1
|
Kocyigit BF, Assylbek MI, Akyol A, Abdurakhmanov R, Yessirkepov M. Vagus nerve stimulation as a therapeutic option in inflammatory rheumatic diseases. Rheumatol Int 2024; 44:1-8. [PMID: 37814148 DOI: 10.1007/s00296-023-05477-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 09/19/2023] [Indexed: 10/11/2023]
Abstract
The vagus nerve forms intricate neural connections with an extensive number of organs, particularly the digestive system. The vagus nerve has a pivotal role as a fundamental component of the autonomic nervous system, exhibiting an essential effect. It establishes a direct link with the parasympathetic system, consequently eliciting the synaptic release of acetylcholine. Recent studies have revealed the potential anti-inflammatory function of the vagus nerve. The activation of the hypothalamic system through the stimulation of vagal afferents is fundamentally involved in regulating inflammation. This activation process leads to the production of cortisol. The other mechanism, defined as the cholinergic anti-inflammatory pathway, is characterized by the involvement of vagal efferents. These fibers release the neurotransmitter acetylcholine at particular synaptic connections, involving interactions with macrophages and enteric neurons. The mechanism under consideration is ascribed to the α-7-nicotinic acetylcholine receptors. The fusion of acetylcholine receptors is responsible for the restricted secretion of inflammatory mediators by macrophages. A potential mechanism for anti-inflammatory effects involves the stimulation of the sympathetic system through the vagus nerve, leading to the control of immunological responses within the spleen. This article offers an extensive summary of the present knowledge regarding the therapeutic effectiveness of stimulating the vagus nerve in managing inflammatory rheumatic conditions based on the relationship of inflammation with the vagus nerve. Furthermore, the objective is to present alternatives that may be preferred while applying vagus nerve stimulation approaches.
Collapse
Affiliation(s)
- Burhan Fatih Kocyigit
- Department of Physical Medicine and Rehabilitation, University of Health Sciences, Adana Health Practice and Research Center, Adana, Turkey.
| | - Meirgul I Assylbek
- Department of Neurology, Psychiatry, Neurosurgery and Rehabilitation, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
- Department of Social Health Insurance and Public Health, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
- Medical Center ''Mediker'', Shymkent, Kazakhstan
| | - Ahmet Akyol
- Physiotherapy and Rehabilitation Application and Research Center, Hasan Kalyoncu University, Gaziantep, Turkey
| | - Ruslan Abdurakhmanov
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Marlen Yessirkepov
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| |
Collapse
|
2
|
Costa T, Rushton SP, Watson S, Ng WF. Depression in Sjögren's syndrome mediates the relationship between pain, fatigue, sleepiness, and overall quality of life. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2023; 4:78-89. [PMID: 37818348 PMCID: PMC10561071 DOI: 10.2478/rir-2023-0012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/28/2023] [Indexed: 10/12/2023]
Abstract
Objectives Sjögren's syndrome (SS) includes many extra-glandular symptoms such as fatigue, pain, sleepiness and depression, which impact on quality of life (QoL). These symptoms also influence each other and could be linked by autonomic nervous system (ANS) dysregulation. Our aim was to model the role of putative predictive variables, including depression in the relationships between ANS function, fatigue, and QoL in SS. Methods Cross-sectional analysis of self-reported data from the multicentre UK primary SS registry. The Composite Autonomic Symptom Scale (COMPASS) was used to assess autonomic function, the Hospital Anxiety and Depression Scale (HADS) to assess anxiety and depression and the EuroQol-5 Dimension (EQ-5D) to assess QoL. Validated scales were used for other clinical variables. Using multiple regression analysis and structural equation modelling (SEM), we investigated how the QoL of people with SS is impacted by the direct and indirect effects of fatigue, sleepiness, depression, symptom burden and ANS function, and their interactions. Results Data was obtained for 1046 people with SS, 56% COMPASS completers. Symptoms of ANS dysregulation were common. Participants with ANS dysregulation had more severe depression, anxiety, dryness, fatigue, pain, sleepiness and QoL (P < 0.01 for all). Depression, anxiety, dryness, and pain were independent predictors of ANS function in the multiple regression model (P < 0.05 for all). ANS function could not be included in the SEM. The SEM model had good fit to the data (comparative fit index = 0.998) and showed that, in people with SS, depression mediates the effects of pain, fatigue and sleepiness on QoL. Conclusion Our results show that diagnosing and treating depression in people with SS could have direct positive impact on QoL, and significantly ameliorate the impact of fatigue and pain.
