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Lee MJ, Park JS, Kim K, Ko JM, Park JD, Suh DI. Congenital central hypoventilation syndrome in korea: 20 years of clinical observation and evaluation of the ventilation strategy in a single center. Eur J Pediatr 2024; 183:3479-3487. [PMID: 38780650 PMCID: PMC11263406 DOI: 10.1007/s00431-024-05611-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/20/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024]
Abstract
Congenital central hypoventilation syndrome (CCHS) is a rare genetic disorder characterized by hypoventilation due to impaired breathing control by the central nervous system and other symptoms of autonomic dysfunction. Mutations in paired-like homeobox 2 B (PHOX2B) are responsible for most cases of CCHS. Patients with CCHS have various phenotypes and severities, making the diagnosis difficult. This study aimed to present a comprehensive single-center experience of patients with CCHS, including key clinical features, treatment strategies, and outcomes. A retrospective chart review was performed for patients diagnosed with CCHS between January 2001 and July 2023 at Seoul National University Children's Hospital. Finally, we selected 24 patients and collected their demographic data, genotypes, ventilation methods, and clinical features related to autonomic dysfunction. The relationship between the clinical manifestations and genotypes was also examined. All patients used home ventilators, and tracheostomy was performed in 87.5% of patients. Fifteen (62.5%) patients had constipation and nine (37.5%) were diagnosed with Hirschsprung disease. Arrhythmia, endocrine dysfunction, and subclinical hypothyroidism were present in nine (37.5%), six patients (25.0%), and two patients (16.7%), respectively. A significant number of patients exhibited neurodevelopmental delays (19 patients, 79.2%). There was a correlation between the phenotype and genotype of PHOX2B in patients with CCHS. (r = 0.71, p < 0.001). Conclusion: There was a positive correlation between paired-like homeobox 2 B mutations (especially the number of GCN repeats in the polyalanine repeat mutations sequence) and clinical manifestations. This study also demonstrated how initial treatment for hypoventilation affects neurodevelopmental outcomes in patients with CCHS. What is Known: • Congenital central hypoventilation syndrome is a rare genetic disorder characterized by hypoventilation and dysfunction of autonomic nervous system. • The disease-defining gene of CCHS is PHOX2B gene - most of the cases have heterozygous PARMs and the number of GCN triplets varies among the patients(20/24 - 20/33). What is New: • We have noted in the Korean patients with CCHS that there is a correlation between genotype (number of GCN repeats) and severity of phenotype. • National support for rare diseases allowed for a prompter diagnosis of patients with CCHS in Korean population.
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Affiliation(s)
- Min Jeong Lee
- Department of Pediatrics, Seoul National University College of Medicine 101, Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Ji Soo Park
- Department of Pediatrics, Seoul National University College of Medicine 101, Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea.
| | - Kyunghoon Kim
- Department of Pediatrics, Seoul National University College of Medicine 101, Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jung Min Ko
- Department of Pediatrics, Seoul National University College of Medicine 101, Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine 101, Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University College of Medicine 101, Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
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Calignano G, Girardi P, Altoè G. First steps into the pupillometry multiverse of developmental science. Behav Res Methods 2024; 56:3346-3365. [PMID: 37442879 PMCID: PMC11133157 DOI: 10.3758/s13428-023-02172-8] [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] [Accepted: 06/14/2023] [Indexed: 07/15/2023]
Abstract
Pupillometry has been widely implemented to investigate cognitive functioning since infancy. Like most psychophysiological and behavioral measures, it implies hierarchical levels of arbitrariness in preprocessing before statistical data analysis. By means of an illustrative example, we checked the robustness of the results of a familiarization procedure that compared the impact of audiovisual and visual stimuli in 12-month-olds. We adopted a multiverse approach to pupillometry data analysis to explore the role of (1) the preprocessing phase, that is, handling of extreme values, selection of the areas of interest, management of blinks, baseline correction, participant inclusion/exclusion and (2) the modeling structure, that is, the incorporation of smoothers, fixed and random effects structure, in guiding the parameter estimation. The multiverse of analyses shows how the preprocessing steps influenced the regression results, and when visual stimuli plausibly predicted an increase of resource allocation compared with audiovisual stimuli. Importantly, smoothing time in statistical models increased the plausibility of the results compared to those nested models that do not weigh the impact of time. Finally, we share theoretical and methodological tools to move the first steps into (rather than being afraid of) the inherent uncertainty of infant pupillometry.
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Affiliation(s)
- Giulia Calignano
- Department of Developmental and Social Psychology, University of Padua, Padua, Italy.
| | - Paolo Girardi
- Department of Developmental and Social Psychology, University of Padua, Padua, Italy
- Department of Environmental Sciences Informatics and Statistics, Ca' Foscari University, Venice, Italy
| | - Gianmarco Altoè
- Department of Developmental and Social Psychology, University of Padua, Padua, Italy
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Slattery SM, Perez IA, Ceccherini I, Chen ML, Kurek KC, Yap KL, Keens TG, Khaytin I, Ballard HA, Sokol EA, Mittal A, Rand CM, Weese-Mayer DE. Transitional care and clinical management of adolescents, young adults, and suspected new adult patients with congenital central hypoventilation syndrome. Clin Auton Res 2023; 33:231-249. [PMID: 36403185 DOI: 10.1007/s10286-022-00908-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/31/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE With contemporaneous advances in congenital central hypoventilation syndrome (CCHS), recognition, confirmatory diagnostics with PHOX2B genetic testing, and conservative management to reduce the risk of early morbidity and mortality, the prevalence of identified adolescents and young adults with CCHS and later-onset (LO-) CCHS has increased. Accordingly, there is heightened awareness and need for transitional care of these patients from pediatric medicine into a multidisciplinary adult medical team. Hence, this review summarizes key clinical and management considerations for patients with CCHS and LO-CCHS and emphasizes topics of particular importance for this demographic. METHODS We performed a systematic review of literature on diagnostics, pathophysiology, and clinical management in CCHS and LO-CCHS, and supplemented the review with anecdotal but extensive experiences from large academic pediatric centers with expertise in CCHS. RESULTS We summarized our findings topically for an overview of the medical care in CCHS and LO-CCHS specifically applicable to adolescents and adults. Care topics include genetic and embryologic basis of the disease, clinical presentation, management, variability in autonomic nervous system dysfunction, and clarity regarding transitional care with unique considerations such as living independently, family planning, exposure to anesthesia, and alcohol and drug use. CONCLUSIONS While a lack of experience and evidence exists in the care of adults with CCHS and LO-CCHS, a review of the relevant literature and expert consensus provides guidance for transitional care areas.
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Affiliation(s)
- Susan M Slattery
- Center for Autonomic Medicine in Pediatrics (CAMP), Division of Autonomic Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Center, 225 E. Chicago Ave, Box #165, Chicago, IL, 60611, USA.
