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Riguetto CM, Takano CR, Admoni SN, Parisi MCR, Giannella MLC, Pavin EJ, Moura Neto A. Identification and performance of multiple clinical and laboratorial risk factors for diagnosis of cardiac autonomic neuropathy in type 1 diabetes patients. J Diabetes Metab Disord 2019; 18:565-573. [PMID: 31890683 DOI: 10.1007/s40200-019-00467-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 11/05/2019] [Indexed: 01/05/2023]
Abstract
Purpose The incidence of cardiac autonomic neuropathy (CAN) in patients with type 1 diabetes (T1D) is frequently underestimated. Individuals with T1D and CAN have an increased mortality risk, mainly from cardiovascular causes. The objectives of the present study were to assess the clinical and laboratory characteristics associated with CAN in patients with T1D and verify the ability of multiple clinical factors to help identify patients with this condition. Methods 102 patients with T1D were evaluated for CAN using standardized cardiovascular reflex testing. Clinical characteristics were used to compute a numerical score for CAN diagnosis and a ROC curve elaborated for assessment of the best cutoff to predict CAN. This score was then applied to the second sample of 120 patients. The sensitivity, specificity, and positive and negative predictive values were calculated. Results Prevalence of CAN was around 35% in the first sample of patients and just below 20% in the second sample. Hypertension, total cholesterol, triglycerides, postprandial sweating, diastolic blood pressure, abnormal right and left 10 g monofilament, retinopathy, and nephropathy were considered independent predictors of CAN. The CAN-score cut-off was 16.88. This yielded a sensitivity of 50%, specificity 73.8%, positive predictive value 22.9%, and negative predictive value 90.5%. Conclusion The use of a subset of clinical and laboratory characteristics can be more accessible than the cardiac reflex tests and more accurate than a single isolated characteristic.
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Affiliation(s)
- Cinthia Minatel Riguetto
- 1Endocrinology Division, Internal Medicine Department, Faculty of Medical Sciences, University of Campinas, Rua Tessália Vieira de Camargo, 126 Campinas, São Paulo, 13084-971 Brazil
| | - Caroline Rigoleto Takano
- 1Endocrinology Division, Internal Medicine Department, Faculty of Medical Sciences, University of Campinas, Rua Tessália Vieira de Camargo, 126 Campinas, São Paulo, 13084-971 Brazil
| | - Sharon Nina Admoni
- 2Serviço de Endocrinologia e Metabologia do Hospital da Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo Brazil
| | - Maria Candida Ribeiro Parisi
- 1Endocrinology Division, Internal Medicine Department, Faculty of Medical Sciences, University of Campinas, Rua Tessália Vieira de Camargo, 126 Campinas, São Paulo, 13084-971 Brazil
| | - Maria Lucia Correa Giannella
- 2Serviço de Endocrinologia e Metabologia do Hospital da Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo Brazil
| | - Elizabeth João Pavin
- 1Endocrinology Division, Internal Medicine Department, Faculty of Medical Sciences, University of Campinas, Rua Tessália Vieira de Camargo, 126 Campinas, São Paulo, 13084-971 Brazil
| | - Arnaldo Moura Neto
- 1Endocrinology Division, Internal Medicine Department, Faculty of Medical Sciences, University of Campinas, Rua Tessália Vieira de Camargo, 126 Campinas, São Paulo, 13084-971 Brazil
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Teixeira ARL, Hecht MM, Guimaro MC, Sousa AO, Nitz N. Pathogenesis of chagas' disease: parasite persistence and autoimmunity. Clin Microbiol Rev 2011; 24:592-630. [PMID: 21734249 PMCID: PMC3131057 DOI: 10.1128/cmr.00063-10] [Citation(s) in RCA: 147] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Acute Trypanosoma cruzi infections can be asymptomatic, but chronically infected individuals can die of Chagas' disease. The transfer of the parasite mitochondrial kinetoplast DNA (kDNA) minicircle to the genome of chagasic patients can explain the pathogenesis of the disease; in cases of Chagas' disease with evident cardiomyopathy, the kDNA minicircles integrate mainly into retrotransposons at several chromosomes, but the minicircles are also detected in coding regions of genes that regulate cell growth, differentiation, and immune responses. An accurate evaluation of the role played by the genotype alterations in the autoimmune rejection of self-tissues in Chagas' disease is achieved with the cross-kingdom chicken model system, which is refractory to T. cruzi infections. The inoculation of T. cruzi into embryonated eggs prior to incubation generates parasite-free chicks, which retain the kDNA minicircle sequence mainly in the macrochromosome coding genes. Crossbreeding transfers the kDNA mutations to the chicken progeny. The kDNA-mutated chickens develop severe cardiomyopathy in adult life and die of heart failure. The phenotyping of the lesions revealed that cytotoxic CD45, CD8(+) γδ, and CD8α(+) T lymphocytes carry out the rejection of the chicken heart. These results suggest that the inflammatory cardiomyopathy of Chagas' disease is a genetically driven autoimmune disease.
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Affiliation(s)
- Antonio R L Teixeira
- Chagas Disease Multidisciplinary Research Laboratory, University of Brasilia, Federal District, Brazil.