Collapse
Affiliation(s)
- Tiago Costa
- Translational and Clinical Research Institute, Faculty of Medical Sciences, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- Northern Centre for Mood Disorders, Wolfson Research Centre, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, St. Nicholas Hospital, Jubilee Road, Gosforth, Newcastle upon Tyne, NE3 3XT, UK
| | - Stephen P Rushton
- School of Natural and Environmental Science, Agriculture Building, Newcastle University, King’s Road, Newcastle upon Tyne, NE1 7RU, UK
| | - Stuart Watson
- Translational and Clinical Research Institute, Faculty of Medical Sciences, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- Northern Centre for Mood Disorders, Wolfson Research Centre, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, St. Nicholas Hospital, Jubilee Road, Gosforth, Newcastle upon Tyne, NE3 3XT, UK
| | - Wan-Fai Ng
- Translational and Clinical Research Institute, Faculty of Medical Sciences, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- National Institute for Health and Care Research (NIHR) Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, UK
- NIHR Newcastle Clinical Research Facility, Level 6, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - On behalf of the UK primary Sjögren's Syndrome Registry
- Translational and Clinical Research Institute, Faculty of Medical Sciences, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- Northern Centre for Mood Disorders, Wolfson Research Centre, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, St. Nicholas Hospital, Jubilee Road, Gosforth, Newcastle upon Tyne, NE3 3XT, UK
- School of Natural and Environmental Science, Agriculture Building, Newcastle University, King’s Road, Newcastle upon Tyne, NE1 7RU, UK
- National Institute for Health and Care Research (NIHR) Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, UK
- NIHR Newcastle Clinical Research Facility, Level 6, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| |
Collapse
|
3
|
Visit-to-visit systolic blood pressure variability is associated with increased fatigue symptoms in multiple sclerosis patients. Mult Scler Relat Disord 2022; 68:104194. [PMID: 36206676 DOI: 10.1016/j.msard.2022.104194] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/08/2022] [Accepted: 09/23/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the relationship between visit-to-visit systolic blood pressure variability (SBPv) and fatigue symptoms in Multiple Sclerosis (MS) patients. METHODS This is a cross-sectional study using data for MS patients who completed the Fatigue Subscale in the Performance Scales (PS), a validated, self-reported measure of MS-related disability, between 2011 and 2015 at an academic medical center. Those who had at least 3 available SBP measures within the prior 12 months of the survey were included in the analysis. Ordinal logistic regression was used to model fatigue as a function of SBP variability, adjusting for demographic factors and mean SBP. RESULTS Data for 91 MS subjects were analyzed. We found that, compared to those with the lowest SBP variability (Tertile 1), subjects in Tertile 2 had 2.2 times higher odds (OR = 2.19; 95% CI, 0.82-5.87; p = 0.120) and those in Tertile 3 (highest variability) 4.2 times higher odds (OR = 4.16; 95% CI, 1.56-11.13; p = 0.005) of being in a higher fatigue level group, independent of age, sex, race/ethnicity, and mean SBP. CONCLUSIONS Our data show that MS patients with higher SBP variability had a greater degree of fatigue. Future research is needed to further explore this relationship and the potential for therapeutic opportunities to improve fatigue.
Collapse
|
4
|
Davies K, Ng WF. Autonomic Nervous System Dysfunction in Primary Sjögren's Syndrome. Front Immunol 2021; 12:702505. [PMID: 34381453 PMCID: PMC8350514 DOI: 10.3389/fimmu.2021.702505] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/13/2021] [Indexed: 11/13/2022] Open
Abstract
Primary Sjögren's syndrome (pSS) is an autoimmune disease which primarily affects the exocrine glands, but can also affect other organs, including the nervous system. Many studies have reported evidence of autonomic nervous system (ANS) dysfunction in pSS which may contribute to a wide range of symptoms and functional burden. Symptoms of ANS dysfunction are common and widespread among patients with pSS and are associated with other features of the disease, particularly fatigue. Accumulating data on the inter-relationship between the ANS and the immune system via the vagus nerve have been reported. Vagus nerve stimulation (VNS) has also been associated with improvement in fatigue in patients with pSS. Taken together, these data suggest that the ANS may be a potential treatment target for pSS, in particularly those with fatigue being a predominant symptom. Future research to dissect the link between the ANS, immune dysregulation and clinical manifestations in pSS and to evaluate the potential of VNS as a therapy for pSS is warranted.