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Iris A Perez
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Isabella Ceccherini
- Laboratory of Genetics and Genomics of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maida L Chen
- Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Kyle C Kurek
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada
| | - Kai Lee Yap
- Molecular Diagnostics Laboratory, Department of Pathology & Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Thomas G Keens
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Ilya Khaytin
- Center for Autonomic Medicine in Pediatrics (CAMP), Division of Autonomic Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Center, 225 E. Chicago Ave, Box #165, Chicago, IL, 60611, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Heather A Ballard
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Anesthesia, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Elizabeth A Sokol
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Hematology/Oncology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Angeli Mittal
- Center for Autonomic Medicine in Pediatrics (CAMP), Division of Autonomic Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Center, 225 E. Chicago Ave, Box #165, Chicago, IL, 60611, USA
| | - Casey M Rand
- Center for Autonomic Medicine in Pediatrics (CAMP), Division of Autonomic Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Center, 225 E. Chicago Ave, Box #165, Chicago, IL, 60611, USA
| | - Debra E Weese-Mayer
- Center for Autonomic Medicine in Pediatrics (CAMP), Division of Autonomic Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Center, 225 E. Chicago Ave, Box #165, Chicago, IL, 60611, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Dudoignon B, Denjoy I, Patout M, Matrot B, Gallego J, Bokov P, Delclaux C. Heart rate variability in congenital central hypoventilation syndrome: relationships with hypertension and sinus pauses. Pediatr Res 2023; 93:1003-1009. [PMID: 35882978 DOI: 10.1038/s41390-022-02215-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/06/2022] [Accepted: 07/09/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Autonomic nervous system (ANS) dysregulation has been described in congenital central hypoventilation syndrome (CCHS). The objectives were to describe heart rate variability (HRV) analyses in children suffering from CCHS both while awake and asleep and their relationships with both ambulatory blood pressure (BP) and ECG monitoring results. METHODS This retrospective study enrolled children with CCHS (n = 33, median age 8.4 years, 18 girls) who had BP and ECG monitored during the same 24 h. From the latter, HRV analyses were obtained during daytime and nighttime. RESULTS The prevalences of hypertension and sinus pauses were 33% (95% confidence interval [CI]: 18-52) and 18% (95% CI: 7-35), respectively. The decrease in systolic BP at night negatively correlated with an increase in very low frequency (VLF) and LF powers at night, and the longest RR interval positively correlated with daytime VLF and LF powers. Among the three groups of children (polyalanine repeat expansion mutation [PARM], moderate [20/25 and 20/26], severe [20/27 and 20/33], and non-PARMs), the prevalence of elevated BP or hypertension was different: in PARM subjects: 6/18 moderate, 7/9 severe versus 0/6 in non-PARM (p = 0.002). CONCLUSION Modifications of cardiac ANS are associated with systemic hypertension and the occurrence of sinus pauses in CCHS. IMPACT Children with congenital central hypoventilation syndrome (CCHS) exhibit an increased prevalence of hypertension and sinus pauses that are linked to cardiac autonomic nervous system dysfunction. Sinus pauses are the main manifestation of sinus nodal dysfunction in children with CCHS. The increased prevalence of hypertension, especially at nighttime, is a new finding in CCHS. Sinus nodal dysfunction can be due to the sole impairment of the cardiac autonomic nervous system. Ambulatory blood pressure and ECG monitoring are mandatory in patients with CCHS.
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Affiliation(s)
- Benjamin Dudoignon
- Université de Paris, AP-HP, Hôpital Robert Debré, Service de Physiologie Pédiatrique Centre du Sommeil-CRMR Hypoventilations alvéolaires rares, INSERM NeuroDiderot, F-75019, Paris, France
| | - Isabelle Denjoy
- AP-HP, Hôpital Robert Debré, Service de Physiologie Pédiatrique, F-75019, Paris, France
| | - Maxime Patout
- Sorbonne Université, AP-HP, Hôpital de la Pitié-Salpêtrière, Service des Pathologies du Sommeil (Département R3S)-CRMR Hypoventilations centrales congénitales, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France
| | - Boris Matrot
- Université de Paris, INSERM NeuroDiderot, F-75019, Paris, France
| | - Jorge Gallego
- Université de Paris, INSERM NeuroDiderot, F-75019, Paris, France
| | - Plamen Bokov
- Université de Paris, AP-HP, Hôpital Robert Debré, Service de Physiologie Pédiatrique Centre du Sommeil-CRMR Hypoventilations alvéolaires rares, INSERM NeuroDiderot, F-75019, Paris, France
| | - Christophe Delclaux
- Université de Paris, AP-HP, Hôpital Robert Debré, Service de Physiologie Pédiatrique Centre du Sommeil-CRMR Hypoventilations alvéolaires rares, INSERM NeuroDiderot, F-75019, Paris, France.
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Harsono M, Chilakala S, Bohn S, Pivnick EK, Pourcyrous M. A Newborn Infant with Congenital Central Hypoventilation Syndrome and Pupillary Abnormalities: A Literature Review. AJP Rep 2022; 12:e139-e143. [PMID: 36187199 PMCID: PMC9522484 DOI: 10.1055/a-1883-0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/01/2022] [Indexed: 12/02/2022] Open
Abstract
We present a neonate with early onset apnea and bradycardia in the absence of primary cardiorespiratory and central nervous system disorders that eventually required chronic ventilator support starting at 6 hours of life. Molecular testing of paired-like homeobox 2b (PHOX2B) gene mutation confirmed the diagnosis of congenital central hypoventilation syndrome (CCHS). CCHS is a rare genetic disorder characterized by impaired central respiratory control with or without broad spectrum of autonomic nervous system (ANS) dysregulations. Ocular ANS dysregulation is a rare finding in CCHS individuals, and it is usually discovered later in life. However, the ophthalmic evaluation of this neonate on first day of life revealed persistent mild dilated oval pupils with limited light reactivity.
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Affiliation(s)
- Mimily Harsono
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Sandeep Chilakala
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Shiva Bohn
- Division of Pediatric Ophthalmology, Department of Ophthalmology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Eniko K Pivnick
- Division of Pediatric Ophthalmology, Department of Ophthalmology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee.,Division of Medical Genetic, Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Massroor Pourcyrous
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
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Ceccherini I, Kurek KC, Weese-Mayer DE. Developmental disorders affecting the respiratory system: CCHS and ROHHAD. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:53-91. [PMID: 36031316 DOI: 10.1016/b978-0-323-91532-8.00005-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Rapid-onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation (ROHHAD) and Congenital Central Hypoventilation Syndrome (CCHS) are ultra-rare distinct clinical disorders with overlapping symptoms including altered respiratory control and autonomic regulation. Although both disorders have been considered for decades to be on the same spectrum with necessity of artificial ventilation as life-support, recent acquisition of specific knowledge concerning the genetic basis of CCHS coupled with an elusive etiology for ROHHAD have definitely established that the two disorders are different. CCHS is an autosomal dominant neurocristopathy characterized by alveolar hypoventilation resulting in hypoxemia/hypercarbia and features of autonomic nervous system dysregulation (ANSD), with presentation typically in the newborn period. It is caused by paired-like homeobox 2B (PHOX2B) variants, with known genotype-phenotype correlation but pathogenic mechanism(s) are yet unknown. ROHHAD is characterized by rapid weight gain, followed by hypothalamic dysfunction, then hypoventilation followed by ANSD, in seemingly normal children ages 1.5-7 years. Postmortem neuroanatomical studies, thorough clinical characterization, pathophysiological assessment, and extensive genetic inquiry have failed to identify a cause attributable to a traditional genetic basis, somatic mosaicism, epigenetic mechanism, environmental trigger, or other. To find the key to the ROHHAD pathogenesis and to improve its clinical management, in the present chapter, we have carefully compared CCHS and ROHHAD.