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Fatigue and autonomic dysfunction in non-alcoholic fatty liver disease. Clin Auton Res 2010; 19:319-26. [PMID: 19768633 DOI: 10.1007/s10286-009-0031-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Accepted: 08/18/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Fatigue is a significant symptom in nonalcoholic fatty liver disease (NAFLD) that impacts upon quality of life and is unrelated to liver disease severity. We examined the relationship between parameters of blood pressure regulation with perception of fatigue in NAFLD. METHODS Thirty-four non-diabetic subjects with histologically proven, non-cirrhotic NAFLD (26 [77%] males and 8 [23%] females) (mean +/- SD age 54 +/- 11) and 34 age, sex and BMI matched non-diabetic controls underwent subjective and objective evaluation of cardiovascular autonomic function (24 h blood pressure and head up tilt testing). All subjects completed the fatigue impact scale. RESULTS The NAFLD group had significantly higher autonomic symptom burden assessed using the orthostatic grading scale (OGS) compared to controls (4 +/- 4 vs. 1 +/- 2; p = 0.0003). Increasing orthostatic symptoms correlated with increasing fatigue (p = 0.006; r(2) = 0.3). Fatigue in NAFLD correlated inversely with 24 h measurement of systolic, diastolic and mean blood pressures (all p < 0.03; r(2) = 0.2). This relationship was predominantly related to lower blood pressure at night (p < 0.003; r(2) = 0.3). On head up tilt testing 57% of the NAFLD group had neurally-mediated hypotension (vasovagal syncope and/or orthostatic hypotension) (p = 0.006 compared to controls). The degree of blood pressure drop in response to standing correlated with fatigue severity (p = 0.008; r(2) = 0.3) and the autonomic symptom burden (OGS) (p = 0.03; r(2) = 0.2). CONCLUSION Autonomic symptoms are prevalent in NAFLD and associate with objective measures of autonomic dysfunction. Fatigue in NAFLD is associated with lower blood pressure and autonomic dysfunction. Studies are needed to determine whether this is a potential therapeutic target for fatigue in NAFLD.
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Vasireddi SR, Mall GD. Two Senior Men with a History of Schizophrenia. Psychiatr Ann 2009. [DOI: 10.3928/00485718-20091022-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Soni D, Shukla G, Singh S, Goyal V, Behari M. Cardiovascular and sudomotor autonomic dysfunction in Wilson's disease--limited correlation with clinical severity. Auton Neurosci 2009; 151:154-8. [PMID: 19665943 DOI: 10.1016/j.autneu.2009.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Revised: 06/10/2009] [Accepted: 07/03/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Wilson's disease, a disorder of copper metabolism, results in abnormal accumulation of copper in liver, brain, kidney and cornea giving rise to protean manifestations. Wilson's disease predominantly affects the basal ganglia and brain stem nuclei which may cause autonomic dysfunction. Disturbances of autonomic nervous system have not received attention in Wilson's disease due to its rarity. The aim of this study was to evaluate autonomic cardiovascular reflexes in patients of Wilson's disease and to look for any relationship between autonomic nervous system disturbances and clinical severity of Wilson's disease. MATERIALS AND METHODS Cardiovascular autonomic reflexes were evaluated clinically and electrophysiologically in 30 patients of Wilson's disease with neurological onset and compared with equal number of age and gender matched healthy controls. RESULTS Significantly abnormal response to the Valsalva maneuver and RR interval variation was seen in patients compared to controls (p<0.05). Latency for sympathetic skin response was also significantly (p<0.02) prolonged in patient group. No specific correlation with clinical severity of Wilson's disease and autonomic dysfunction could be established. CONCLUSION Autonomic dysfunction occurs in Wilson's disease and affects parasympathetic more than the sympathetic functions.
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Affiliation(s)
- Dilip Soni
- Department of Neurology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
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Abstract
Orthostatic hypotension (OH) occurs in 0.5% of individuals and as many as 7-17% of patients in acute care settings. Moreover, OH may be more prevalent in the elderly due to the increased use of vasoactive medications and the concomitant decrease in physiologic function, such as baroreceptor sensitivity. OH may result in the genesis of a presyncopal state or result in syncope. OH is defined as a reduction of systolic blood pressure (SBP) of at least 20 mm Hg or diastolic blood pressure (DBP) of at least 10 mm Hg within 3 minutes of standing. A review of symptoms, and measurement of supine and standing BP with appropriate clinical tests should narrow the differential diagnosis and the cause of OH. The fall in BP seen in OH results from the inability of the autonomic nervous system (ANS) to achieve adequate venous return and appropriate vasoconstriction sufficient to maintain BP. An evaluation of patients with OH should consider hypovolemia, removal of offending medications, primary autonomic disorders, secondary autonomic disorders, and vasovagal syncope, the most common cause of syncope. Although further research is necessary to rectify the disease process responsible for OH, patients suffering from this disorder can effectively be treated with a combination of nonpharmacologic treatment, pharmacologic treatment, and patient education. Agents such as fludrocortisone, midodrine, and selective serotonin reuptake inhibitors have shown promising results. Treatment for recurrent vasovagal syncope includes increased salt and water intake and various drug treatments, most of which are still under investigation.
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Ozawa T. Morphological substrate of autonomic failure and neurohormonal dysfunction in multiple system atrophy: impact on determining phenotype spectrum. Acta Neuropathol 2007; 114:201-11. [PMID: 17593377 DOI: 10.1007/s00401-007-0254-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Revised: 06/06/2007] [Accepted: 06/07/2007] [Indexed: 01/25/2023]
Abstract
Autonomic failure is a prominent clinical feature of patients with multiple system atrophy (MSA). Neurohormonal dysfunction is also a frequent accompaniment in patients with MSA. The determination of the pathological involvement of the autonomic neurons, which are responsible for circadian rhythms and responses to stress, provides new insight into autonomic failure and neurohormonal dysfunction in MSA. The disruptions of circadian rhythms and responses to stress may underlie the impairment of homeostatic integration responsible for cardiovascular and respiratory failures. These notions lead to the hypothesis that a pathological involvement of autonomic neurons is a significant factor of the poor prognosis of MSA. Beyond this perspective, endeavors to find the morphological phenotype that represents a predominant loss of autonomic neurons may elucidate the full spectrum of pathological involvements in MSA.
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Affiliation(s)
- Tetsutaro Ozawa
- Department of Neurology, Niigata University Brain Research Institute, 1 Asahimachi, Niigata, 951-8585, Japan.