Collapse
Affiliation(s)
- Kristen Davies
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Wan-Fai Ng
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- National Institute for Health Research (NIHR) Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals National Health Service (NHS) Foundation Trust, Newcastle upon Tyne, United Kingdom
| |
Collapse
|
5
|
Abstract
Fatigue is highly prevalent in inflammatory arthritis, and people living with the symptom have described it as overwhelming and a challenge to manage. In this article, we explore the experience, impact and non-pharmacological management of fatigue from a multi-disciplinary perspective. We start by presenting qualitative evidence from people living with fatigue, including the physical, cognitive and emotional nature of the symptom and its impact on daily life. This is followed by discussion of current conceptual models of mechanisms and factors that may cause and maintain fatigue, within and between individuals. We then address the issue of fatigue measurement and modes of assessment, which is an integral aspect of management and evaluating support provision. This leads to a review of the research evidence for non-pharmacological interventions to reduce fatigue severity and impact. Finally, we consider implementation of this evidence in clinical practice and we introduce some key practical tools and techniques.
Collapse
|
6
|
Ganglionic Acetylcholine Receptor Antibodies and Autonomic Dysfunction in Autoimmune Rheumatic Diseases. Int J Mol Sci 2020; 21:ijms21041332. [PMID: 32079137 PMCID: PMC7073227 DOI: 10.3390/ijms21041332] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/13/2020] [Accepted: 02/13/2020] [Indexed: 12/12/2022] Open
Abstract
Autonomic neuropathy has been reported in autoimmune rheumatic diseases (ARD) including Sjögren’s syndrome, systemic sclerosis, rheumatoid arthritis, and systemic lupus erythematosus. However, the pathophysiological mechanism underlying autonomic dysfunction remains unknown to researchers. On the other hand, autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated disorder, which causes dysautonomia that is mediated by autoantibodies against ganglionic acetylcholine receptors (gAChRs). The purpose of this review was to describe the characteristics of autonomic disturbance through previous case reports and the functional tests used in these studies and address the importance of anti-gAChR antibodies. We have established luciferase immunoprecipitation systems to detect antibodies against gAChR in the past and determined the prevalence of gAChR antibodies in various autoimmune diseases including AAG and rheumatic diseases. Autonomic dysfunction, which affects lower parasympathetic and higher sympathetic activity, is usually observed in ARD. The anti-gAChR antibodies may play a crucial role in autonomic dysfunction observed in ARD. Further studies are necessary to determine whether anti-gAChR antibody levels are correlated with the severity of autonomic dysfunction in ARD.
Collapse
|
7
|
Abstract
PURPOSE OF REVIEW Autonomic disorders sometimes occur in the context of systemic autoimmune disease or as a direct consequence of autoimmunity against the nervous system. This article provides an overview of autonomic disorders with potential autoimmune etiology. RECENT FINDINGS Recent evidence highlights a close association between the autonomic nervous system and inflammation. The autonomic nervous system regulates immune function, and autonomic manifestations may occur in a number of systemic autoimmune diseases. In a few instances, autoimmunity directly influences autonomic function. Autoimmune autonomic ganglionopathy is the prototypic antibody-mediated autonomic disorder. Over time, a better understanding of the clinical spectrum of autoimmune autonomic ganglionopathy, the significance of ganglionic nicotinic acetylcholine receptor antibodies, other immune-mediated autonomic neuropathies, and autonomic manifestations of other systemic or neurologic autoimmune disorders has emerged. SUMMARY Autoimmune autonomic disorders may be challenging, but correct identification of these conditions is important. In some cases, potential exists for effective immunomodulatory treatment.
Collapse
|
8
|
Brunetta E, Shiffer D, Mandelli P, Achenza S, Folci M, Zumbo A, Minonzio M, Cairo B, Jacob G, Boccassini L, Puttini PS, Porta A, Furlan R. Autonomic Abnormalities in Patients With Primary Sjogren's Syndrome - Preliminary Results. Front Physiol 2019; 10:1104. [PMID: 31551801 PMCID: PMC6736624 DOI: 10.3389/fphys.2019.01104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 08/08/2019] [Indexed: 12/31/2022] Open
Abstract