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Affiliation(s)
- Isabella Ceccherini
- Laboratory of Genetics and Genomics of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Kyle C Kurek
- Department of Pathology & Laboratory Medicine, University of Calgary, Calgary, AB, Canada
| | - Debra E Weese-Mayer
- Division of Autonomic Medicine, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute; and Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.
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Adolescent Congenital Central Hypoventilation Syndrome: An Easily Overlooked Diagnosis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182413402. [PMID: 34949014 PMCID: PMC8703802 DOI: 10.3390/ijerph182413402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022]
Abstract
Congenital central hypoventilation syndrome (CCHS), also known as Ondine’s curse, is a rare, potentially fatal genetic disease, manifesting as a lack of respiratory drive. Most diagnoses are made in pediatric patients, however late-onset cases have been rarely reported. Due to the milder symptoms at presentation that might easily go overlooked, these late-onset cases can result in serious health consequences later in life. Here, we present a case report of late-onset CCHS in an adolescent female patient. In this review we summarize the current knowledge about symptoms, as well as clinical management of CCHS, and describe in detail the molecular mechanism responsible for this disorder.
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Ansari AS, Vehof J, Hammond CJ, Bremner FD, Williams KM. Evidence That Pupil Size and Reactivity Are Determined More by Your Parents Than by Your Environment. Front Neurol 2021; 12:651755. [PMID: 34012416 PMCID: PMC8127779 DOI: 10.3389/fneur.2021.651755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 03/29/2021] [Indexed: 01/19/2023] Open
Abstract
Purpose: A classic twin study to evaluate the relative contributions of genetic and environmental factors to resting pupil size and reactivity. Methods: Pupillometry was performed on 326 female twins (mean age 64 years) from the TwinsUK Adult Twin Registry, assessing resting pupil diameter in darkness and increasing levels of ambient light, alongside dynamic pupillary characteristics. Maximum-likelihood structural equation models estimated the proportion of trait variance attributable to genetic factors. Results: Mean (SD) pupil diameter in darkness was 5.29 mm (0.81), decreasing to 3.24 mm (0.57) in bright light. Pupil light reaction (PLR) had a mean (SD) amplitude of 1.38 mm (0.27) and latency of 250.34 milliseconds (28.58). Pupil size and PLR were not associated with iris colour, intraocular pressure or refractive error, but were associated with age (diameter β = -0.02, p = 0.016, constriction amplitude β = -0.01, p < 0.001, velocity β = 0.03, p < 0.001, and latency β = 0.98, p < 0.001). In darkness the resting pupil size showed a MZ intraclass correlation coefficient of 0.85, almost double that of DZ (0.44), suggesting strong additive genetic effects, with the most parsimonious model estimating a heritability of 86% [95% confidence interval (CI) 79-90%] with 14% (95% CI 10-21%) explained by unique environmental factors. PLR amplitude, latency and constriction velocity had estimated heritabilities of 69% (95% CI 54-79%), 40% (95% CI 21-56%), and 64% (95% CI 48-75%), respectively. Conclusion: Genetic effects are key determinants of resting pupil size and reactivity. Future studies to identify these genetic factors could improve our understanding of variation in pupil size and pupillary reactions in health and disease.
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Affiliation(s)
- Abdus Samad Ansari
- Section of Academic Ophthalmology, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Jelle Vehof
- Section of Academic Ophthalmology, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
- Department of Ophthalmology and Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Christopher J. Hammond
- Section of Academic Ophthalmology, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Fion D. Bremner
- Department of Neuro-Ophthalmology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Katie M. Williams
- Section of Academic Ophthalmology, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
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Pinheiro HM, da Costa RM. Pupillary light reflex as a diagnostic aid from computational viewpoint: A systematic literature review. J Biomed Inform 2021; 117:103757. [PMID: 33826949 DOI: 10.1016/j.jbi.2021.103757] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 01/06/2023]
Abstract
This work presents a detailed and complete review of publications on pupillary light reflex (PLR) used to aid diagnoses. These are computational techniques used in the evaluation of pupillometry, as well as their application in computer-aided diagnoses (CAD) of pathologies or physiological conditions that can be studied by observing the movements of miosis and mydriasis of the human pupil. A careful survey was carried out of all studies published over the last 10 years which investigated, electronic devices, recording protocols, image treatment, computational algorithms and the pathologies related to PLR. We present the frontier of existing knowledge regarding methods and techniques used in this field of knowledge, which has been expanding due to the possibility of performing diagnoses with high precision, at a low cost and with a non-invasive method.
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Trang H, Bourgeois P, Cheliout-Heraut F. Neurocognition in Congenital Central Hypoventilation Syndrome: influence of genotype and ventilation method. Orphanet J Rare Dis 2020; 15:322. [PMID: 33203435 PMCID: PMC7670788 DOI: 10.1186/s13023-020-01601-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/26/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Congenital Central Hypoventilation Syndrome (CCHS) is characterized by central hypoventilation due to abnormal autonomic control of breathing and global dysautonomia. Patients harbour heterozygous PHOX-2B gene mutations which are polyalanine repeats of various lengths in most of the cases. A few previous studies have reported learning difficulties and neuropsychological disorders in patients with CCHS. The aims of the present study were (1) to explore the intellectual abilities of a group of children with CCHS followed up in the centre of reference for CCHS in France using the Wechsler batteries of tests, (2) and to assess whether there was any association between CCHS characteristics and various domains of the intellectual functioning. RESULTS There were 34 consecutive patients (15 males, 19 females) of mean (SD) age of 7.8 (3.8) years, ranging from 4 to 16 years and 6 months. Mean score of full-scale intelligence quotient was 82 (20), being in the low average range. Indexes of working memory and processing speed were significantly lower as compared to the other Wechsler indexes. There were two important findings: (1) full-scale intelligence quotient as well as indexes of verbal comprehension and processing speed were significantly greater in patients with mask ventilation than in those with tracheostomy ventilation (p = 0.012, 0.032 and 0.042 respectively); (2) most interestingly, in the patients with polyalanine repeats mutations, all intellectual indexes negatively correlated with the number of polyalanine expansion, with statistical significance reached for indexes of fluid reasoning and working memory (R = - 0.449, p = 0.032 and R = - 0.562, p = 0.012 respectively). CONCLUSIONS CCHS increased the risk to develop neurocognitive deficiencies, affecting particularly speed of processing and working memory. Our results suggested that both genetics and ventilation method could be also involved in the physiopathology of neurocognitive impairment. Further investigations were required to untangle the complex underlying processes. Neurocognitive assessments should be performed regularly in children with CCHS in order to plan re-education programs, adapt school integration and improve quality of life.
