Distinct activation of the sympathetic adreno-medullar system and hypothalamus pituitary adrenal axis following the caloric vestibular test in healthy subjects

Assessing the impact of migraine on benign paroxysmal positional vertigo symptoms and recovery

BACKGROUND

During episodes of benign paroxysmal positional vertigo (BPPV), individuals with migraine, compared with individuals without migraine, may experience more severe vestibular symptoms because of their hyperexcitable brain structures, more adverse effects on quality of life, and worse recovery processes from BPPV.

METHODS

All patients with BPPV were assigned to the migraine group (MG, n = 64) and without migraine group (BPPV w/o MG, n = 64) and completed the Vertigo Symptom Scale (VSS), Vertigo Dizziness Imbalance Symptom Scale (VDI-SS), VDI Health-Related Quality of Life Scale (VDI-HRQoLS), Beck Anxiety Inventory (BAI), and Beck Depression Inventory (BDI) at the time of BPPV diagnosis (baseline) and on the one-month follow-up. Headache Impact Test-6 and Migraine Disability Assessment Scale were used for an assessment of headache. Motion sickness was evaluated based on the statement of each patient as present or absent.

RESULTS

Compared with the BPPV w/o MG, the MG had higher VSS scores at baseline [19.5 (10.7) vs. 11.3 (8.5); p < 0.001] and on one-month follow-up [10.9 (9.3) vs. 2.2 (2.7), p < 0.001]; experienced more severe dizziness and imbalance symptoms based on the VDI-SS at baseline (61.9% vs. 77.3%; p < 0.001) and after one month (78.9% vs. 93.7%, p < 0.001); and more significantly impaired quality of life according to the VDI-HRQoLS at baseline (77.4% vs. 91.8%, p < 0.001) and after one month (86.3% vs. 97.6%, p < 0.001). On the one-month follow-up, the subgroups of patients with moderate and severe scores of the BAI were higher in the MG (39.2%, n = 24) than in the BPPV w/o MG (21.8%, n = 14) and the number of patients who had normal scores of the BDI was lower in the MG than in the BPPV w/o MG (67.1% vs. 87.5%, p = 0.038).

CONCLUSION

Clinicians are advised to inquire about migraine when evaluating patients with BPPV because it may lead to more intricate and severe clinical presentation. Further studies will be elaborated the genuine nature of the causal relationship between migraine and BPPV.

Vestibular Disorders and Hormonal Dysregulations: State of the Art and Clinical Perspectives

The interaction between endocrine and vestibular systems remains poorly documented so far, despite numerous observations in humans and animals revealing direct links between the two systems. For example, dizziness or vestibular instabilities often accompany the menstrual cycle and are highly associated with the pre-menopause period, while sex hormones, together with their specific receptors, are expressed at key places of the vestibular sensory network. Similarly, other hormones may be associated with vestibular disorders either as causal/inductive factors or as correlates of the pathology. This review was carried out according to the PRISMA method, covering the last two decades and using the MEDLINE and COCHRANE databases in order to identify studies associating the terms vestibular system and/or vestibular pathologies and hormones. Our literature search identified 646 articles, 67 of which referred directly to vestibular dysfunction associated with hormonal variations. While we noted specific hormonal profiles depending on the pathology considered, very few clinical studies attempted to establish a direct link between the expression of the vestibular syndrome and the level of circulating hormones. This review also proposes different approaches to shed new light on the link between hormones and vestibular disorders, and to improve both the diagnosis and the therapeutic management of dizzy patients.

Establishment of quantitative indicators for an efficient treatment on masticatory muscle pain

BACKGROUND

Although several studies have investigated effective treatments for masticatory muscle pain (MMP), no unified conclusion has been drawn regarding the effectiveness of these treatments.

OBJECTIVES

This study aimed to define quantitative indicators for predicting the outcome of MMP treatment.