Primary Sjögren's syndrome (pSS) is an autoimmune disease affecting exocrine glands and extra-glandular organs. There are conflicting reports on the presence of autonomic dysfunction in pSS and no data are available on the functional status of sympathetic outflow to the vessels and baroreceptor [baroreflex sensitivity (BRS)] control mechanisms. We investigated the cardiac (cBRS) and sympathetic (sBRS) baroreceptor modulation in both time and frequency domains and the cardiovascular autonomic profile in pSS patients compared to healthy controls. Autonomic symptoms were quantified by the Composite Autonomic Symptom Scale (COMPASS31) three-item questionnaire. The EULAR Sjogren's syndrome patient reported index (ESSPRI) questionnaire evaluated the magnitude of pSS clinical symptoms, i.e., fatigue, pain, and sicca symptoms. Electrocardiogram, beat-by-beat arterial pressure (AP) and respiratory activity were continuously recorded in 17 pSS patients and 16 healthy controls, while supine and during 75° head-up tilt. In seven patients and seven controls, muscle sympathetic nerve activity (MSNA) was measured. Spectrum analysis of RR variability provided markers of cardiac vagal modulation (HFRR nu) and sympatho-vagal balance [low frequency (LF)/high frequency (HF)]. The power of LF (0.1 Hz) oscillations of systolic arterial pressure (SAP) variability (LFSAP) evaluated the vasomotor response to sympathetic stimulation. Compared to controls, pSS patients scored higher in total COMPASS31 (p < 0.0001) and all ESSPRI subdomains (fatigue, p = 0.005; pain, p = 0.0057; dryness, p < 0.0001). Abnormal scialometry (<1.5 ml/15 min) and Schirmer tests (<5 mm/5 min) were found in pSS patients and salivary flow rate was negatively associated with ESSPRI dryness (p = 0.0014). While supine, pSS patients had lower SEQcBRS index of cardiac baroreceptor sensitivity, higher HFRRnu (p = 0.021), lower LF/HF (p = 0.007), and greater MSNA (p = 0.038) than controls. No differences were observed in LFSAP between groups. During orthostatic challenge, although LFSAP increased similarly in both groups, MSNA was greater in pSS patients (p = 0.003). At rest pSS patients showed lower cBR control and greater parasympathetic modulation. Furthermore, greater sympathetic nerve activity was observed in pSS patients while supine and in response to gravitational challenge. We hypothesized that such enhanced sympathetic vasoconstrictor activity might reflect an attempt to maintain blood pressure in a setting of likely reduced vascular responsiveness.
Collapse
Affiliation(s)
- Enrico Brunetta
- Department of Internal Medicine, Humanitas Clinical and Research Center - IRCCS, Milan University, Milan, Italy
| | - Dana Shiffer
- Department of Internal Medicine, Humanitas Clinical and Research Center - IRCCS, Milan University, Milan, Italy
| | - Pietro Mandelli
- Department of Pathophysiology and Transplantation, Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Sara Achenza
- Department of Nephrology, Humanitas Clinical and Research Center - IRCCS, Milan University, Milan, Italy
| | - Marco Folci
- Department of Internal Medicine, Humanitas Clinical and Research Center - IRCCS, Milan University, Milan, Italy
| | - Aurora Zumbo
- Department of Internal Medicine, Humanitas Clinical and Research Center - IRCCS, Milan University, Milan, Italy
| | - Maura Minonzio
- Department of Internal Medicine, Humanitas Clinical and Research Center - IRCCS, Milan University, Milan, Italy
| | - Beatrice Cairo
- Department of Biomedical Sciences for Health, Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Giris Jacob
- Department of Internal Medicine F, J. Recanati Autonomic Dysfunction Center, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Laura Boccassini
- Reumathology Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Piercarlo Sarzi Puttini
- Reumathology Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Alberto Porta
- Department of Biomedical Sciences for Health, Faculty of Medicine and Surgery, University of Milan, Milan, Italy.,Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | - Raffaello Furlan
- Department of Internal Medicine, Humanitas Clinical and Research Center - IRCCS, Milan University, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| |
Collapse
|
9
|
Golden EP, Vernino S. Autoimmune autonomic neuropathies and ganglionopathies: epidemiology, pathophysiology, and therapeutic advances. Clin Auton Res 2019; 29:277-288. [DOI: 10.1007/s10286-019-00611-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/03/2019] [Indexed: 12/12/2022]
|
10
|
Miyamoto ST, Valim V, Fisher BA. Health-related quality of life and costs in Sjögren's syndrome. Rheumatology (Oxford) 2019; 60:2588-2601. [PMID: 30770918 DOI: 10.1093/rheumatology/key370] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 10/13/2018] [Indexed: 02/06/2023] Open
Abstract
Health-related quality of life (HRQoL) has an increasing role in medical decision-making. This review of the literature aims to provide an overview on HRQoL, costs, and work disability in SS, a disease characterized by focal lymphocytic infiltration of exocrine glands with no therapeutics of proven immunomodulatory potential. HRQoL is markedly reduced in SS in multiple studies across many countries when compared with HRQoL in healthy controls. The reduction in HRQoL is similar to that observed in other chronic diseases such as RA, SLE, FM and, interestingly, non-SS sicca syndrome. Impaired HRQoL in SS has been found to be associated with fatigue, pain/articular involvement, ocular and oral involvement, pruritus, sexual dysfunction, impaired sleep, pulmonary manifestations, psychological dysfunction and impaired physical function. Until now, no therapeutic has been shown to improve HRQoL in an adequately powered double-blind, placebo-controlled randomized controlled trial. Although primary SS does not, in general, impair life expectancy and is often inappropriately considered a benign 'nuisanvce' disease for those patients without systemic manifestations, the associated costs and work disability are striking. This, together with the significant reduction in HRQoL, strongly argues for the development of new therapeutic approaches to manage this neglected disease.