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Tyagi A, Girotra G, Mohta M, Bhardwaj R, Sethi AK. Autonomic dysfunction and adrenal insufficiency in thoracic spine tuberculosis. Clin Orthop Relat Res 2007; 460:56-61. [PMID: 17483731 DOI: 10.1097/blo.0b013e318073c228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
While autonomic dysfunction has been reported in patients with spinal TB, little is known of the consequences. We matched 25 paraplegic patients with thoracic spine tuberculosis scheduled for spinal surgery (Group S) with 25 nontubercular American Society of Anesthesiologists Grade I patients scheduled for nonspinal surgeries (Group C) under identical operative conditions. All patients underwent four autonomic tests in the operating room, and a preoperative adrenocorticotropic hormone stimulation test was performed for patients in Group S. Compared to Group C, Group S had higher resting heart rate (103 +/- 20 beats/minute versus 81 +/- 10 beats/minute), lower expiratory:inspiratory ratio (1.14 +/- 0.11 versus 1.22 +/- 0.10), and higher heart rate variability (20 +/- 12 beats/minute versus 14 +/- 7 beats/minute), indicating probable parasympathetic dysfunction along with a relative sympathetic overactivity. Eight of the 17 patients who received an adrenocorticotropic hormone stimulation test had evidence of adrenal insufficiency. Incidence of hypotension in Group S and Group C was 100% and 44%, respectively. Mean systolic and diastolic blood pressure in Group S showed substantial decrease after induction and positioning of patients not associated with compensatory tachycardia. Coexisting pulmonary tuberculosis appears an important determinant of surgical approach as well as postoperative respiratory morbidity.
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Affiliation(s)
- Asha Tyagi
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and GTB Hospital, Delhi, India.
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Laksiri N, Azulay JP, Uzenot D, Pouget J. [Idiopathic chronic dysautonomia: when should the diagnosis be made?]. Rev Neurol (Paris) 2006; 162:869-71. [PMID: 17028551 DOI: 10.1016/s0035-3787(06)75093-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Chronic autonomic disorders may complicate a wide range of conditions which can be divided into secondary, due to specific diseases, and primary, in which no cause has been determined. CASE REPORT We report the case of a 43-year-old woman, who presented a chronic autonomic failure, which had begun by symptomatic orthostatic hypotension. Progressively, syncopes became daily, causing considerable discomfort associated with other signs of sympathic dysfunction: unilateral Horner's syndrome, diarrhea and hypohidrosis. The autonomic involvement was confirmed by study of the cardiovascular responses to tilt-up and electrophysiological autonomic testing. Etiologic search for a chronic acquired neuropathy (diabetes, amyloidis, paraneoplastic) or an inherited neuropathy was not conclusive. After five years, dysautonomic symptoms increased, but remained isolated. The physical examination did not show other clinical abnormalities such as cerebellar, pyramidal or extrapyramidal failure in favor of a multiple system atrophy or Parkinson's disease. All these data suggest the diagnosis of a primary autonomic failure. CONCLUSION The diagnosis of primary autonomic failure is difficult to make because it requires that all the investigations in search of an etiology are negative and a long follow-up to be sure that dysautonomic symptoms persist isolated after many years of progression.
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Affiliation(s)
- N Laksiri
- Service de Neurologie et Maladies Neuromusculaires, CHU Timone, Marseille
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Strasser F, Palmer JL, Schover LR, Yusuf SW, Pisters K, Vassilopoulou-Sellin R, DeGracia B, Willey JS, Bruera E. The impact of hypogonadism and autonomic dysfunction on fatigue, emotional function, and sexual desire in male patients with advanced cancer. Cancer 2006; 107:2949-57. [PMID: 17103445 DOI: 10.1002/cncr.22339] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The objective of this study was to determine whether hypogonadism and autonomic dysfunction contribute substantially to cancer-related fatigue, decreased sexual desire, and depression in male patients with advanced, incurable cancer. METHODS Forty-eight patients who had received no major antineoplastic intervention for at least 2 weeks were tested for autonomic dysfunction by using Ewing tests. Total and free testosterone levels were measured. Multivariate analyses were performed to test the relation of these factors with the Functional Assessment of Cancer Therapy (FACT) (the Functional Assessment of Anorexia/Cachexia Therapy [FAACT] scale and the Functional Assessment of Chronic Illness Therapy-Fatigue [FACIT-F] subscale), the Hospital Anxiety and Depression Scale (HADS), the Edmonton Symptom Assessment Scale, the Sexual Desire Inventory, and sexual function (Cancer Rehabilitation Evaluation System subscale). Common causes for fatigue (anemia, depression, malnutrition, symptom distress, and medications) also were considered. RESULTS Thirty-eight of 47 patients (81%) had autonomic dysfunction, although it was not associated significantly with the other variables examined. Twenty-nine of 45 patients (64%) had a low level of free testosterone (hypogonadism), which was correlated with the HADS Anxiety score (P = .002), the FACT Emotional Well-Being score (P = .02), and the HADS Depression score (P = .04). Hypogonadal men also had lower scores on the FACT Functional Well-Being scale (P = .01) and the FACIT-F subscale (P = .05). Men who reported symptoms related to weight loss (FAACT scale) had significantly lower levels of free testosterone (r = 0.34; P = .02) but did not differ from the other group in actual weight loss (P = .22). The total testosterone level was not appropriate for screening of hypogonadism unless the patients had values <100 ng/ mL. Logistic regression analysis failed to reveal a distinct multivariate model of autonomic dysfunction or hypogonadism that predicted clinical outcomes. CONCLUSIONS Hypogonadism is a frequent condition in patients with advanced, incurable cancer and is associated with negative mood, fatigue, and symptoms related to anorexia/cachexia.
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Affiliation(s)
- Florian Strasser
- Section of Oncology/Hematology, Department Internal Medicine, Cantonal Hospital, St. Gallen, Switzerland
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Campo SMA, Balsamo G, Zullo A, Hassan C, Morini S. Management of idiopathic achalasia: drugs, balloon or knife? Expert Opin Ther Pat 2005. [DOI: 10.1517/13543776.14.3.367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
There are many causes of syncope that include neurological (autonomic and non-autonomic), cardiac and psychiatric causes, amongst others. Disorders of the autonomic nervous system, either intermittent or fixed, are increasingly recognised as contributing to a large proportion of syncope. However, the majority of guidelines focus on cardiological and neurological evaluation in these disorders. In this overview we focus specifically on the role of autonomic evaluation. This has dual purposes; to aid the diagnosis and cause of syncope, and furthermore to provide information to understand the pathophysiological basis of syncope and thus improve management of such disorders.