MATERIALS AND METHODS

In total, patients aged 20-70 years were recruited and divided into the MMP (n = 24) and control (n = 36) groups, based on the presence of MMP according to the Diagnostic Criteria for Temporomandibular Disorders. At pretreatment, the MMP group was assessed using quantitative indicators such as subjective pain levels, pain duration, graded chronic pain scale (GCPS), and perceived stress scale (PSS). Salivary alpha-amylase (sAA) and interleukin-6 (IL-6) levels were analyzed. The masticatory muscle palpation score and the range of mouth opening were measured. At posttreatment, subjective pain levels, mouth opening, and treatment/medication duration were examined. The PSS and sAA levels were assessed in the control group.

RESULTS

sAA levels in the MMP group were significantly higher than those in the control group (p < .05). The masseter muscle palpation score (MPS) showed a positive correlation with IL-6 levels (ρ = 0.503, p < .05) and a negative correlation with nonsteroidal anti-inflammatory drug (NSAID) treatment period (ρ = -0.462, p < .05). The temporalis muscle palpation score (TPS) was positively correlated with pain duration and GCPS grade (ρ = 0.483, p < .05, and ρ = 0.445, p < .05, respectively).

CONCLUSIONS

Treatment with NSAIDs was effective in the MMP group with high MPS and IL-6 levels, but not in the MMP group with high TPS, pain duration, and GCPS grade.

Cortisol awake response imbalance as an indicator of acute central serous chorioretinopathy: Relationship with choriocapillaris and choroidal features

Purpose

The purpose of the present study was to measure in central serous chorioretinopathy (CSC) the salivary cortisol awake response (CAR) delta percentage (Δ%) variation, a distinct and robust indicator of cortisol rhythm during wakefulness, commonly proposed as a marker of hypothalamic-pituitary adrenal (HPA) axis activity, whose alteration is frequently associated with several adverse health outcomes.

Methods

In the present cross-sectional observational study, salivary CAR Δ% variation was assessed in 17 adult male subjects affected by acute naïve CSC and compared to 17 matched healthy controls. Choroid vasculature metrics were assessed in the study population by measuring the subfoveal choroidal thickness (FCT) and the choroidal vascularity index (CVI) by the imaging technique of enhanced-depth imaging spectral-domain optical coherence tomography (EDI-SD-OCT). Furthermore, flow signal void area features of the choriocapillaris were evaluated in the study population using OCT angiography (OCTA).

Results

Both the control and CSC groups showed a physiological cortisol increase that occurred during the first 30 min after awaking. However, CSC adult male patients showed remarkably blunted CAR Δ% variation in comparison with controls, which might reflect a CSC-related imbalance of HPA axis activity. Statistically significant correlations were shown by Pearson’s correlation test between salivary CAR Δ% and the selected choroidal and choriocapillaris imaging biomarkers (FCT, CVI, and flow signal void area) in the study population.

Conclusion

In conclusion, alterations of the CAR Δ% increase, associated with choroidal-retinal metrics, might provide a window into the physiopathology of acute CSC, suggesting a possible common factor to explain the association between stress and CSC.

A review on pathophysiological aspects of Sleep Deprivation

Sleep deprivation (SD) (also referred as insomnia) is a condition in which peoples fails to get enough sleep due to excessive yawning, facing difficulty to learn new concepts, forgetfulness as well as depressed mood. This could be occurs due to several possible reasons including medications, stress (caused by shift work). Despite the fact that sleep is important for the normal physiology, it currently affects millions of people around the world US (70 million) and Europe (45 million). Due to increase work demand nowadays lots of peoples experiencing sleep deprivation hence, this could be the reason for several car accident followed by death and morbidity. This review highlighted the impact of SD on neurotransmitter release and functions, theories (Flip-flop theory, oxidative stress theory, neuroinflammation theory, neurotransmitter theory, and hormonal theory) associated with SD pathogenesis apart from this it also demonstrate the molecular pathways underlying SD (PI3K and Akt , NF-κB, Nrf2, and adenosine pathway. However, this study also elaborates the SD induced changes in the level of neurotransmitters, hormonal, and mitochondrial functions. Along with this, it also covers several molecular aspects associated with SD as well. Through this study a link is made between SD and associated causes, which will further help to develop potential therapeutic strategy against SD.