Collapse
Affiliation(s)
- Samira T Miyamoto
- Department of Integrated Education in Health, Universidade Federal do Espírito Santo, Vitória, Brazil
| | - Valéria Valim
- Department of Medical Clinic, Universidade Federal do Espírito Santo, Vitória, Brazil
| | - Benjamin A Fisher
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK.,Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Rheumatology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
11
|
Tarn J, Legg S, Mitchell S, Simon B, Ng WF. The Effects of Noninvasive Vagus Nerve Stimulation on Fatigue and Immune Responses in Patients With Primary Sjögren's Syndrome. Neuromodulation 2018; 22:580-585. [PMID: 30328647 DOI: 10.1111/ner.12879] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 09/11/2018] [Accepted: 09/16/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Primary Sjögren's syndrome (pSS) sufferers have rated chronic fatigue as the most important symptom needing improvement. Emerging data suggest that stimulation of the vagus nerve can modulate immunological responses. The gammaCore device (electroCore), developed to stimulate the cervical vagus nerve noninvasively, was used to assess the effects of vagus nerve activation on immune responses and clinical symptoms of pSS. MATERIALS AND METHODS Fifteen female pSS subjects used the nVNS device twice daily a 26-day period. At baseline, blood was drawn before and after application of the gammaCore device for 90 sec over each carotid artery. The following fatigue-related outcome measures were collected at baseline, day 7 and day 28: EULAR patient reported outcome index, profile of fatigue (Pro-F), visual analogue scale of abnormal fatigue, and Epworth sleepiness scale (ESS). Whole blood samples were stimulated with 2 ng/mL lipopolysaccharide (LPS) and the supernatant levels of IFNγ, IL12-p70, TNFα, MIP-1α, IFNα, IL-10, IL-1β, IL-6, and IP-10 were measured at 24 hours. In addition, clinical hematology and flow cytometric profiles of whole blood immune cells were analyzed. RESULTS Pro-F and ESS scores were significantly reduced across all three visits. LPS-stimulated production of IL-6, IL-1β, IP-10, MIP-1α, and TNFα were significantly reduced over the study period. Patterns of NK- and T-cell subsets also altered significantly over the study period. Interestingly, lymphocyte counts at baseline visit correlated to the reduction in fatigue score. CONCLUSION The vagus nerve may play a role in the regulation of fatigue and immune responses in pSS and nVNS may reduce clinical symptoms of fatigue and sleepiness. However, a sham-controlled follow-up study with a larger sample size is required to confirm the findings.
Collapse
Affiliation(s)
- Jessica Tarn
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah Legg
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Sheryl Mitchell
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | | | - Wan-Fai Ng
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
12
|
Hammitt KM, Naegeli AN, van den Broek RWM, Birt JA. Patient burden of Sjögren's: a comprehensive literature review revealing the range and heterogeneity of measures used in assessments of severity. RMD Open 2017; 3:e000443. [PMID: 28955493 PMCID: PMC5604724 DOI: 10.1136/rmdopen-2017-000443] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 06/20/2017] [Accepted: 08/11/2017] [Indexed: 12/11/2022] Open
Abstract
CONTEXT The severity of Sjögren's syndrome has been evaluated using a wide variety of clinical measures and patient-reported outcomes (PROs). This may contribute to the lack of clarity concerning the burden of Sjögren's from the patient perspective. OBJECTIVE To perform a comprehensive peer-reviewed literature analysis of the patient aspects of Sjögren's, focusing on PROs, to investigate the complexity underlying the evaluation of the syndrome and to elucidate the discordance between the different measures. METHODS We searched Embase for articles published between January 2005 and September 2015. Research articles, clinical and diagnostic reviews, and validation studies with a focus on patient aspects of Sjögren's were selected as the primary information source. RESULTS 157 articles met the eligibility criteria. A wide variety of assessment measures used to evaluate glandular, extraglandular and functional domains were observed. Many different, non-validated Visual Analogue Scales, with a wide range of anchor words, were used in the quantification of Sjögren's disease burden, impeding comparisons between studies. Relatively few clinical trials of drug therapies used validated scales: European League Against Rheumatism Sjögren's Syndrome Patient Reported Index was used most often for symptom assessment and 36 Item Short Form Survey for quality of life (QoL). CONCLUSION A wide range and diversity of measures are used to evaluate the patient burden of Sjögren's; most are not validated for use in this disease. PRO endpoints, validated specifically in Sjögren's, that demonstrate improvement are needed. These measures should focus on QoL aspects important to patients and will most likely involve gauging change in function rather than patient-reported symptoms.