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Affiliation(s)
- Christopher J Mathias
- Neurovascular Medicine Unit, Faculty of Medicine, Imperial College London at St Mary's Hospital, 2nd Floor, Queen Elizabeth the Queen, Mother Wing, Praed Street, London W2 1NY, UK.
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Abstract
Multiple system atrophy (MSA) is a sporadic neurodegenerative disorder characterised clinically by any combination of parkinsonian, autonomic, cerebellar, or pyramidal signs and pathologically by cell loss, gliosis, and glial cytoplasmic inclusions in several CNS structures. Owing to the recent advances in its molecular pathogenesis, MSA has been firmly established as an alpha-synucleinopathy along with other neurodegenerative diseases. In parallel, the clinical recognition of MSA has improved and the recent consensus diagnostic criteria have been widely established in the research community as well as movement disorders clinics. Although the diagnosis of this disorder is largely based on clinical expertise, several investigations have been proposed in the past decade to assist in early differential diagnosis. Symptomatic therapeutic strategies are still limited; however, several candidate neuroprotective agents have entered phase II and phase III clinical trials.
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Affiliation(s)
- Gregor K Wenning
- Department of Neurology, University Hospital, A-6020 Innsbruck, Austria
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Frishman WH, Azer V, Sica D. Drug treatment of orthostatic hypotension and vasovagal syncope. HEART DISEASE (HAGERSTOWN, MD.) 2003; 5:49-64. [PMID: 12549988 DOI: 10.1097/01.hdx.0000050416.53995.43] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Orthostatic hypotension is a common problem, estimated to occur in 5 out of every 1000 individuals and in as many as 7% to 17% of patients in an acute care setting. Moreover, orthostatic hypotension may be more prominent in elderly patients due to the increased intake of vasoactive medications and concomitant decrease in physiologic function, such as baroreceptor sensitivity, often seen with aging. Orthostatic hypotension is a fall in blood pressure on assuming an upright position. Absolute cutoffs for the drop in blood pressure are often difficult to determine because different patients exhibit varying degrees of tolerance to falls in blood pressure. Therefore, strict numerical criteria may lead to underdiagnosis and improper intervention. A thorough review of patient symptomatology combined with appropriate clinical tests should be employed to narrow the vast differential diagnosis and pinpoint the etiology. The fall in blood pressure seen in orthostatic hypotension results from the inability of the autonomic nervous system to adequately compensate for the 500 mL blood that is estimated to pool in the lower extremities on assuming an upright posture. The decrease in venous return results in a concomitant decrease in cardiac output and thus hypoperfusion of the cerebral circulation, possibly resulting in syncope or various other symptoms. A complete investigation should consider hypovolemia, removal of offending medications, primary autonomic disorders, secondary autonomic disorders and, of course, vasovagal syncope, the most common cause of syncope. Although further research is still necessary to rectify the disease process responsible for orthostatic hypotension, patients suffering from this disorder can effectively be treated through a combination of nonpharmacologic treatment, pharmacologic treatment and patient education. Agents such as fludrocortisone, midodrine and erythropoietin show promising results as therapeutic adjuncts. Treatment for recurrent vasovagal syncope includes increased salt intake, and various drug treatments, most of which are still under investigation.
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Affiliation(s)
- William H Frishman
- Department of Medicine, New York Medical College/Westchester Medical Center, Valhalla, New York 10595, USA.
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Kempler P, Tesfaye S, Chaturvedi N, Stevens LK, Webb DJ, Eaton S, Kerényi Z, Tamás G, Ward JD, Fuller JH. Autonomic neuropathy is associated with increased cardiovascular risk factors: the EURODIAB IDDM Complications Study. Diabet Med 2002; 19:900-9. [PMID: 12421426 DOI: 10.1046/j.1464-5491.2002.00821.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIMS To assess the prevalence of and risk factors for autonomic neuropathy in the EURODIAB IDDM Complications Study. METHODS The study involved the examination of randomly selected Type I (insulin-dependent) diabetic patients from 31 centres in 16 European countries. Neuropathic symptoms and two tests of autonomic function (changes in heart rate and blood pressure from lying to standing) were assessed and data from 3007 patients were available for the present analysis. Autonomic neuropathy was defined as an abnormality of at least one of the tests. RESULTS The prevalence of autonomic neuropathy was 36% with no sex differences. The frequency of one and two abnormal reflex tests was 30% and 6%, respectively. The R-R ratio was abnormal in 24% of patients while 18% had orthostatic hypotension defined as a fall in systolic blood pressure > 20 mmHg on standing. Significant correlations were observed between autonomic neuropathy and age (P < 0.01), duration of diabetes (P < 0.0001), HbA1c (P < 0.0001), diastolic blood pressure (P < 0.05), lower HDL-cholesterol (P < 0.01), the presence of retinopathy (P < 0.0001) and albuminuria (P < 0.0001). New associations have been identified from the study: the strong relationship of autonomic neuropathy to cigarette smoking (P < 0.01), total cholesterol/HDL-cholesterol ratio (P < 0.05) and fasting triglyceride (P < 0.0001). As a key finding, autonomic neuropathy was related to the presence of cardiovascular disease (P < 0.0001). All analyses were adjusted for age, duration of diabetes and HbA1c. However, data have been only partly confirmed by logistic regression analyses. Frequency of dizziness on standing up was 18%, while only 4% of patients had nocturnal diarrhoea and 5% had problems with bladder control. CONCLUSION Cardiovascular reflex tests, even in the form of the two tests applied, rather than a questionnaire, seem to be appropriate for the diagnosis of autonomic neuropathy. The study has identified previously known and new potential risk factors for the development of autonomic neuropathy, which may be important for the development of risk reduction strategies. Our results may support the role of vascular factors in the pathogenesis of autonomic neuropathy.