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Affiliation(s)
- Ha Trang
- Centre de référence de Maladies Respiratoires Rares Syndrome d’Ondine, Hôpital Universitaire Robert Debré, 48 Boulevard Sérurier, 75019 Paris, France
- Université de Paris, 10 avenue de Verdun, 75010 Paris, France
| | - Pauline Bourgeois
- Centre de référence de Maladies Respiratoires Rares Syndrome d’Ondine, Hôpital Universitaire Robert Debré, 48 Boulevard Sérurier, 75019 Paris, France
| | - Fawzia Cheliout-Heraut
- Centre de référence de Maladies Respiratoires Rares Syndrome d’Ondine, Hôpital Universitaire Robert Debré, 48 Boulevard Sérurier, 75019 Paris, France
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Winston M, Zhou A, Rand CM, Dunne EC, Warner JJ, Volpe LJ, Pigneri BA, Simon D, Bielawiec T, Gordon SC, Vitez SF, Charnay A, Joza S, Kelly K, Panicker C, Rizvydeen S, Niewijk G, Coleman C, Scher BJ, Reed DW, Hockney SM, Buniao G, Stewart T, Trojanowski L, Brogadir C, Price M, Kenny AS, Bradley A, Volpe NJ, Weese-Mayer DE. Pupillometry measures of autonomic nervous system regulation with advancing age in a healthy pediatric cohort. Clin Auton Res 2019; 30:43-51. [DOI: 10.1007/s10286-019-00639-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/13/2019] [Indexed: 02/03/2023]
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Bishara J, Keens TG, Perez IA. The genetics of congenital central hypoventilation syndrome: clinical implications. APPLICATION OF CLINICAL GENETICS 2018; 11:135-144. [PMID: 30532577 PMCID: PMC6241683 DOI: 10.2147/tacg.s140629] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Congenital central hypoventilation syndrome (CCHS) is a rare genetic disorder of the autonomic nervous system (ANS) and respiratory control. This disorder, formerly referred to as Ondine’s curse, is due to a mutation in the PHOX2B gene that affects the development of the neural crest cells. CCHS has an autosomal dominant pattern of inheritance. Majority of the patients have a polyalanine repeat mutation (PARM) of the PHOX2B, while a small group has non-PARM (NPARM). Knowledge of the patient’s PHOX2B gene mutation helps predict a patient’s clinical presentation and outcome and aids in anticipatory management of the respiratory and ANS dysfunction.
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Affiliation(s)
- John Bishara
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA,
| | - Thomas G Keens
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA, .,Department of Pediatrics, Keck School of Medicine of USC, Los Angeles, CA, USA,
| | - Iris A Perez
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA, .,Department of Pediatrics, Keck School of Medicine of USC, Los Angeles, CA, USA,
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Badke CM, Marsillio LE, Weese-Mayer DE, Sanchez-Pinto LN. Autonomic Nervous System Dysfunction in Pediatric Sepsis. Front Pediatr 2018; 6:280. [PMID: 30356758 PMCID: PMC6189408 DOI: 10.3389/fped.2018.00280] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 09/14/2018] [Indexed: 12/17/2022] Open
Abstract
The autonomic nervous system (ANS) plays a major role in maintaining homeostasis through key adaptive responses to stress, including severe infections and sepsis. The ANS-mediated processes most relevant during sepsis include regulation of cardiac output and vascular tone, control of breathing and airway resistance, inflammation and immune modulation, gastrointestinal motility and digestion, and regulation of body temperature. ANS dysfunction (ANSD) represents an imbalanced or maladaptive response to injury and is prevalent in pediatric sepsis. Most of the evidence on ANSD comes from studies of heart rate variability, which is a marker of ANS function and is inversely correlated with organ dysfunction and mortality. In addition, there is evidence that other measures of ANSD, such as respiratory rate variability, skin thermoregulation, and baroreflex and chemoreflex sensitivity, are associated with outcomes in critical illness. The relevance of understanding ANSD in the context of pediatric sepsis stems from the fact that it might play an important role in the pathophysiology of sepsis, is associated with outcomes, and can be measured continuously and noninvasively. Here we review the physiology and dysfunction of the ANS during critical illness, discuss methods for measuring ANS function in the intensive care unit, and review the diagnostic, prognostic, and therapeutic value of understanding ANSD in pediatric sepsis.
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Affiliation(s)
- Colleen M. Badke
- Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Lauren E. Marsillio
- Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Debra E. Weese-Mayer
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Center for Autonomic Medicine in Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Stanley Manne Children's Research Institute, Chicago, IL, United States
| | - L. Nelson Sanchez-Pinto
- Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Stanley Manne Children's Research Institute, Chicago, IL, United States
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McAnany JJ, Smith BM, Garland A, Kagen SL. iPhone-based Pupillometry: A Novel Approach for Assessing the Pupillary Light Reflex. Optom Vis Sci 2018; 95:953-958. [PMID: 30234829 PMCID: PMC6166694 DOI: 10.1097/opx.0000000000001289] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 06/10/2018] [Indexed: 11/25/2022] Open
Abstract
SIGNIFICANCE The response of the pupil to a flash of light, the pupillary light reflex (PLR), is an important measure in optometry and in other fields of medicine that is typically evaluated by qualitative observation. Here we describe a simple, portable, iPhone-based pupillometer that quantifies the PLR in real time. PURPOSES The purposes of this study were to describe a novel application that records the PLR and to compare its technical capabilities with a laboratory-based infrared (IR) camera system. METHODS Pupil sizes were measured from 15 visually normal subjects (age, 19 to 65 years) using an IR camera system and the Sensitometer test. This test elicits pupillary constriction using the iPhone flash, records pupil size using the camera, and provides measurements in real time. Simultaneous recordings were obtained with the Sensitometer test and IR camera, and two measures were calculated: (1) dark-adapted steady-state pupil size and (2) minimum pupil size after the flash. The PLR was defined as the difference between these two measures. Pupil size was also recorded during the redilation phase after the flash. Bland-Altman analysis was used to assess the limits of agreement between the two methods. RESULTS Statistically significant correlations between the IR and Sensitometer test measures were found for the PLR (r = 0.91, P < .001) and redilation size (r = 0.65, P = .03). Bland-Altman analysis indicated a mean PLR difference of 6% between these two methods. The PLR limit of agreement was 14%, indicating that 95% of subjects are expected to have IR and Sensitometer test measurements that differ by 14% or less. Bland-Altman analysis indicated a mean redilation size difference of 1% between the two methods; the limit of agreement was 5%. CONCLUSIONS There is excellent agreement between pupil responses recorded using the Sensitometer test and IR camera. The Sensitometer test provides a highly promising approach for simple, portable, inexpensive pupillary measurements.
