without any significant change in the level of coherence in postprandial state. These results indicate that finger PPG signal contains GM-related information. The findings are sufficiently encouraging to motivate further exploration of finger PPG as a non-invasive source of GM-related information.
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Uchino M, Ito K, Kuwahara M, Ebukuro S, Tsubone H. Interactions of carotid sinus or aortic input with emetic signals from gastric afferents and vestibular system. Auton Neurosci 2008; 144:36-42. [DOI: 10.1016/j.autneu.2008.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2008] [Revised: 08/07/2008] [Accepted: 09/12/2008] [Indexed: 02/06/2023]
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Abstract
Orthostatic hypotension (OH) is common in elderly people and in patients with disorders such as diabetes and Parkinson's disease. Grading of the severity of OH and its effect on the patient's quality of life are important. The symptoms vary with orthostatic stress, and subtle symptoms such as tiredness and cognitive impairment should be recognised. Standard drug treatment for OH is effective but worsens supine hypertension, whereas pyridostigmine can improve OH slightly but significantly without worsening of supine hypertension. Because orthostatic stress varies from moment to moment and drug treatment is suboptimal, drug treatment of OH needs to be combined with non-pharmacological approaches, such as compression of venous capacitance beds, use of physical counter-manoeuvres, and intermittent water-bolus treatment.
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Affiliation(s)
- Phillip A Low
- Department of Neurology, Mayo Clinic Rochester, MN 55905, USA.
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21
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Abstract
The human colon serves to absorb water and electrolytes, store intraluminal contents until elimination is socially convenient, and salvage nutrients by bacterial metabolism of carbohydrates that have not been absorbed in the small intestine. The anorectum is responsible for fecal continence and defecation. This article is a broad perspective of the current status and a personal perspective of future challenges in understanding lower gastrointestinal functions in health and disease in humans.
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Affiliation(s)
- A E Bharucha
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), Mayo Clinic, Rochester, MN 55905, USA.
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22
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van Orshoven NP, van Schelven LJ, Akkermans LMA, Jansen PAF, Horowitz M, Feinle-Bisset C, van Huffelen AC, Oey PL. The effect of intraduodenal glucose on muscle sympathetic nerve activity in healthy young and older subjects. Clin Auton Res 2008; 18:28-35. [PMID: 18236004 DOI: 10.1007/s10286-008-0452-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 11/19/2007] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The cardiovascular response to a meal is modulated by gastric distension and the interaction of nutrients, particularly carbohydrate, within the small intestine. We tested the hypothesis that the depressor effect of small intestinal glucose is greater in older than in young subjects, because the reflex increase in muscle sympathetic nerve activity (MSNA) is blunted by age. METHODS The effects of intraduodenal glucose infusion (IDGI) on blood pressure, heart rate and MSNA were evaluated in eight healthy young subjects (4 women; mean age +/- SEM: 28.8 +/- 3.4 years), eight healthy elderly (4 women; 75.3 +/- 1.6 years) and in two patients with symptomatic postprandial hypotension (PPH), one young (21 years), and one old (90 years). RESULTS In both young and elderly healthy subjects, IDGI decreased blood pressure (P < 0.05), but the fall in systolic blood pressure was greater in the older subjects (-17.0 +/- 4.1 vs. -6.5 +/- 1.6 mmHg, P < 0.03). MSNA increased similarly, after infusion in both young (9.0 +/- 3.4 bursts/min) and elderly (7.8 +/- 1.0 bursts/min) subjects. Baroreflex sensitivity for number of sympathetic bursts was attenuated in the elderly (P < 0.03). The increase in burst area in the young patient with PPH was attenuated (18 vs. 63% in the healthy young group). INTERPRETATION The fall in BP induced by IDGI was greater in healthy elderly compared to healthy young subjects. The reason for this is unclear, as they have similar increases in MSNA.