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Affiliation(s)
- P Kempler
- Department of Medicine, Semmelweis University, Budapest, Hungary, Royal Hallamshire Hospital, Sheffield, London, UK
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Mickey I, Kilford L, Kingsbury A, Loesch A. Endothelin in the middle cerebral artery: a case of multiple system atrophy. THE HISTOCHEMICAL JOURNAL 2002; 34:469-77. [PMID: 12945729 DOI: 10.1023/a:1024758504647] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In this study, we show the changes in the wall of the middle cerebral artery of a subject who suffered multiple system atrophy with autonomic failure. An electron-immunocytochemical approach was employed to reveal the presence of endothelin-1. Our results demonstrate the presence of immunoreactive endothelin-1 in the endothelial cells of the intima, vascular smooth muscle cells and macrophages of the media and neointima, and perivascular nerves/axons varicosities at the adventitial-medial border of the artery. It is concluded that endothelin-1 may, therefore, play a number of roles within diseased cerebral artery. The finding of endothelin-1-positive varicosities of autonomic innervation to this artery suggests an influence of neural endothelin on vascular smooth muscle in multiple system atrophy with autonomic failure. However, the presence of features such as neointima formation, wall irregularities and foam cells suggest the coexistence of atherosclerosis.
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Affiliation(s)
- Isla Mickey
- Department of Anatomy and Developmental Biology, University College London, Gower Street, London, WC1E 6BT, UK
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Abstract
Declining physical, emotional, and social function as a result of anorexia and cachexia are considerable contributors to discomfort for cancer patients and their families, and they impair the patient's ability to express optimal physical and psychosocial potential as long as possible. This decline no longer has to be accepted as an indispensable sequel to advanced cancer, just as pain is no longer considered to be unavoidable. A routine screening for anorexia and cachexia and associated symptoms is necessary, as is a careful, comprehensive assessment, because the condition is not always obvious. Decisions about anorexia and cachexia treatment are guided by prioritizing the different, concurrent physical, psychosocial, and existential problems and by considering the natural course of the cancer and the effects of antineoplastic therapies. Reversible causes for anorexia and cachexia need to be identified and treated, if appropriate. Nutritional interventions are often indicated; patients with a predominant starvation component and without inflammation may profit the most. New pharmacologic therapies for primary anorexia and cachexia syndrome are expected to enter clinical practice soon; however, until then, treatment with corticosteroids, progestins, or prokinetics may be indicated for some patients. To understand a multicausal syndrome, multimodal and interdisciplinary therapy is required. Specialist palliative care services can be helpful to provide, hand-in-hand with the disease specialists [172], assessment and management of psychophysical symptoms and sociospiritual needs of patients during the course of the illness and at the end of life [173]. Research efforts aim to better characterize subgroups of patients suffering from secondary causes of anorexia and cachexia and to elucidate the mechanisms involved in the primary anorexia and cachexia syndrome. Increasingly individualized treatments are expected with combination treatments that involve different mechanisms including nutrition.
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Affiliation(s)
- Florian Strasser
- Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Box 0008, Houston, TX 77030, USA
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Abstract
Multiple system atrophy (MSA) is a neurodegenerative disease of undetermined aetiology that occurs sporadically and manifests itself as a combination of parkinsonian, autonomic, cerebellar and pyramidal signs. Despite the lack of any effective therapy to reverse this condition, some of the symptoms may be, at least temporarily, improved with adequate symptomatic therapies. Medical treatment is largely aimed at mitigating the parkinsonian and autonomic features. The therapeutic results of levodopa therapy in cases of MSA are difficult to interpret because of their variability. Nevertheless, the statement that patients with MSA are non or poorly levodopa-responsive is misleading. Clinical and pathologically proven series document about 40-60% levodopa efficacy in patients with MSA presenting with predominant parkinsonian features. Unfortunately, other antiparkinsonian compounds (dopamine agonists, amantadine) are not more effective than levodopa. Orthostatic hypotension (OH) can be suspected from the patient's history and subsequently documented in the clinic by measuring lying and standing blood pressure. The diagnosis ideally should be confirmed in the laboratory with additional tests to determine the cause and evaluate the functional deficit, so as to aid treatment. A variety of pharmacological agents with different mechanisms of action have been used in MSA to reduce OH when this is symptomatic. OH can also be alleviated by avoiding aggravating factors, such as the effects of food, micturition, exposure to a warm environment and physiological diurnal changes and by using other non-pharmacological strategies. The treatment of the very common genito-urinary symptoms (incontinence, retention, impotence) should also be considered in order to improve the quality of life of these patients.
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Affiliation(s)
- C Colosimo
- Dipartimento di Scienze Neurologiche, Università La Sapienza, Rome, Italy.
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Siddiqui MF, Rast S, Lynn MJ, Auchus AP, Pfeiffer RF. Autonomic dysfunction in Parkinson's disease: a comprehensive symptom survey. Parkinsonism Relat Disord 2002; 8:277-84. [PMID: 12039423 DOI: 10.1016/s1353-8020(01)00052-9] [Citation(s) in RCA: 150] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Autonomic dysfunction occurs in Parkinson's disease (PD), but few studies have addressed it in a comprehensive manner. METHODS Autonomic symptoms were evaluated by a questionnaire in sixty-eight subjects (44 patients and 24 controls). RESULTS PD patients experienced higher frequency and severity of autonomic dysfunction. When all autonomic symptoms were pooled into an aggregate score, differences between patients and controls were highly statistically significant (p<0.0001). 'Increased salivation', 'frequency of dysphagia', decreased 'BM (bowel movement) frequency', i.e. constipation, and 'orthostatic dizziness' were more frequent in PD patients (p<0.05). A prediction model to determine the predictors of autonomic dysfunction was unsuccessful. CONCLUSION Differences in the prevalence of autonomic symptoms in PD and non-parkinsonian controls are apparent from this study.