Hormones and Vestibular Disorders: The Quest for Biomarkers

The vestibular system exerts control over various functions through neural pathways that are not yet fully mapped. Functional dysregulations or tissue lesions at different levels of the peripheral and the central vestibular networks can alter these different functions, causing a wide variety of symptoms, ranging from posturo-locomotor alterations to psychiatric syndromes such as PPPD, including the deregulation of the main biological functions. These different symptoms differ by their expression kinetics (they each appear and regress with their own kinetics) by the targets affected (muscles, organs, and brain areas) and by the sensitivity specific to each individual. Vestibular pathologies thus cover a mosaic of distinct effects, and they involve various effectors—which constitute the many markers of their different types and stages. It is therefore crucial, to predict the onset of a vertigo syndrome, to follow its temporal course, or to monitor the impact of therapeutic approaches, and to have specific and reliable biomarkers. Hormonal variations are among the possible sources of biomarkers for neurotology. We know that specific hormonal profiles can promote the appearance of vestibular disorders. We also know that the expression of vertigo syndrome is accompanied by measurable hormonal variations. The link between endocrine deregulation and vestibular alterations therefore no longer needs to be proven. However, there are still few data on their precise correlations with the vertigo syndrome. This study was undertaken with the aim to deliver an extensive review of the hormonal alterations linked to vestibular disorders. A review of the literature covering the last two decades was carried out using the MEDLINE and COCHRANE databases in order to identify studies associating the terms vestibular system or vestibular pathologies and hormones. Bibliographic data provides several outcomes in terms of therapeutic innovation in the diagnosis and therapeutic follow-up of vestibular pathologies.

Relationship of Choroidal Vasculature and Choriocapillaris Flow With Alterations of Salivary α-Amylase Patterns in Central Serous Chorioretinopathy

Purpose

An abnormality in choroidal vasculature is a known factor in the pathogenesis of central serous chorioretinopathy (CSC), a chorioretinal disease affecting mostly middle-aged males. The purpose of the present study was to investigate the role of the autonomic nervous system (ANS) in the pathophysiology of CSC.

Methods

This was a cross-sectional observational study in which characteristic choroidal vasculature metrics were assessed by measuring the subfoveal choroidal thickness (FCT) and the choroidal vascularity index (CVI) using the imaging technique of enhanced-depth imaging spectral-domain optical coherence tomography (EDI-SD-OCT). Furthermore, flow signal void area features were also evaluated in the study population using OCT angiography (OCTA). Diurnal patterns of salivary α-amylase (a-AMY) production, proposed as a marker of autonomic activity, were assessed in an adult male study population affected by acute naïve CSC in comparison with matched healthy controls.

Results

Results include an overall higher diurnal output of salivary a-AMY production, which is in line with the phenomenon of a sympathetic “drive” playing a role in the pathophysiology of CSC, and a flattened diurnal percentage variation in α-AMY in CSC-affected subjects. Furthermore, Pearson's coefficient test revealed statistically significant correlations between salivary α-AMY diurnal percentage variation and selected choroidal imaging biomarkers (FCT, CVI, and flow signal void area). Finally, multiple linear regression analysis identified salivary α-AMY diurnal percentage production as the sole predictor of the CVI and flow signal void area in the study population.

Conclusions

Autonomic nervous system dysregulation was highlighted in CSC patients.

The effect of migraine and motion sickness on symptoms evoked by the caloric vestibular test

BACKGROUND

The caloric vestibular test (CVT) may evoke headache and vestibular symptoms in susceptible people. Patients with migraines have higher susceptibility to motion sickness. In migraines, impaired habituation to repetitive stimuli is a well-known interictal abnormality.

OBJECTIVE

This study is aimed at evaluating CVT-evoked headache, nausea, vomiting, and imbalance in patients with and without migraine and/or motion sickness.

METHODS

A retrospective data analysis was performed on 554 patients with a complaint of dizziness who underwent bithermal CVT at a tertiary referral center. The occurrences of CVT-evoked headache, nausea, vomiting, and imbalance were observed in four groups: patients with only migraine (MG; n = 94), those with only motion sickness (MSG; n = 89), those with migraine and motion sickness (MMSG; n = 122), and those without migraine and motion sickness (non-MMSG; n = 146). The differences between the groups were assessed.