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Affiliation(s)
| | - Brandon M. Smith
- Department of Computer Sciences, University of Wisconsin–Madison, Madison, Wisconsin
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15
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Riffard C, Viêt TQ, Desgranges FP, Bouvet L, Allaouchiche B, Stewart A, Chassard D. The pupillary light reflex for predicting the risk of hypotension after spinal anaesthesia for elective caesarean section. Anaesth Crit Care Pain Med 2018; 37:233-238. [DOI: 10.1016/j.accpm.2016.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/29/2016] [Accepted: 10/03/2016] [Indexed: 10/20/2022]
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Congenital central hypoventilation syndrome: An overview of etiopathogenesis, associated pathologies, clinical presentation, and management. Auton Neurosci 2017; 210:1-9. [PMID: 29249648 DOI: 10.1016/j.autneu.2017.11.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 10/10/2017] [Accepted: 11/12/2017] [Indexed: 12/19/2022]
Abstract
Congenital central hypoventilation syndrome (CCHS), known colloquially as Ondine's curse, is a rare disorder characterized by impaired autonomic control of breathing during sleep from the loss of vagal input and diminished sensitivity of CO2 receptors in the medulla. CCHS correlates to the malformation of the neural crest located in the brainstem; this consequently affects the loss of sensitivity of CO2 chemoreceptors, bringing about hypoventilation during sleep. The primary cause of CCHS is the mutation of the paired-like homeobox PHO2XB gene, found in 90% of the patients. This mutation not only affects breathing but also drives neurological abnormalities such as autonomic and neurocognitive dysfunction. Though typically congenital, there have been late-onset (i.e., acquired) cases reported. It is vital for physicians and clinicians to be able to diagnose CCHS due to its similar presentation to other syndromes and disorders, which may cause it to be misdiagnosed and may account for its deleterious effects. CCHS can lead to a constellation of symptoms, and consideration of diseases that present concomitantly with CCHS affords us a better understanding of the etiology of this illness. Although a rare syndrome, we aim to review the current literature to emphasize the pathogenesis, etiology, clinical presentation, symptoms, diagnosis, and current treatment methods of CCHS for clinicians to better identify and understand this condition.
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Kontos A, Lushington K, Martin J, Schwarz Q, Green R, Wabnitz D, Xu X, M Sokoya E, Willoughby S, Baumert M, Ferrante A, La Forgia M, Kennedy D. Relationship between Vascular Resistance and Sympathetic Nerve Fiber Density in Arterial Vessels in Children With Sleep Disordered Breathing. J Am Heart Assoc 2017; 6:JAHA.117.006137. [PMID: 28716800 PMCID: PMC5586314 DOI: 10.1161/jaha.117.006137] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Sleep disordered breathing in children is associated with increased blood flow velocity and sympathetic overactivity. Sympathetic overactivity results in peripheral vasoconstriction and reduced systemic vascular compliance, which increases blood flow velocity during systole. Augmented blood flow velocity is recognized to promote vascular remodeling. Importantly, increased vascular sympathetic nerve fiber density and innervation in early life plays a key role in the development of early‐onset hypertension in animal models. Examination of sympathetic nerve fiber density of the tonsillar arteries in children undergoing adenotonsillectomy for Sleep disordered breathing will address this question in humans. Methods and Results Thirteen children scheduled for adenotonsillectomy to treat sleep disordered breathing underwent pupillometry, polysomnography, flow‐mediated dilation, resting brachial artery blood flow velocity (velocity time integral), and platelet aggregation. The dorsal lingual artery (tonsil) was stained and immunofluorescence techniques used to determine sympathetic nerve fiber density. Sympathetic nerve fiber density was correlated with increased resting velocity time integral (r=0.63; P<0.05) and a lower Neuronal Pupillary Index (r=−0.71, P<0.01), as well as a slower mean pupillary constriction velocity (mean, r=−0.64; P<0.05). A faster resting velocity time integral was associated with a slower peak pupillary constriction velocity (r=−0.77; P<0.01) and higher platelet aggregation to collagen antigen (r=0.64; P<0.05). Slower mean and peak pupillary constriction velocity were associated with higher platelet aggregation scores (P<0.05; P<0.01, respectively). Conclusions These results indicate that sympathetic activity is associated with change in both the function and structure of systemic vasculature in children with sleep disordered breathing.
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Affiliation(s)
- Anna Kontos
- Robinson's Research Institute, School of Medicine, Discipline of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia
| | - Kurt Lushington
- School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, Australia
| | - James Martin
- Robinson's Research Institute, School of Medicine, Discipline of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia.,Department of Respiratory and Sleep Medicine, Women's and Children's Hospital, Adelaide, Australia
| | - Quenten Schwarz
- Neurovascular Research Laboratory, Centre for Cancer Biology, University of South Australia, Adelaide, Australia
| | - Ryan Green
- Department of Information Technology, Engineering and the Environment, University of South Australia, Adelaide, Australia
| | - David Wabnitz
- Department of Otolaryngology-Head and Neck Surgery, Women's and Children's Hospital, Adelaide, Australia
| | - Xiangjun Xu
- Neurovascular Research Laboratory, Centre for Cancer Biology, University of South Australia, Adelaide, Australia
| | - Elke M Sokoya
- Department of Human Physiology, Flinders University, Adelaide, South Australia, Australia
| | - Scott Willoughby
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Mathias Baumert
- School of Electrical and Electronic Engineering, University of Adelaide, Adelaide, Australia
| | - Antonio Ferrante
- Robinson's Research Institute, School of Medicine, Discipline of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia.,Department of Immunology SA Pathology, Schools of Medicine and Biological Science, University of Adelaide, Adelaide, Australia
| | - Melissa La Forgia
- Department of Medical Imaging, Women's and Children's Hospital, Adelaide, Australia
| | - Declan Kennedy
- Robinson's Research Institute, School of Medicine, Discipline of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia.,Department of Respiratory and Sleep Medicine, Women's and Children's Hospital, Adelaide, Australia
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Spanish patients with central hypoventilation syndrome included in the European Registry. The 2015 data. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.anpede.2016.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Milioni ALV, Nagy BV, Moura ALA, Zachi EC, Barboni MT, Ventura DF. Neurotoxic impact of mercury on the central nervous system evaluated by neuropsychological tests and on the autonomic nervous system evaluated by dynamic pupillometry. Neurotoxicology 2017; 59:263-269. [DOI: 10.1016/j.neuro.2016.04.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 04/09/2016] [Accepted: 04/11/2016] [Indexed: 11/25/2022]
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Kasi AS, Perez IA, Kun SS, Keens TG. Congenital central hypoventilation syndrome: diagnostic and management challenges. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2016; 7:99-107. [PMID: 29388615 PMCID: PMC5683295 DOI: 10.2147/phmt.s95054] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Congenital central hypoventilation syndrome (CCHS) is a rare genetic disorder with failure of central control of breathing and of the autonomic nervous system function due to a mutation in the paired-like homeobox 2B (PHOX2B) gene. Affected patients have absent or negligible ventilatory sensitivity to hypercapnia and hypoxemia, and they do not exhibit signs of respiratory distress when challenged with hypercarbia or hypoxia. The diagnosis of CCHS must be confirmed with PHOX2B gene mutation. Generally, the PHOX2B mutation genotype can aid in anticipating the severity of the phenotype. They require ventilatory support for life. Home assisted ventilation options include positive pressure ventilation via tracheostomy, noninvasive positive pressure ventilation, and diaphragm pacing via phrenic nerve stimulation, but each strategy has its associated limitations and challenges. Since all the clinical manifestations of CCHS may not manifest at birth, periodic monitoring and early intervention are necessary to prevent complications and improve outcome. Life-threatening arrhythmias can manifest at different ages and a normal cardiac monitoring study does not exclude future occurrences leading to the dilemma of timing and frequency of cardiac rhythm monitoring and treatment. Given the rare incidence of CCHS, most health care professionals are not experienced with managing CCHS patients, particularly those with diaphragm pacers. With early diagnosis and advances in home mechanical ventilation and monitoring strategies, many CCHS children are surviving into adulthood presenting new challenges in their care.