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Affiliation(s)
- Narender P van Orshoven
- Department of Clinical Neurophysiology, Rudolf Magnus Institute of Neuroscience, Utrecht, The Netherlands
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Wilson TE, Sauder CL, Kearney ML, Kuipers NT, Leuenberger UA, Monahan KD, Ray CA. Skin-surface cooling elicits peripheral and visceral vasoconstriction in humans. J Appl Physiol (1985) 2007; 103:1257-62. [PMID: 17673561 DOI: 10.1152/japplphysiol.00401.2007] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Skin-surface cooling elicits a pronounced systemic pressor response, which has previously been reported to be associated with peripheral vasoconstriction and may not fully account for the decrease in systemic vascular conductance. To test the hypothesis that whole body skin-surface cooling would also induce renal and splanchnic vasoconstriction, 14 supine subjects performed 26 skin-surface cooling trials (15-18 degrees C water perfused through a tube-lined suit for 20 min). Oral and mean skin temperature, heart rate, stroke volume (Doppler ultrasound), mean arterial blood pressure (MAP), cutaneous blood velocity (laser-Doppler), and mean blood velocity of the brachial, celiac, renal, and superior mesenteric arteries (Doppler ultrasound) were measured during normothermia and skin-surface cooling. Cardiac output (heart rate x stroke volume) and indexes of vascular conductance (flux or blood velocity/MAP) were calculated. Skin-surface cooling increased MAP (n = 26; 78 +/- 5 to 88 +/- 5 mmHg; mean +/- SD) and decreased mean skin temperature (n = 26; 33.7 +/- 0.7 to 27.5 +/- 1.2 degrees C) and cutaneous (n = 12; 0.93 +/- 0.68 to 0.36 +/- 0.20 flux/mmHg), brachial (n = 10; 32 +/- 15 to 20 +/- 12), celiac (n = 8; 85 +/- 22 to 73 +/- 22 cm.s(-1).mmHg(-1)), superior mesenteric (n = 8; 55 +/- 16 to 48 +/- 10 cm.s(-1).mmHg(-1)), and renal (n = 8; 74 +/- 26 to 64 +/- 20 cm.s(-1).mmHg(-1); all P < 0.05) vascular conductance, without altering oral temperature, cardiac output, heart rate, or stroke volume. These data identify decreases in vascular conductance of skin and of brachial, celiac, superior mesenteric, and renal arteries. Thus it appears that vasoconstriction in both peripheral and visceral arteries contributes importantly to the pressor response produced during skin-surface cooling in humans.
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Affiliation(s)
- Thad E Wilson
- Heart and Vascular Institute, General Clinical Research Center, Pennsylvania State University College of Medicine, Hershey, PA, USA.
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Vernino S, Low PA. Autonomic Neuropathies. Neurobiol Dis 2007. [DOI: 10.1016/b978-012088592-3/50091-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Fiore G, Brienza N, Cicala P, Tunzi P, Marraudino N, Schinosa LDLT, Fiore T. Superior Mesenteric Artery Blood Flow Modifications During Off-Pump Coronary Surgery. Ann Thorac Surg 2006; 82:62-7. [PMID: 16798189 DOI: 10.1016/j.athoracsur.2006.02.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2005] [Revised: 01/26/2006] [Accepted: 02/02/2006] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients undergoing cardiac surgery are at increased risk of gut hypoperfusion. During off-pump surgery, hemodynamic derangements at the time of heart displacement could reduce splanchnic perfusion, outweighing the beneficial effects of avoiding cardiopulmonary bypass. The purpose of this study is to assess, prospectively, blood flow modifications in the superior mesenteric artery during off-pump surgery using transesophageal echocardiography. METHODS In 19 patients undergoing multivessel elective off-pump coronary revascularization, systemic hemodynamics and superior mesenteric flow were assessed. Blood flow in the superior mesenteric artery was evaluated with duplex ultrasound using a transesophageal echo probe. Measurements were made four times: T0 (baseline), T1 (left anterior descendent anastomosis), T2 (heart displacement to expose the inferolateral and inferior walls), and T3 (closed chest, at the end of surgery). RESULTS Superior mesenteric blood flow significantly decreased at T2 (from 426.4 +/- 83.1 mL to 212.9 +/- 48.6 mL, p < 0.001), when also cardiac output was reduced. The percentage of the cardiac output directed toward the mesenteric arterial bed was also decreased at this time. At the end of surgery (T3), whereas cardiac output returned to the initial values, mesenteric flow was significantly increased compared with baseline, with a higher percentage of the systemic output flowing through the superior mesenteric artery. CONCLUSIONS Hemodynamic changes during off-pump coronary surgery induce a significant mesenteric hypoperfusion followed by a hyperemic response at the end of surgery. Transesophageal echo-Doppler allows the intraoperative measurement of blood flow distribution to splanchnic viscera.