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Affiliation(s)
- M F Siddiqui
- Florida Atlantic University, Boca Raton, FL, USA
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22
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Affiliation(s)
- Christopher J Mathias
- University Department of Clinical Neurology, National Hospital for Neurology, University College London, UK.
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23
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Strasser F, Bruera E. Mechanism of Cancer Cachexia: Progress on Disentangling a Complex Problem. PROGRESS IN PALLIATIVE CARE 2002. [DOI: 10.1080/09699260.2002.11746631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ozawa T, Soma Y, Yoshimura N, Fukuhara N, Tanaka M, Tsuji S. Reduced morning cortisol secretion in patients with multiple system atrophy. Clin Auton Res 2001; 11:271-2. [PMID: 11710802 DOI: 10.1007/bf02298961] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
To determine whether daytime or nighttime cortisol secretion is aberrant in patients with multiple system atrophy (MSA), the plasma cortisol concentrations in 20 patients with MSA were measured at 4-hr intervals for one day. Ten age-matched healthy individuals and 20 patients with cerebral infarction but without hypothalamic lesions were used as controls. The results showed that morning (8 A.M.) cortisol concentrations in patients with MSA were significantly lower than those in the control subjects. This phenomenon is highly associated with dysfunction in the autonomic nervous system in MSA.
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Mathias CJ, Senard JM, Braune S, Watson L, Aragishi A, Keeling JE, Taylor MD. L-threo-dihydroxyphenylserine (L-threo-DOPS; droxidopa) in the management of neurogenic orthostatic hypotension: a multi-national, multi-center, dose-ranging study in multiple system atrophy and pure autonomic failure. Clin Auton Res 2001; 11:235-42. [PMID: 11710796 DOI: 10.1007/bf02298955] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study was designed to determine the efficacy and tolerability of increasing doses of L-threo-dihydroxyphenylserine (L-threo-DOPS) in treating symptomatic orthostatic hypotension associated with multiple system atrophy (MSA) and pure autonomic failure (PAF). Following a one-week run-in, patients (26 MSA; 6 PAF) with symptomatic orthostatic hypotension received increasing doses of L-threo-DOPS (100, 200 and 300 mg, twice daily) in an open, dose-ranging study. Incremental dose adjustment (after weeks two and four of outpatient treatment) was based on clinical need until blood pressure (BP), and symptoms improved. Final dosage was maintained for six weeks. With L-threo-DOPS, systolic BP decrease was reduced during orthostatic challenge (-22+/-28 mm Hg reduction from a baseline decrease of 54.3+/-27.7 mm Hg, p = 0.0001, n = 32; supine systolic BP at final visit was 118.9+/-28.2 mm Hg). By the end of the study, 25 patients (78%) improved, and in 14 patients (44%) orthostatic hypotension was no longer observed. Decreased orthostatic systolic BP decrease occurred in 22% (7/32), 24% (6/25) and 61% (11/18) of patients treated with 100, 200, and 300 mg L-threo-DOPS twice daily, respectively. An improvement occurred in symptoms associated with orthostatic hypotension, such as light-headedness, dizziness (p = 0.0125), and blurred vision (p = 0.0290). L-threo-DOPS was well tolerated, with the 2 serious adverse events reported being a possible complication of the disease under study, and with no reports of supine hypertension. In conclusion, L-threo-DOPS (100, 200, and 300 mg, twice daily) was well tolerated. The dosage of 300 mg twice daily L-threo-DOPS seemed to offer the most effective control of symptomatic orthostatic hypotension in MSA and PAF.
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Affiliation(s)
- C J Mathias
- Neurovascular Medicine Unit, Division of NeuroScience and Psychological Medicine, Imperial College of Science, Technology, and Medicine at St Mary's, London, UK.
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Kempler P, Tesfaye S, Chaturvedi N, Stevens LK, Webb DJ, Eaton S, Kerényi Z, Tamás G, Ward JD, Fuller JH. Blood pressure response to standing in the diagnosis of autonomic neuropathy: the EURODIAB IDDM Complications Study. Arch Physiol Biochem 2001; 109:215-22. [PMID: 11880924 DOI: 10.1076/apab.109.3.215.11589] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Autonomic neuropathy is associated with poor prognosis. Cardiovascular reflexes are essential for the diagnosis of autonomic nerve dysfunction. Blood pressure response to standing is the most simple test for the evaluation of sympathetic integrity, however it is still discussed which diagnostic criteria of abnormal response should be considered as optimal. The EURODIAB IDDM Complications Study involved the examination of randomly selected Type 1 diabetic patients from 31 centres in 16 European counties. Data from 3007 patients were available for the present evaluation. Two tests of autonomic function (response of heart rate /R-R ratio/ and blood pressure from lying to standing) just as the frequency of feeling faint on standing up were assessed. R-R ratio was abnormal in 24% of patients. According to different diagnostic criteria of abnormal BP response to standing (>30 mmHg, >20 mmHg, and >10 mmHg fall in systolic BP), the frequency of abnormal results was 5.9%, 18% and 32%, respectively (p < 0.001). The frequency of feeling faint on standing was 18%, thus, it was identical with the prevalence of abnormal blood pressure response to standing when >20 mmHg fall in systolic blood pressure was considered as abnormal. Feeling faint on standing correlated significantly with both autonomic test results (p < 0.001). A fall >20 mmHg in systolic blood pressure after standing up seems to be the most reliable criterion for the assessment of orthostatic hypotension in the diagnosis of autonomic neuropathy in patients with Type 1 diabetes mellitus.