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Affiliation(s)
- Ajay S Kasi
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles
| | - Iris A Perez
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles.,Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Sheila S Kun
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles
| | - Thomas G Keens
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles.,Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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[Spanish patients with central hypoventilation syndrome included in the European Registry. The 2015 data]. An Pediatr (Barc) 2016; 86:255-263. [PMID: 27377324 DOI: 10.1016/j.anpedi.2016.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 05/10/2016] [Accepted: 05/17/2016] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Congenital Central Hypoventilation Syndrome (CCHS) is a very rare genetic disease. In 2012 the European Central Hypoventilation Syndrome (EuCHS) Consortium created an online patient registry in order to improve care. AIM To determine the characteristics and outcomes of Spanish patients with CCHS, and detect clinical areas for improvement. MATERIALS AND METHOD An assessment was made on the data from Spanish patients in the European Registry, updated on December 2015. RESULTS The Registry contained 38 patients, born between 1987 and 2013, in 18 hospitals. Thirteen (34.2%) were older than 18 years. Three patients had died. Genetic analysis identified PHOX2B mutations in 32 (86.5%) out of 37 patients assessed. The 20/25, 20/26 and 20/27 polyalanine repeat mutations (PARMs) represented 84.3% of all mutations. Longer PARMs had more, as well as more severe, autonomic dysfunctions. Eye diseases were present in 47%, with 16% having Hirschsprung disease, 13% with hypoglycaemia, and 5% with tumours. Thirty patients (79%) required ventilation from the neonatal period onwards, and 8 (21%) later on in life (late onset/presentation). Eight children (21%) were using mask ventilation at the first home discharge. Five of them were infants with neonatal onset, two of them, both having a severe mutation, were switched to tracheostomy after cardiorespiratory arrest at home. Approximately one-third (34.3%) of patients were de-cannulated and switched to mask ventilation at a mean age of 13.7 years. Educational reinforcement was required in 29.4% of children attending school. CONCLUSION The implementation of the EuCHS Registry in Spain has identified some relevant issues for optimising healthcare, such as the importance of genetic study for diagnosis and assessment of severity, the high frequency of eye disease and educational reinforcement, as well as some limitations in ventilatory techniques.
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Noninvasive Brain Physiology Monitoring for Extreme Environments: A Critical Review. J Neurosurg Anesthesiol 2016; 27:318-28. [PMID: 25811362 DOI: 10.1097/ana.0000000000000175] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Our ability to monitor the brain physiology is advancing; however, most of the technology is bulky, expensive, and designed for traditional clinical settings. With long-duration space exploration, there is a need for developing medical technologies that are reliable, low energy, portable, and semiautonomous. Our aim was to review the state of the art for noninvasive technologies capable of monitoring brain physiology in diverse settings. A literature review of PubMed and the Texas Medical Center library sites was performed using prespecified search criteria to identify portable technologies for monitoring physiological aspects of the brain physiology. Most brain-monitoring technologies require a moderate to high degree of operator skill. Some are low energy, but many require a constant external power supply. Most of the technologies lack the accuracy seen in gold standard measures, due to the need for calibration, but may be useful for screening or monitoring relative changes in a parameter. Most of the technologies use ultrasound or electromagnetic radiation as energy sources. There is an important need for further development of portable technologies that can be operated in a variety of extreme environments to monitor brain health.
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Nobuta H, Cilio MR, Danhaive O, Tsai HH, Tupal S, Chang SM, Murnen A, Kreitzer F, Bravo V, Czeisler C, Gokozan HN, Gygli P, Bush S, Weese-Mayer DE, Conklin B, Yee SP, Huang EJ, Gray PA, Rowitch D, Otero JJ. Dysregulation of locus coeruleus development in congenital central hypoventilation syndrome. Acta Neuropathol 2015; 130:171-83. [PMID: 25975378 PMCID: PMC4503865 DOI: 10.1007/s00401-015-1441-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 05/01/2015] [Accepted: 05/02/2015] [Indexed: 12/29/2022]
Abstract
Human congenital central hypoventilation syndrome (CCHS), resulting from mutations in transcription factor PHOX2B, manifests with impaired responses to hypoxemia and hypercapnia especially during sleep. To identify brainstem structures developmentally affected in CCHS, we analyzed two postmortem neonatal-lethal cases with confirmed polyalanine repeat expansion (PARM) or Non-PARM (PHOX2B∆8) mutation of PHOX2B. Both human cases showed neuronal losses within the locus coeruleus (LC), which is important for central noradrenergic signaling. Using a conditionally active transgenic mouse model of the PHOX2B∆8 mutation, we found that early embryonic expression (<E10.5) caused failure of LC neuronal specification and perinatal respiratory lethality. In contrast, later onset (E11.5) of PHOX2B∆8 expression was not deleterious to LC development and perinatal respiratory lethality was rescued, despite failure of chemosensor retrotrapezoid nucleus formation. Our findings indicate that early-onset mutant PHOX2B expression inhibits LC neuronal development in CCHS. They further suggest that such mutations result in dysregulation of central noradrenergic signaling, and therefore, potential for early pharmacologic intervention in humans with CCHS.
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Herrera-Flores EH, Rodríguez-Tejada A, Reyes-Zúñiga MM, Torres-Fraga MG, Castorena-Maldonado A, Carrillo-Alduenda JL. [Congenital central alveolar hypoventilation syndrome]. BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO 2015; 72:262-270. [PMID: 29421146 DOI: 10.1016/j.bmhimx.2015.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/25/2015] [Accepted: 07/02/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Congenital central alveolar hypoventilation syndrome (CCAHS) is a rare sleep-related breathing disorder. Although increasingly frequently diagnosed in sleep clinics and pediatric pulmonology services, its epidemiology is not known. There are about 300 reported cases reported in the literature with an incidence of 1 case per 200,000 live births. CCAHS is characterized by alveolar hypoventilation that occurs or worsens during sleep and is secondary to a reduction/absence of the ventilatory response to hypercapnia and/or hypoxemia. In 90% of the cases it is due to a PARM-type mutation of the PHOX2B gene. Treatment includes mechanical ventilation and diaphragmatic pacemaker. If therapy is not initiated promptly the patient can evolve to chronic respiratory failure, pulmonary hypertension, cor pulmonale and death. CASE REPORTS In this paper we present three cases of CCAHS diagnosed, treated and followed up at the Sleep Disorders Clinic of the National Institute of Respiratory Diseases in Mexico. CONCLUSIONS Early diagnosis is important to initiate ventilatory support so as to prevent any complications and to reduce mortality.