Collapse
Affiliation(s)
| | - April N Naegeli
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana, USA
| | | | - Julie A Birt
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana, USA
| |
Collapse
|
13
|
Hammitt KM, Naegeli AN, van den Broek RWM, Birt JA. Patient burden of Sjögren's: a comprehensive literature review revealing the range and heterogeneity of measures used in assessments of severity. RMD Open 2017. [PMID: 28955493 DOI: 10.1136/rmdopen-2017-000443%jrmdopen] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
CONTEXT The severity of Sjögren's syndrome has been evaluated using a wide variety of clinical measures and patient-reported outcomes (PROs). This may contribute to the lack of clarity concerning the burden of Sjögren's from the patient perspective. OBJECTIVE To perform a comprehensive peer-reviewed literature analysis of the patient aspects of Sjögren's, focusing on PROs, to investigate the complexity underlying the evaluation of the syndrome and to elucidate the discordance between the different measures. METHODS We searched Embase for articles published between January 2005 and September 2015. Research articles, clinical and diagnostic reviews, and validation studies with a focus on patient aspects of Sjögren's were selected as the primary information source. RESULTS 157 articles met the eligibility criteria. A wide variety of assessment measures used to evaluate glandular, extraglandular and functional domains were observed. Many different, non-validated Visual Analogue Scales, with a wide range of anchor words, were used in the quantification of Sjögren's disease burden, impeding comparisons between studies. Relatively few clinical trials of drug therapies used validated scales: European League Against Rheumatism Sjögren's Syndrome Patient Reported Index was used most often for symptom assessment and 36 Item Short Form Survey for quality of life (QoL). CONCLUSION A wide range and diversity of measures are used to evaluate the patient burden of Sjögren's; most are not validated for use in this disease. PRO endpoints, validated specifically in Sjögren's, that demonstrate improvement are needed. These measures should focus on QoL aspects important to patients and will most likely involve gauging change in function rather than patient-reported symptoms.
Collapse
Affiliation(s)
| | - April N Naegeli
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana, USA
| | | | - Julie A Birt
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana, USA
| |
Collapse
|
14
|
Inskip JA, Ravensbergen H(RJC, Sahota IS, Zawadzki C, McPhail LT, Borisoff JF, Claydon VE. Dynamic wheelchair seating positions impact cardiovascular function after spinal cord injury. PLoS One 2017; 12:e0180195. [PMID: 28666000 PMCID: PMC5493360 DOI: 10.1371/journal.pone.0180195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 06/12/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Innovative wheelchairs allow individuals to change position easily for comfort and social situations. While these wheelchairs are beneficial in multiple ways, the effects of position changes on blood pressure might exacerbate hypotension and cerebral hypoperfusion, particularly in those with spinal cord injury (SCI) who can have injury to autonomic nerves that regulate cardiovascular control. Conversely, cardiovascular benefits may be obtained with lowered seating. Here we investigate the effect of moderate changes in wheelchair position on orthostatic cardiovascular and cerebrovascular reflex control. METHODS Nineteen individuals with SCI and ten neurologically-intact controls were tested in supine and seated positions (neutral, lowered, and elevated) in the Elevation™ wheelchair. Participants with SCI were stratified into two groups by the severity of injury to cardiovascular autonomic pathways. Beat-to-beat blood pressure, heart rate and middle cerebral artery blood flow velocity (MCAv) were recorded non-invasively. RESULTS Supine blood pressure and MCAv were reduced in individuals with lesions to autonomic pathways, and declined further with standard seating compared to those with preserved autonomic control. Movement to the elevated position triggered pronounced blood pressure and MCAv falls in those with autonomic lesions, with minimum values significantly reduced compared to the seated and lowered positions. The cumulative duration spent below supine blood pressure was greatest in this group. Lowered seating bolstered blood pressure in those with lesions to autonomic pathways. CONCLUSIONS Integrity of the autonomic nervous system is an important variable that affects cardiovascular responses to orthostatic stress and should be considered when individuals with SCI or autonomic dysfunction are selecting wheelchairs. SPONSORSHIP This work was supported in part by the Heart and Stroke Foundation of British Columbia and the Yukon (V.E.C).