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Affiliation(s)
- P Kempler
- First Department of Medicine, Semmelweis University, Budapest, Hungary
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27
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Campo SM, Capria A, Antonucci F, Martino G, Ciamei A, Rossini PM, Bologna E, Cannata D. Decreased sympathetic inhibition in gastroesophageal reflux disease. Clin Auton Res 2001; 11:45-51. [PMID: 11503951 DOI: 10.1007/bf02317802] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This study was undertaken to evaluate autonomic nervous system function in patients with gastroesophageal reflux disease. Based on clinical criteria, 28 consecutive patients with no history of heart, metabolic, or neurologic disease (mean age 41 y, range 20-62 y) reporting with upper gastrointestinal symptoms typical of gastroesophageal reflux underwent esophageal manometry, ambulatory 24-hour pH study with electrocardiographic monitoring, power spectral analysis of heart rate variability, and cardiovascular tests. Twelve healthy subjects served as controls. A positive result of prolonged esophageal pH study (pH in the distal esophagus less than 4, lasting more than 4.2% of recording time) was observed in 21 patients (reflux group); seven patients were categorized in the nonreflux group. No patient showed arrhythmias or any correlation between heart rate variability changes during electrocardiographic monitoring and episodes of reflux (pH less than 4, lasting more than 5 minutes). A decrease of sympathetic function occurred only in the reflux group (p <0.05) supported by the lower increase of systolic/diastolic blood pressure at sustained handgrip. No other cardiovascular tests showed statistically significant differences in the control or nonreflux groups. Total time reflux showed an inverse correlation with sympathetic function in the reflux group (r = -0.415, p <0.028). We concluded that there is some evidence for a slightly decreased sympathetic function in patients with gastroesophageal reflux disease that is inversely correlated with total time reflux. In these patients, decreased sympathetic function may cause dysfunction of intrinsic inhibitory control with increased transient spontaneous lower-esophageal sphincter relaxations, thus resulting in gastroesophageal reflux disease.
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Affiliation(s)
- S M Campo
- Centro Ricovero e Cura a Carattere Scientifico-Associazione Fatebenefratelli per la Ricerca, Divisone di Medicina, Ospedale S. Giovanni Calibita Fatebenefratelli, Tiberina, Rome, Italy.
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28
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Dickson DW, Anderton B, Morris H, Hodges J, Bak TH, Dubois B, Pillon B, Bak T, Rafal R, Grafman J, Golbe LI, Steele J, Maraganore DM, Vidailhet M, Rivaud-Pechoux S, Livan I, Pierrot-Deseilligny C, Fowler CJ, Lynch T, Bergeron C, Bhatia K, Rossor MN, Wenning GK, Mathias CJ, Klockgether T, Abele M, Wullner U, Lantos P, Brooks DJ, Caparros-Lefebvre D. International Medical Workshop covering progressive supranuclear palsy, multiple system atrophy and cortico basal degeneration. Mov Disord 2001. [DOI: 10.1002/mds.1074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Abstract
Hypothalamic dopaminergic pathways are involved in the regulation of growth hormone and prolactin release from the anterior pituitary. Neuroendocrine studies in patients with multiple system atrophy (MSA), in whom there is a reported loss of hypothalamic dopamine, are few and contradictory. We therefore studied the neuroendocrine responses to 250 mg levodopa (plus 25 mg carbidopa) in subjects with MSA (n = 15), and compared them with age- and sex-matched healthy control subjects (n = 8). There were no significant differences in basal or post-levodopa levels of growth hormone (GH), growth hormone-releasing hormone (GHRH), glucose, insulin-like growth factor (IGF-1), or thyroid-stimulating hormone (TSH) between the groups. In patients with MSA, basal levels of prolactin were elevated (21.1 +/- 5.2 ng/mL [mean +/-standard error]) compared with control subjects (12.1 +/- 1.7, p <0.05), and after L-dopa there was increased variability in prolactin response with less suppression compared with control subjects. In conclusion, in patients with MSA, the GHRH and GH responses to L-dopa were preserved and were similar to responses in age-matched control subjects. In contrast, there was impaired dopaminergic suppression of prolactin secretion. In patients with MSA this may represent a selective dysfunction, rather than generalized loss, of tubero-infundibular dopaminergic neurones.
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Affiliation(s)
- J Kimber
- Division of Neuroscience and Psychological Medicine, Imperial College School of Medicine at St. Mary's Hospital, London, UK
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Goin JC, Sterin-Borda L, Bilder CR, Varrica LM, Iantorno G, Ríos MC, Borda E. Functional implications of circulating muscarinic cholinergic receptor autoantibodies in chagasic patients with achalasia. Gastroenterology 1999; 117:798-805. [PMID: 10500061 DOI: 10.1016/s0016-5085(99)70337-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Autoantibodies against M(2)-muscarinic acetylcholine receptors (M(2) mAChR) have been reported in patients with chronic Chagas' disease who have cardiac dysautonomia. The aim of this study was to investigate the presence of such antibodies in chronic chagasic and non-chagasic patients with esophageal achalasia and their ability to activate M(2) mAChR in the isolated esophagus. METHODS Enzyme-linked immunosorbent assay was used to detect serum immunoglobulin (Ig) G antibodies against a synthetic 24-mer peptide corresponding to the second extracellular loop of human M(2) mAChR. The effects of both total serum IgG and affinity-purified antipeptide antibodies on the contractile activity and adenosine 3', 5'-cyclic monophosphate (cAMP) production in rat esophageal strips were also tested. RESULTS Circulating IgG antibodies from chagasic achalasia patients recognized the M(2)-peptide more often than those from non-chagasic achalasia patients (P < 0.0005) and normal subjects (P < 0.0001). A strong association between the existence of circulating anti-M(2) mAChR antibodies and the presence of achalasia in chagasic patients was found (P < 0.01). Both the total IgG fraction and anti-M(2)-peptide antibodies increased the basal tone, reduced the relaxant effect of isoproterenol, and decreased cAMP accumulation in esophageal strips, displaying a muscarinic agonist-like activity on M(2) mAChR. CONCLUSIONS Patients with chronic Chagas' disease have circulating autoantibodies against M(2) mAChR. These antibodies could be involved in the pathophysiological mechanism of chagasic achalasia.