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Affiliation(s)
- Giuseppe Fiore
- Dipartimento dell'Emergenza e Trapianti d'Organo, Azienda Ospedaliero-Universitaria Policlinico, Bari, Italy.
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Cheshire WP, Meschia JF. Postprandial limb-shaking: an unusual presentation of transient cerebral ischemia. Clin Auton Res 2006; 16:243-6. [PMID: 16763755 DOI: 10.1007/s10286-006-0344-5] [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] [Received: 06/18/2005] [Accepted: 03/23/2006] [Indexed: 10/24/2022]
Abstract
We describe a 61-year-old woman with complete occlusion of the left carotid artery who presented with shaking of the right limbs after eating. She was found to have profound postprandial hypotension, and the episodes were interpreted as an unusual transient ischemic attack.
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Affiliation(s)
- William P Cheshire
- Dept. of Neurology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224, USA.
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Uchino M, Kuwahara M, Ebukuro S, Tsubone H. Modulation of emetic response by carotid baro- and chemoreceptor activations. Auton Neurosci 2006; 128:25-36. [PMID: 16490404 DOI: 10.1016/j.autneu.2005.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2005] [Revised: 12/08/2005] [Accepted: 12/19/2005] [Indexed: 11/19/2022]
Abstract
We hypothesized that baroreceptor or chemoreceptor activation might be involved in the emetic, and prodromal cardiovascular and respiratory responses. To test this hypothesis, we induced the emetic responses by gastric distension in anesthetized Suncus murinus (house musk shrew), that had intact and absent baroreceptor and chemoreceptor afferents. Secondly, we stimulated the aortic depressor nerve (ADN) and the carotid sinus nerve (CSN) with or without gastric distension. Internal carotid artery ligation in the bifurcation area, which abolished reflex bradycardia by baroreceptor activation, and abolition of chemoreceptor reflex bradycardia and hyperventilation, by carotid body denervation, suppressed the emetic response but did not abolish it. ADN denervation, which produced no significant effects on the baroreceptor or chemoreceptor reflex bradycardia, had no effect on the emetic response, including the prodromal phase. CSN stimulation with gastric distension elicited retching accompanied by reflex bradycardia and hypotension during or just after stimulation, whereas ADN stimulation with gastric distension did not induce the cardiovascular reflex, and had no effects on the emetic response. These results indicate that carotid, rather than aortic, baroreceptor or chemoreceptor activation plays an important role in the augmentation of cardiac parasympathetic activity and the development of emetic response. In conclusion, carotid baroreceptor or chemoreceptor activation, which is non-emetic stimulation, acts as a modulator in the central mechanisms of emesis.
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Affiliation(s)
- Masahiro Uchino
- Department of Comparative Pathophysiology, Graduate School of Agricultural and Life Sciences, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan.