Collapse
Affiliation(s)
- Jessica A. Inskip
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Henrike (Rianne) J. C. Ravensbergen
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Inderjeet S. Sahota
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Christine Zawadzki
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Lowell T. McPhail
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Jaimie F. Borisoff
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Institute of Technology (BCIT), Burnaby, British Columbia, Canada
| | - Victoria E. Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
15
|
Koh JH, Kwok SK, Lee J, Park SH. Autonomic dysfunction in primary Sjogren's syndrome: a prospective cohort analysis of 154 Korean patients. Korean J Intern Med 2017; 32:165-173. [PMID: 27017389 PMCID: PMC5214725 DOI: 10.3904/kjim.2015.219] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 08/04/2015] [Accepted: 08/10/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIMS To determine the prevalence of autonomic dysfunction among Korean patients with primary Sjogren's syndrome (pSS) and its associations with the clinical features of pSS. METHODS We analyzed 154 participants from the Korean Initiative of primary Sjogren's Syndrome (KISS) as a prospective pSS cohort and 154 age- and sex-matched healthy controls. A standardized 5-minute, supine, resting heart rate variability (HRV) test was performed, and autonomic dysfunction was defined as standard deviation of normal-to-normal RR intervals (SDNN) < 30 ms in patients < 50 years old and SDNN < 20 ms in patients ≥ 50 years old. The associations between autonomic dysfunction and various clinical features of pSS were analyzed. RESULTS The overall autonomic activity in patients with pSS was significantly lower than that in controls. Autonomic dysfunction with the HRV test was observed in 35.7% of the KISS participants and was associated with a higher European League Against Rheumatism Sjogren's Syndrome Patient Reported Index fatigue score (p = 0.024). Raynaud's phenomenon was a more frequent clinical presentation in pSS patients with autonomic dysfunction than in those without autonomic dysfunction (29.4% and 14.4%, respectively; p = 0.048). Decreased parasympathetic activity was observed in 41.6% of pSS patients. No differences were found in the oral and ocular signs of pSS according to the decreased parasympathetic activity. CONCLUSIONS In Korean patients with pSS, decreased and imbalanced autonomic activity is prevalent and is associated with fatigue. However, an association between autonomic dysfunction and glandular manifestations was not detected.
Collapse
Affiliation(s)
- Jung Hee Koh
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Seung-Ki Kwok
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jennifer Lee
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Correspondence to Sung-Hwan Park, M.D. Division of Rheumatology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6011 Fax: +82-2-3476-2274 E-mail:
| |
Collapse
|
16
|
Mukaino A, Nakane S, Higuchi O, Nakamura H, Miyagi T, Shiroma K, Tokashiki T, Fuseya Y, Ochi K, Umeda M, Nakazato T, Akioka S, Maruoka H, Hayashi M, Igarashi SI, Yokoi K, Maeda Y, Sakai W, Matsuo H, Kawakami A. Insights from the ganglionic acetylcholine receptor autoantibodies in patients with Sjögren's syndrome. Mod Rheumatol 2016; 26:708-15. [PMID: 26873295 DOI: 10.3109/14397595.2016.1147404] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE It is not known whether autonomic neuropathy is a feature of Sjögren's syndrome (SS) or whether it is related to circulating antiganglionic acetylcholine receptor (gAChR) antibodies. The goal of the present study was to investigate the autonomic dysfunction in patients with SS and the associations between autonomic dysfunction, anti-gAChR antibodies, and clinical features of SS. METHODS (1) The first observational study tested for the presence of gAChR antibodies in the serum samples from 39 patients with SS (absent information regarding autonomic symptoms) and healthy volunteers. (2) In the second study, serological and clinical data from 10 Japanese patients diagnosed with SS were reviewed. These patients showed autonomic dysfunction, and luciferase immunoprecipitation systems (LIPS) test was conducted to detect anti-α3 and anti-β4 gAChR antibodies. (3) In the final analysis, we combined the data of seropositive SS patients with autonomic symptom from the first study with all of the patients from the second study, and analyzed the clinical features. RESULTS (1) The LIPS assay revealed that anti-gAChRα3 and anti-gAChRβ4 antibodies were detected in the sera from patients with SS (23.1%, 9/39). Five of nine SS patients had autonomic symptoms. (2) Anti-α3 and anti-β4 gAChR antibodies were also detected in 80.0% (8/10) of patients with SS with autonomic symptoms. Six of the ten patients were diagnosed as having SS after neurological symptoms developed. These seropositive patients had predominant and severe autonomic symptoms and were diagnosed with autonomic neuropathy. (3) Thirteen of fifteen SS patients with autonomic symptoms (86.7%) were seropositive for anti-gAChR antibodies, and we confirmed sicca complex, orthostatic hypotension, upper and lower gastrointestinal (GI) symptoms, and bladder dysfunction at high rates. CONCLUSION The present results suggest the possibility of anti-gAChR antibodies aiding the diagnostics of SS with autonomic dysfunction.