RESULTS

The mean ages of groups were similar (p = 0.534). The proportions of females were higher in the MG, MSG, and MMSG (p = 0.001). The severity of nausea and headache for each gender was higher in the MG, MSG, and MMSG (p <  0.001). Vomiting was more common in MMSG among males (p = 0.003), while there was no difference between groups among females (p = 0.099). Imbalance was more common in MMSG among females (p <  0.001). A relationship was detected between age and imbalance (p <  0.001), where an increased risk for imbalance was evident with greater age. Three patients in the MMSG needed hospitalization after CVT.

CONCLUSIONS

Special caution is needed when performing caloric testing for patients with migraines or MS since CVT-evoked symptoms may occur with higher incidence and intensity, which might be related to a lack of habituation in neuronal information processing after robust sensory stimuli like CVT.

Venoarterial Extracorporeal Membrane Oxygenation as an Effective Therapeutic Support for Refractory Cardiac Arrest in the Setting of Spinal Anesthesia: A Case Report and Literature Review

Cardiac arrest is the most serious event among the complications associated with spinal anesthesia. Spinal anesthesia reduces the release of catecholamines and impairs neuroendocrine response following cardiac arrest, which contributes cardiopulmonary resuscitation (CPR) more difficult. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) may be a bridge to provide a more effective and durable mechanical solution under this extremely critical condition. This study reports a 50-year-old man who was scheduled to undergo surgical great saphenous vein varices under spinal anesthesia. A sudden cardiac arrest occurred after spinal anesthesia. Standard CPR was performed and large doses of vascular drugs are administered, but the effect of resuscitation was still poor. We fastly initiated VA-ECMO to provide cardiopulmonary support for this refractory cardiac arrest. Fortunately, the patient was successfully resuscitated with complete recovery. In summary, standard CPR might more difficult during spinal block anesthesia. Quick-started VA-ECMO is a potential option under this situation, which protects the patient from further harm from repeated prolonged CPR, refractory hypotension and deteriorated desaturation, and therefore benefit for patient in this critical condition.

Psychological Profile and Distinct Salivary Cortisol Awake Response (CAR) in Two Different Study Populations with Obstructive Sleep Apnea (OSA) and Central Serous Chorioretinopathy (CSC)

Obstructive sleep apnea (OSA) and central serous chorioretinopathy (CSC) are in terms of nosography different pathologies, however they share a stress-related physio-pathogenetic component, not yet explored in depth. Therefore, the aim of the present study was to ascertain whether OSA and CSC share a common profile, specifically in cortisol production focusing on the cortisol awake response (CAR), the area under curve (AUC_CAR) and the SLOPE_CAR compared with healthy matched controls. Furthermore, standardized self-administered questionnaires were used to identify mental health status related to depression, anxiety and subjective stress perception levels in the study populations. The results showed hypothalamus-pituitary-adrenal (HPA) axis activity anomalies, represented by a flattening CAR in the OSA group and a statistically significant increase in cortisol production in CSC patients at awakening. This disarrangement of the HPA axis activity associated with elevated distress and mental health scores, and its presence in both patients with OSA and patients with CSC, might represent the shared path explaining the stress-related component in these diseases. Further research is needed to investigate the psycho-neuro-endocrinological aspects of OSA and CSC to determine whether psychoeducation on effective stress coping strategies might be of value in improving the quality of life of OSA and CSC patients.

Stress and the vestibular system

In this chapter we review the existing literature regarding the interactions between stress and the mechanisms that maintain balance. Evidence suggests that the interplay between neuro-endocrine and psychological factors may have a significant role in balance function. For example, in healthy individuals vestibular stimulation has been shown to trigger the stress response as indicated by increased blood cortisol levels, whereas in patients with vestibular pathology factors such as resilience and anxiety may be the key focus of interactions with stress. Critically, factors such as anxiety are known to influence clinical outcomes, despite our mechanistic understanding of these processes remaining in their infancy.