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van Orshoven NP, Oey PL, van Schelven LJ, Roelofs JMM, Jansen PAF, Akkermans LMA. Effect of gastric distension on cardiovascular parameters: gastrovascular reflex is attenuated in the elderly. J Physiol 2004; 555:573-83. [PMID: 14724212 PMCID: PMC1664840 DOI: 10.1113/jphysiol.2003.056580] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/28/2003] [Accepted: 01/06/2004] [Indexed: 12/22/2022] Open
Abstract
Stretching the stomach wall in young healthy subjects causes an increase in muscle sympathetic nerve activity and in blood pressure, the gastrovascular reflex. We compared healthy elderly subjects with healthy young subjects to find out whether the gastrovascular reflex attenuates in normal ageing and we studied whether there was a difference in autonomic function or gastric compliance that could explain this possible attenuation. Muscle sympathetic nerve activity, finger blood pressure and heart rate were continuously recorded during stepwise isobaric gastric distension using a barostat in eight healthy young (6 men and 2 women, 27 +/- 3.2 years, mean +/-s.e.m.) and eight healthy elderly subjects (7 men and 1 woman, 76 +/- 1.5 years). Changes in cardiac output and total peripheral arterial resistance were calculated from the blood pressure signal. The baseline mean arterial pressure and muscle sympathetic nerve activity were higher in the elderly group (both P < 0.05) and muscle sympathetic nerve activity increase during the cold pressor test was lower in the elderly group (P = 0.005). During stepwise gastric distension, the elderly subjects showed an attenuated increase in muscle sympathetic nerve activity compared to the young subjects (P < 0.01). The older group tended to show a higher increase in mean arterial pressure (P = 0.08), heart rate (P = 0.06) and total peripheral arterial resistance (P = 0.09) The cardiac output rose slightly in both groups without significant difference between groups. The fundic compliance did not differ between groups. We conclude that stepwise gastric distension caused an increase in muscle sympathetic nerve activity in both groups, but the increase in the elderly was attenuated.
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Affiliation(s)
- N P van Orshoven
- Rudolf Magnus Institute of Neuroscience, Department of Neurology and Neurosurgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Tani H, Singer W, McPhee BR, Opfer-Gehrking TL, Haruma K, Kajiyama G, Low PA. Splanchnic-mesenteric capacitance bed in the postural tachycardia syndrome (POTS). Auton Neurosci 2000; 86:107-13. [PMID: 11269915 DOI: 10.1016/s1566-0702(00)00205-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Gastroenterologic symptoms are common in the postural tachycardia syndrome (POTS), and postprandial worsening of orthostatic symptoms often occurs. We, therefore, investigated splanchnic-mesenteric vasoregulation in POTS. SUBJECTS AND METHODS Eleven patients with POTS (one man, 10 women, 29.4 +/- 7.7 (S.D.) years) and 10 controls (two men, eight women, 27.9 +/- 5.6 years) participated in this study. The protocol included 5 min of 70 degrees head-up tilt (HUT) before and after a liquid meal, as well as 1.5 min of hyperventilation. Blood pressure (BP), heart rate (HR), endtidal CO2, and cardiovascular indices derived from thoracic electrical bioimpedance were continuously monitored. Superior mesenteric artery (SMA) blood flow was measured by real time Doppler ultrasound and analyzed off-line. Cross-sectional area of SMA (SMA-area) and time-averaged velocity (SMA-TAV) were measured; SMA blood flow (SMA-BF) and vascular resistance (SMA-VR) were derived. RESULTS The following significant results were found: at supine rest, the POTS group had higher HR, BP, SMA-TAV and SMA-BF and a lower SMA-VR than the control group. HUT resulted in a reduction of pulse pressure, CO2 level, SMA-area, SMA-TAV and SMA-VF and increment of HR and SMA-VR in both groups. The POTS group underwent greater increment of HR and greater reduction of CO2 than controls. Hyperventilation induced increment of HR and cardiac index (CI) and reduction of SMA-VR in controls; no significant change occurred in POTS. The test meal induced increments of HR, CI, SMA-area, SMA-TAV and SMA-VF and reduction of SMA-VR in patients and controls for both supine rest and HUT. CONCLUSION The main novel observations of increased resting SMA-BF, SMA-TAV supine, and reduced SMA-VR when compared with controls support the notion that there is excessive splanchnic capacity (pooling) at rest in POTS.
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Affiliation(s)
- H Tani
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Abstract
A limited autonomic neuropathy may underlie some unusual clinical syndromes, including the postural tachycardia syndrome, pseudo-obstruction syndrome, heat intolerance, and perhaps chronic fatigue syndrome. Antibodies to autonomic structures are common in diabetes, but their specificity is unknown. The presence of autonomic failure worsens prognosis in the diabetic state. Some autonomic neuropathies are treatable. Familial amyloid polyneuropathy may respond to liver transplantation. There are anecdotal reports of acute panautonomic neuropathy responding to intravenous gamma globulin. Orthostatic hypotension may respond to erythropoietin or midodrine.
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Affiliation(s)
- P A Low
- Mayo Medical School, Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
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