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Affiliation(s)
- Edwin Hernando Herrera-Flores
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - Alfredo Rodríguez-Tejada
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - Martha Margarita Reyes-Zúñiga
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - Martha Guadalupe Torres-Fraga
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - Armando Castorena-Maldonado
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - José Luis Carrillo-Alduenda
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México.
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Philby MF, Aydinoz S, Gozal D, Kilic S, Bhattacharjee R, Bandla HP, Kheirandish-Gozal L. Pupillometric findings in children with obstructive sleep apnea. Sleep Med 2015; 16:1187-91. [PMID: 26429743 DOI: 10.1016/j.sleep.2015.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 05/28/2015] [Accepted: 06/01/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) leads to intermittent hypoxia, activation of the sympathetic nervous system, and eventually cardiovascular morbidity. Alterations in autonomic nervous system (ANS) tone and reflexes are likely to play major roles in OSA-associated morbidities, and have been identified in a subset of children with OSA. OBJECTIVES To evaluate whether pupillometry, a noninvasive and rapid bedside test for the assessment of autonomic nervous system dysfunction (ANS), would detect abnormal ANS function in children with OSA. METHODS Children ages 2-12 years underwent polysomnography (PSG), and were divided based on PSG findings into two groups; Habitual Snorers (HS; AHI < 1 h/TST, n = 17) and OSA (AHI > 1 h/TST, n = 49), the latter then sub-divided into AHI severity categories (>1 but <5, >5 but <10, and >10 h/TST). Pupillometric measurements were performed during the clinic visit in a dark room using an automated pupillometer device. RESULTS A total of 66 subjects with a mean age of 7.3 ± 2.6 years were recruited. There were no statistically significant differences between any of the groups, even when comparing severe OSA (n = 15) and HS in any of the measures related to pupillary reflexes. However, mild, yet significant increases in systolic blood pressure and morning plasma norepinephrine levels were detected in the severe OSA group. CONCLUSION Although ANS perturbations are clearly present in a proportion of children with OSA, particularly those with severe disease, pupillary responses do not appear to provide a sensitive method for the detection of ANS dysfunction in OSA children.
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Affiliation(s)
- Mona F Philby
- Section of Pediatric Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, IL, USA
| | - Secil Aydinoz
- Section of Pediatric Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, IL, USA; Department of Pediatrics, GATA Haydarpasa Teaching Hospital, Istanbul, Turkey
| | - David Gozal
- Section of Pediatric Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, IL, USA; Section of Pediatric Pulmonology, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, IL, USA
| | - Selim Kilic
- Department of Pediatrics, GATA Haydarpasa Teaching Hospital, Istanbul, Turkey
| | - Rakesh Bhattacharjee
- Section of Pediatric Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, IL, USA; Section of Pediatric Pulmonology, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, IL, USA
| | - Hari P Bandla
- Section of Pediatric Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, IL, USA; Section of Pediatric Pulmonology, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, IL, USA
| | - Leila Kheirandish-Gozal
- Section of Pediatric Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, IL, USA.
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Rand CM, Carroll MS, Weese-Mayer DE. Congenital Central Hypoventilation Syndrome. Clin Chest Med 2014; 35:535-45. [DOI: 10.1016/j.ccm.2014.06.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Saiyed R, Rand CM, Carroll MS, Weese-Mayer DE. Hypoventilation Syndromes of Infancy, Childhood, and Adulthood. Sleep Med Clin 2014. [DOI: 10.1016/j.jsmc.2014.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Boulanger-Scemama E, Fardeau C, Straus C, Simon C, Touitou V, Touhami S, Amini M, Similowski T, LeHoang P. Ophthalmologic impairment during adulthood in central congenital hypoventilation syndrome: a longitudinal cohort analysis of nine patients. Ophthalmic Genet 2014; 35:229-34. [PMID: 25113442 DOI: 10.3109/13816810.2014.946056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Congenital central hypoventilation syndrome (CCHS) is a rare dysgenetic form of neurocristopathy associated with dysfunction of the autonomic nervous system. Ophthalmologic abnormalities are reported in CCHS children, and range from pupillary and iris abnormalities to ptosis, strabismus and convergence deficiency. Since earlier CCHS diagnosis and multidisciplinary management, combined with improved ventilatory support techniques, the lifespan of children with CCHS has been considerably lengthened. The oldest of them have now reached adult age and we report in this study the results of their ophthalmologic examination. MATERIALS AND METHODS Nine CCHS adult patients were prospectively included during a 14-month period. Each patient underwent complete ophthalmologic examination, static pupillometry with scotopic and photopic pupillary diameter (PD) measures, Humphrey 24-2 visual field analysis, macular OCT and complete orthoptic assessment including a Hess-Lancaster test. RESULTS Ophthalmologic abnormalities were found in six of the nine patients (66%). The main features were strabismus in six patients (66%). Four patients (44%) displayed abnormal pupillary function, with a decrease in average scotopic PD (3.8 ± 1.4 mm), average photopic PD (3.5 ± 1.2 mm), and average percentage of pupillary constriction (7.6 ± 8.5%). Three patients (33%) exhibited iris abnormalities such as iris atrophy, smooth iris surface and atrophic sphincter. CONCLUSION This study allowed the description of ophthalmologic abnormalities occurring in CCHS in a series of adult patients, thus improving current knowledge of the disease. The prevalence of pupillary and iris lesions were lower than those observed in a series of children, suggesting that they could be considered as systemic disease severity markers.
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Affiliation(s)
- Elise Boulanger-Scemama
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service d'Ophtalmologie, Centre de Référence en Maladies Rares, Département Hospitalo-universitaire Vision et Handicap , Paris , France
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Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation: review and update. Curr Opin Pediatr 2014; 26:487-92. [PMID: 24914877 DOI: 10.1097/mop.0000000000000118] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The focus of this review is to compare and contrast two orphan disorders of late-onset hypoventilation. Specifically, rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) and congenital central hypoventilation syndrome (CCHS) are distinct in presentation, pathophysiology, and etiology. RECENT FINDINGS While limited new information is available, appreciation and understanding of rare disorders can be attained through case reports. Recent literature in ROHHAD has included case reports with new findings that may provide insight into pathophysiology involving possible aberrant immune process and dysregulation at the level of the orexinergic system. SUMMARY The etiology of ROHHAD continues to be elusive. The hope is that, with growing recognition, discussion, and investigation into the overlap of ROHHAD with disorders outside congenital central hypoventilation syndrome, further advancement will be made.