Diurnal trajectories of salivary cortisol and α-amylase and psychological profiles in patients with central serous chorioretinopathy

It has been hypothesized that the occurrence of central serous chorioretinopathy (CSC) might be associated with stress. Therefore, our purpose was to investigate the diurnal trajectories of salivary cortisol and α-amylase (α-Amy) - markers of hypothalamic-pituitary-adrenal (HPA) axis and sympathetic-adrenal-medullary (SAM) system activity, respectively - and psychological profiles in idiopathic acute CSC. This cross-sectional observational case-control study, which included self-reported psychometric questionnaires, was formally approved by the Ethics Committee. Written informed consent was obtained from all participants. Home diurnal saliva collection was scheduled at several timepoints: at awakening, 30 and 60 min later, and at approximately 13:00 h and 20:00 h. Twenty consecutive male subjects with first-episode CSC attending the outpatient clinic of the Retina Medical Service at the Bietti Foundation were enrolled in the study. Twenty age-matched subjects were recruited as controls. After their initial enrollment, 3 subjects per group were excluded. The production of cortisol and α-Amy and the scores on the negative subscale of the Positive/Negative Affect Schedule, the Daily Hassles and Stress Scale and the Beck Depression Inventory were higher in the CSC group than in the control group. To estimate the diurnal trends in the production of salivary cortisol and α-Amy, an equation was derived for each group of the study population. The equations describing the interpolated regression lines gave salivary cortisol and salivary α-Amy slopes that were determined to be significantly different by Student's t-test (cortisol: t = 3.533, p < .001; α-Amy: t = 2.382, p = .018). Furthermore, the area under the curve with respect to the ground (AUC_G) was calculated to summarize repeated salivary biomarker measurements from 07:00 h to 08:00 h for assessment of the cortisol awakening response (CAR) and the α-Amy awakening response (AR). The diurnal cortisol AUC_G and diurnal α-Amy AUC_G were calculated from 07:00 h to 20:00 h. The CAR AUC_G values of the CSC patients were significantly higher than those of the controls. No differences between the two groups were detected for the α-Amy AR AUC_G. The present study adds novel information to the growing body of data suggesting that abnormal diurnal activity of the HPA axis and the SAM system is associated with CSC in susceptible individuals, providing ophthalmologists with a new chronobiological approach for these patients.

Investigating the Hypothesis of Stress System Dysregulation as a Risk Factor for Central Serous Chorioretinopathy: A Literature Mini-Review

Background: This mini-review addressed the question "what do we know about the association between the dysregulation of stress systems (HPA axis and SAM) and the onset and prognosis of CSC in adult populations?" Methods: The literature mini-review was conducted through electronic searches using the PubMed, Web of Science, and Scopus databases. All published human and animal studies with both observational and experimental designs from 1966 to October 2018 were included. Results: Our search identified 229 reports, of which 32 articles were ultimately identified to be reviewed in this paper. Among these key articles, twenty-three were related to exogenous and/or endogenous high glucocorticoids as risk factors for CSC, seven were related to Type-A behavior and chronic psychological distress as risk factors for idiopathic CSC, and two were related to stress-induced animal models of CSC. Nineteen out of twenty-three studies in the first group reported a consistent association between high circulating corticosteroids and the onset and prognosis of CSC. Six out of seven studies in the second group reported a consistent association between stress-induced allostatic (over)load and the appearance of more- or less-severe CSC disorders, assuming that elevated circulating steroids may constitute a kind of risk factor for the eye through dysregulation of the HPA axis. All the selected studies reported HPA axis dysregulation as a possible common factor to explain the association between high circulating corticosteroids and CSC. In contrast, the involvement of the SAM system is only indirectly taken into consideration through the PA and HR measures and/or plasma and 24-h urinary catecholamine levels. Therefore, information regarding the involvement of SAM system dysregulation in the onset and prognosis of CSC is lacking. This observation is particularly relevant in view of the fact that animal models of CSC in monkeys are primarily induced by adrenergic hypertonia and that the course of experimental CSC is not further exacerbated by the administration of corticosteroids.