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Affiliation(s)
- J C Goin
- Pharmacological Units, School of Dentistry, University of Buenos Aires, Argentina
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The American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes. ARTHRITIS AND RHEUMATISM 1999; 42:599-608. [PMID: 10211873 DOI: 10.1002/1529-0131(199904)42:4<599::aid-anr2>3.0.co;2-f] [Citation(s) in RCA: 1352] [Impact Index Per Article: 54.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To develop a standardized nomenclature system for the neuropsychiatric syndromes of systemic lupus erythematosus (NPSLE). METHODS An international, multidisciplinary committee representing rheumatology, neurology, psychiatry, neuropsychology, and hematology developed case definitions, reporting standards, and diagnostic testing recommendations. Before and after the meeting, clinician committee members assigned diagnoses to sets of vignettes randomly generated from a pool of 108 NPSLE patients. To assess whether the nomenclature system improved diagnostic agreement, a consensus index was developed and pre- and postmeeting scores were compared by t-tests. RESULTS Case definitions including diagnostic criteria, important exclusions, and methods of ascertainment were developed for 19 NPSLE syndromes. Recommendations for standard reporting requirements, minimum laboratory evaluation, and imaging techniques were formulated. A short neuropsychological test battery for the diagnosis of cognitive deficits was proposed. In the postmeeting exercise, a statistically significant improvement in diagnostic agreement was observed. CONCLUSION The American College of Rheumatology (ACR) Nomenclature for NPSLE provides case definitions for 19 neuropsychiatric syndromes seen in SLE, with reporting standards and recommendations for laboratory and imaging tests. It is intended to facilitate and enhance clinical research, particularly multicenter studies, and reporting. In clinical settings, consultation with other specialists may be required. It should be useful for didactic purposes but should not be used uncritically or as a substitute for a clinical diagnosis. The complete case definitions are available on the ACR World Wide Web site: http://www.rheumatology .org/ar/ar.html.
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Mathias CJ, Kimber JR. Postural hypotension: causes, clinical features, investigation, and management. Annu Rev Med 1999; 50:317-36. [PMID: 10073281 DOI: 10.1146/annurev.med.50.1.317] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Postural hypotension may result from various neurogenic and non-neurogenic causes. It may be a key feature of certain disorders, such as the primary chronic autonomic failure syndromes; it can complicate a variety of diseases, such as diabetes mellitus; and its prevalence increases with advancing age. When symptomatic, it may result in loss of consciousness and thus cause injury. Postural hypotension can be suspected from the patient's history and is readily documented in the clinic by measuring lying and standing blood pressure. The diagnosis ideally should be confirmed in the laboratory with additional tests to determine the cause and evaluate the functional deficit, so as to aid treatment. Treatment of the causative disorder is often curative when there are non-neurogenic causes. A combination of nonpharmacological and pharmacological measures is needed in the management of neurogenic postural hypotension.
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Affiliation(s)
- C J Mathias
- Neurovascular Medicine Unit, Imperial College School of Medicine at St Mary's, London, United Kingdom.
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Bleasdale-Barr KM, Mathias CJ. Neck and other muscle pains in autonomic failure: their association with orthostatic hypotension. J R Soc Med 1998; 91:355-9. [PMID: 9771493 PMCID: PMC1296807 DOI: 10.1177/014107689809100704] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Neck pain in the suboccipital and paracervical region ('coathanger' configuration) is often reported by patients with autonomic failure and orthostatic hypotension. The frequency of this pain, along with pains in the buttock and calf regions, was determined by questionnaire in two major groups with primary chronic autonomic failure--pure autonomic failure (PAF) and multiple system atrophy (MSA). Comparisons were made with Parkinson's disease, cerebellar degeneration and other disorders in which neurological symptoms overlap but in which there was neither autonomic failure nor orthostatic hypotension. Neck pain was present in 93% of patients with PAF, 51% of patients with MSA and 38-47% of the non-autonomic groups. Buttock pain was present in smaller but similar proportions (8-19%) of each group, like calf pain (23-37%). Neck pain in PAF and MSA differed from that in the other groups in being relieved by sitting or lying flat and in being associated with factors that lower blood pressure in these patients. Buttock pain was posturally related in PAF and MSA; for calf pain there was no difference between groups. Neck pain was related to the degree of orthostatic hypotension; in PAF patients, whose postural blood-pressure fall was greater than that in MSA, there was a greater frequency of neck pain.
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Affiliation(s)
- K M Bleasdale-Barr
- University Department of Clinical Neurology, National Hospital for Neurology & Neurosurgery, London, UK
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Saper CB. "All fall down": the mechanism of orthostatic hypotension in multiple systems atrophy and Parkinson's disease. Ann Neurol 1998; 43:149-51. [PMID: 9485053 DOI: 10.1002/ana.410430202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Linden D, Diehl RR, Berlit P. Sympathetic cardiovascular dysfunction in long-standing idiopathic Parkinson's disease. Clin Auton Res 1997; 7:311-4. [PMID: 9430803 DOI: 10.1007/bf02267723] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Standard autonomic tests (heart rate response to deep breathing--HRDB, heart rate and systolic blood pressure response to tilt--delta HR and delta SBP) and spectral analysis of heart rate and arterial blood pressure and their transfer function (for the mid-frequency band a measure of baroreflex sensitivity) were performed in 20 patients with idiopathic Parkinson's disease (IPD) and 20 age-matched controls. Patients showed significantly diminished delta SBP, and reduced sympathetic vasomotor and cardiomotor outflow (diminished Mayer waves), consistent with an alteration of the efferent arc of the baroreflex. These results were only significant in long-standing IPD (IPD-l, > 5 years), whereas patients with short disease duration (IPD-s, < 5 years) showed values comparable to controls. Respiratory-related heart rate variability was slightly reduced in IPD-1 but this was mainly due to diminished respiratory effort, indicated by low respiratory-related blood pressure variability. We conclude that autonomic abnormalities are only present in long-standing IPD and consist in reduced sympathetic vasomotor and cardiomotor outflow.
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Affiliation(s)
- D Linden
- Department of Neurology and Clinical Neurophysiology, Alfried Krupp Hospital, Essen, Germany
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