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Monaco A, Cattaneo R, Mesin L, Fiorucci E, Pietropaoli D. Evaluation of autonomic nervous system in sleep apnea patients using pupillometry under occlusal stress: a pilot study. Cranio 2014; 32:139-47. [DOI: 10.1179/0886963413z.00000000022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Carroll MS, Patwari PP, Kenny AS, Brogadir CD, Stewart TM, Weese-Mayer DE. Residual chemosensitivity to ventilatory challenges in genotyped congenital central hypoventilation syndrome. J Appl Physiol (1985) 2013; 116:439-50. [PMID: 24381123 DOI: 10.1152/japplphysiol.01310.2013] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Congenital central hypoventilation syndrome (CCHS) is a neurodevelopmental disorder characterized by life-threatening hypoventilation, possibly resulting from disruption of central chemosensory integration. However, animal models suggest the possibility of residual chemosensory function in the human disease. Cardioventilatory function in a large cohort with CCHS and verified paired-like homeobox 2B (PHOX2B) mutations was assessed to determine the extent and genotype dependence of any residual chemosensory function in these patients. As part of inpatient clinical care and evaluation, 64 distinct studies from 32 infants, children, and young adults with the disorder were evaluated for physiological response to three different inspired steady-state gas exposures of 3 min each: hyperoxia [100% oxygen (O2)]; hyperoxic hypercapnia [95% O2 and 5% carbon dioxide (CO2)]; and hypoxic hypercapnia [14% O2 and 7% CO2 balanced with nitrogen (N2)]. These were followed by a hypoxia challenge consisting of five or seven breaths of N2 (100% N2). In addition, a control group of 15 young adults was exposed to all but the hypoxic challenge. Comprehensive monitoring was used to derive breath-to-breath and beat-to-beat measures of ventilatory, cardiovascular, and cerebrovascular function. On average, patients showed a residual awake ventilatory response to chemosensory challenge, independent of the specific patient PHOX2B genotype. Graded dysfunction in cardiovascular regulation was found to associate with genotype, suggesting differential effects on different autonomic subsystems. In addition, differences between cases and controls in the cerebrovascular response to chemosensory challenge may indicate alterations in cerebral autoregulation. Thus residual cardiorespiratory responses suggest partial preservation of central nervous system networks that could provide a fulcrum for potential pharmacological interventions.
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Affiliation(s)
- Michael S Carroll
- Center for Autonomic Medicine in Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Whiting REH, Yao G, Narfström K, Pearce JW, Coates JR, Dodam JR, Castaner LJ, Katz ML. Quantitative assessment of the canine pupillary light reflex. Invest Ophthalmol Vis Sci 2013; 54:5432-40. [PMID: 23847311 DOI: 10.1167/iovs.13-12012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To develop instrumentation and methods for thorough quantitative assessment of the pupillary light reflex (PLR) in dogs under varying stimulus conditions. METHODS The PLR was recorded in normal Dachshunds using a custom system allowing full user control over stimulus intensity, color, and duration. Chemical restraint protocols were compared to determine which protocol provided for optimal baseline stability of pupil size and appropriate eye positioning. A series of white light stimuli of increasing intensity was used to elicit pupil constriction. Pupil images were concurrently recorded using continuous infrared illumination and an infrared-sensitive camera. The PLR was also recorded in response to blue and red stimuli. RESULTS With injectable chemical restraint alone, spontaneous fluctuations in pupil size occurred independent of light stimulation, and spontaneous eye movements made it difficult to fully visualize the pupil. Combined injectable chemical and inhalation restraint provided a steady baseline pupil size throughout PLR assessment and allowed for stable positioning of the eye using a conjunctival stay suture. Robust PLRs were elicited with all light colors. PLR constriction amplitude increased with increasing flash intensity and ranged from 5% to 70%. CONCLUSIONS A recording system and protocol have been developed to reliably quantify the canine PLR. The techniques and instrumentation will be useful for objective quantitative assessment of the PLR in dogs and other species in research applications and may be useful in clinical veterinary ophthalmology and neurology if PLR abnormalities detected with these procedures can be associated with specific diseases.
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Affiliation(s)
- Rebecca E H Whiting
- Department of Biological Engineering, College of Engineering, University of Missouri, Columbia, Missouri 65212, USA
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Abstract
The autonomic nervous system controls a variety of fundamental physiological processes in the human body including regulation of breathing, heart rate, blood pressure, temperature, and gastrointestinal motility. Although, methods of testing autonomic function have been developed and normative data have been collected in adults, development of child-friendly testing and the field of pediatric autonomic medicine is just beginning. These noninvasive testing methods serve to identify changes in autonomic functioning and to clarify whether dysfunction is isolated or crosses into multiple systems. Methods for testing cardiovagal, adrenergic, sudomotor, pupillary, enteric, and bladder function need to be refined and made more child friendly at the same time that age and gender appropriate normative values are developed for children.
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Affiliation(s)
- Nancy L Kuntz
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Monaco A, Cattaneo R, Mesin L, Ciarrocchi I, Sgolastra F, Pietropaoli D. Dysregulation of the autonomous nervous system in patients with temporomandibular disorder: a pupillometric study. PLoS One 2012; 7:e45424. [PMID: 23028999 PMCID: PMC3445536 DOI: 10.1371/journal.pone.0045424] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 08/16/2012] [Indexed: 11/18/2022] Open
Abstract
The role of the autonomic nervous system (ANS) was recently investigated in Temporomandibular disorders (TMD). Several authors argue that in subjects with TMD there is a dysregulation of ANS. Recent literature support that Pupillometry is a simple non-invasive tool to study ANS. The aim of this study was to investigate the relationship between TMD and ANS activity using pupillometry recording in Infrared light at rest Mandible Position (RP); Infrared light at Forced Habitual Occlusion (FHO); Yellow-green light at RP; Yellow-green light at FHO. Forty female subjects were enrolled: 20 case patients showed TMD based on the Research Diagnostic Criteria for TMD, and 20 control patients, aged matched, had no signs or symptoms of TMD. Statistical analysis was performed on average pupil size. Ratio between pupil size in FHO and RP (FHO/RP ratio) and yellow-green and infrared (light/darkness ratio) lighting were carried out. Within group differences of pupil size and of “ratio” were analyzed using a paired t test, while differences of pupil size between groups were tested using an unpaired t test. Statistical comparisons between groups showed no significant differences of absolute values of pupil dimension in RP and FHO, both in yellow-green and in infrared lighting. In addition, there were no significant differences within groups comparing RP and FHO in yellow-green light. In within group comparison of pupil size, differences between RP and FHO were significant in infrared conditions. Control subjects increased, whereas TMD patients decreased pupil size at FHO in infrared lightening. FHO/RP ratio in darkness and light/darkness ratio in RP were significantly different between groups. Taken together, these data suggest that TMD subjects have an impairment of the sympathetic-adrenergic component of the ANS to be activated under stress. The present study provides preliminary pupillometric data confirming that adrenergic function is dysregulated in patients with TMD.
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Affiliation(s)
- Annalisa Monaco
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
| | - Ruggero Cattaneo
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
| | - Luca Mesin
- Department of Electronics and Telecommunications, Politecnico di Torino, Torino, Italy
| | - Irma Ciarrocchi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
| | - Fabrizio Sgolastra
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
| | - Davide Pietropaoli
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
- * E-mail:
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