Collapse
Affiliation(s)
- Akihiro Mukaino
- a Department of Clinical Neuroscience and Neurology , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Shunya Nakane
- b Department of Clinical Research and.,c Department of Neurology , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | | | - Hideki Nakamura
- d Department of Immunology and Rheumatology , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Tomo Miyagi
- e Department of Cardiovascular Medicine, Nephrology and Neurology , University of the Ryukyu School of Medicine , Okinawa , Japan
| | - Kanako Shiroma
- e Department of Cardiovascular Medicine, Nephrology and Neurology , University of the Ryukyu School of Medicine , Okinawa , Japan
| | - Takashi Tokashiki
- e Department of Cardiovascular Medicine, Nephrology and Neurology , University of the Ryukyu School of Medicine , Okinawa , Japan
| | - Yasuhiro Fuseya
- f Department of Neurology , Kitano Hospital Medical Research Institute , Osaka , Japan
| | - Kazuhide Ochi
- g Department of Neurology , Hiroshima University Hospital , Hiroshima , Japan
| | - Masataka Umeda
- d Department of Immunology and Rheumatology , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Tetsuya Nakazato
- h Department of Neurology , Sapporo Yamanoue Hospital , Sapporo , Japan
| | - Shinji Akioka
- i Department of Pediatrics, Graduate School of Medical Science , Kyoto Prefectural University of Medicine , Kyoto , Japan
| | - Hiroyuki Maruoka
- j Department of Neurology and Neurological Science, and Predictive and Preventive Medicine , Tokyo Medical and Dental University , Tokyo , Japan
| | | | - Shu-Ichi Igarashi
- l Department of Neurology , Niigata City General Hospital , Niigata , Japan , and
| | - Katsunori Yokoi
- m Department of Neurology , Anjo Kosei Hospital , Aichi , Japan
| | - Yasuhiro Maeda
- c Department of Neurology , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Waka Sakai
- c Department of Neurology , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Hidenori Matsuo
- c Department of Neurology , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Atsushi Kawakami
- d Department of Immunology and Rheumatology , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| |
Collapse
|
17
|
Imrich R, Alevizos I, Bebris L, Goldstein DS, Holmes CS, Illei GG, Nikolov NP. Predominant Glandular Cholinergic Dysautonomia in Patients With Primary Sjögren's Syndrome. Arthritis Rheumatol 2015; 67:1345-52. [PMID: 25622919 DOI: 10.1002/art.39044] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 01/20/2015] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The autonomic nervous system (ANS) modulates exocrine gland function. Available data show poor correlation between the degree of function and destruction of the exocrine glands in primary Sjögren's syndrome (SS), suggesting that other mechanisms, such as autonomic dysfunction, may be important in these patients. The aim of this study was to perform a comprehensive analysis of sympathoneural and sympathetic cholinergic function in well-characterized patients with primary SS. METHODS Twenty-one patients with primary SS (mean ± SEM age 44.2 ± 2.8 years) and 13 healthy control subjects (mean ± SEM age 50.8 ± 1.9 years) were assessed during orthostasis and intravenous injection of edrophonium (10 mg). The postganglionic sympathetic cholinergic system was evaluated by assessing sweat production by means of the Quantitative Sudomotor Axon Reflex Test (QSART). Tests of gastric emptying were used to assess the gastrointestinal ANS in primary SS patients. RESULTS The velocity index and the acceleration index were significantly higher (P < 0.05) in patients with primary SS as compared to controls, both before and during the orthostatic and edrophonium tests. Findings of other hemodynamic and neurochemical parameters did not differ between primary SS patients and controls during the orthostasis and edrophonium test; however, the edrophonium-induced saliva increment was lower in primary SS patients (P = 0.002). Abnormally low sweat production was found in 4 primary SS patients but in none of the controls, as determined by the QSART. Gastric empting was delayed in 53% of primary SS patients. CONCLUSION We observed subtle differences in several ANS domains, including the gastrointestinal and sympathocholinergic systems, suggesting the presence of a complex ANS dysfunction in primary SS. The impact was greatest on the exocrine glands, with subtle differences in the cardiac parasympathetic function that were independent of glandular inflammation and atrophy, suggesting an alternative mechanism of disease pathogenesis in primary SS.
Collapse
Affiliation(s)
- Richard Imrich
- Institute of Experimental Endocrinology, Slovak Academy of Sciences, Bratislava, Slovak Republic
| | | | | | | | | | | | | |
Collapse
|