Cardiac autonomic imbalance in children with allergic rhinitis

The 24-Hour Cardiac Autonomic Activity in Patients With Allergic Rhinitis

BACKGROUND

Definitive knowledge of the 24-hour cardiac autonomic activity in patients with allergic rhinitis (AR) is lacking. Thus, we aimed to evaluate heart rate variability (HRV), which is used to measure cardiac autonomic activity by 24-hour Holter monitoring in patients with AR.

METHODS

We enrolled 32 patients who visited our clinic and were diagnosed with AR. The control group was selected four-fold (n = 128) by matching (age, sex, hypertension, and diabetes) in the AR group from a Holter registry in the cardiology department. The HRV results, which were measured using 24-hour Holter monitoring, were compared between the AR and control groups.

RESULTS

All time-domain parameters of HRV revealed no differences between the groups. However, among the frequency domain parameters of HRV, the low-frequency to high-frequency ratio and low-frequency power in normalized units were significantly lower in the AR group. Conversely, high-frequency power in normalized units was significantly higher in the AR group. In the multiple regression analysis, AR was independently associated with sympathetic withdrawal (adjusted odds ratio = 3.393, P = 0.020) after adjusting for age, sex, hypertension, diabetes mellitus, and hyperlipidemia.

CONCLUSIONS

The present findings suggest differences in cardiac autonomic activity which are related with sympathetic withdrawal in patients with AR compared with that in the normal population over 24 hours.

Neonatal rhinorrhea, heart rate variability, and childhood exercise-induced wheeze

Background

There is increasing evidence linking infant rhinorrhea to school-age exercise-induced wheeze (EIW) via a parasympathetic nervous system pathway. The ratio of the root mean square of successive differences in heart beats (RMSSD) measured in quiet sleep versus active sleep (RMSSDQS:AS) is a novel biomarker in asthma.

Objective

We tested the hypotheses that (1) neonatal rhinorrhea predicts childhood EIW independent of other neonatal respiratory symptoms, (2) neonatal RMSSDQS:AS predicts childhood EIW, and (3) RMSSDQS:AS mediates the association between neonatal rhinorrhea and childhood EIW.

Methods

Participants from the Safe Passage/Environmental Influences on Child Health Outcomes (PASS/ECHO) prospective birth cohort had heart rate variability extracted from electrocardiogram traces acquired in the first month of life. Parents reported on rhinorrhea in their child at age 1 month and on EIW in their child at ages 4 to 11 years.

Results

In models (N = 831) adjusted for potential confounders and covariates, including neonatal wheeze, cough and fever, neonatal rhinorrhea-predicted childhood EIW (relative risk [RR] = 2.22; P = .040), specifically, among females (RR = 3.38; P = .018) but not males (RR = 1.39; P = .61). Among participants contributing data in both active and quiet sleep (n = 231), RMSSDQS:AS predicted EIW (RR = 2.36; P = .003) and mediated the effect estimate of neonatal rhinorrhea predicting EIW among females. Half of the females with a higher RMSSDQS:AS and neonatal rhinorrhea (n = 5 of 10) developed EIW as compared with 1.8% of the other females (n = 2 of 109) (P < .001).

Conclusions

Our findings support dysregulation of the parasympathetic nervous system in infancy as one of the possible underlying mechanisms for the development of EIW later in childhood among females, which could aid in the development of future interventions.

Daily allergy burden and heart rate characteristics in adults with allergic rhinitis based on a wearable telemonitoring system

BACKGROUND

Allergic rhinitis includes a certain degree of autonomic imbalance. However, no information is available on how daily changes in allergy burden affect autonomic imbalance. We aimed to estimate associations between daily allergy burden (allergy symptoms and mood) and daily heart rate characteristics (resting heart rate and sample entropy, both biomarkers of autonomic balance) of adults with allergic rhinitis, based on real-world measurements with a wearable telemonitoring system.

METHODS

Adults with a tree pollen allergy used a smartphone application to self-report daily allergy symptoms (score 0-44) and mood (score 0-4), and a Mio Alpha 2 wristwatch to collect heart rate characteristics during two pollen seasons of hazel, alder and birch in Belgium. Associations between daily allergy burden and heart rate characteristics were estimated using linear mixed effects distributed lag models with a random intercept for individuals and adjusted for potential confounders.

RESULTS

Analyses included 2497 participant-days of 72 participants. A one-point increase in allergy symptom score was associated with an increase in next-day resting heart rate of 0.08 (95% CI: 0.02-0.15) beats per minute. A one-point increase in mood score was associated with an increase in same-day sample entropy of 0.80 (95% CI: 0.34-1.26) × 10^-2 . No associations were found between allergy symptoms and heart rate sample entropy, nor between mood and resting heart rate.

CONCLUSION

Daily repeated measurements with a wearable telemonitoring system revealed that the daily allergy burden of adults with allergic rhinitis has systemic effects beyond merely the respiratory system.

Mild allergic airways responses to an environmental mixture increase cardiovascular risk in rats

Recent epidemiological findings link asthma to adverse cardiovascular responses. Yet, the precise cardiovascular impacts of asthma have been challenging to disentangle from the potential cardiovascular effects caused by asthma medication. The purpose of this study was to determine the impacts of allergic airways disease alone on cardiovascular function in an experimental model. Female Wistar rats were intranasally sensitized and then challenged once per week for 5 weeks with saline vehicle or a mixture of environmental allergens (ragweed, house dust mite, and Aspergillus fumigatus). Ventilatory and cardiovascular function, measured using double-chamber plethysmography and implantable blood pressure (BP) telemetry and cardiovascular ultrasound, respectively, were assessed before sensitization and after single and final allergen challenge. Responses to a single 0.5 ppm ozone exposure and to the cardiac arrhythmogenic agent aconitine were also assessed after final challenge. A single allergen challenge in sensitized rats increased tidal volume and specific airways resistance in response to provocation with methacholine and increased bronchoalveolar lavage fluid (BALF) eosinophils, neutrophils, lymphocytes, cytokines interleukin (IL)-4, IL-5, IL-10, IL-1β, tumor necrosis factor-α, and keratinocyte chemoattract-growth-related oncogene characteristic of allergic airways responses. Lung responses after final allergen challenge in sensitized rats were diminished, although ozone exposure increased BALF IL-6, IL-13, IL-1 β, and interferon-γ and modified ventilatory responses only in the allergen group. Final allergen challenge also increased systolic and mean arterial BP, stroke volume, cardiac output, end-diastolic volume, sensitivity to aconitine-induced cardiac arrhythmia, and cardiac gene expression with lesser effects after a single challenge. These findings demonstrate that allergic airways responses may increase cardiovascular risk in part by altering BP and myocardial function and by causing cardiac electrical instability.

Increased Heart Rate Variability Response Among Infants with Reported Rhinorrhea and Watery Eyes: A Pilot Study

Introduction

Previously, we found that reported infant rhinorrhea and watery eyes without a cold (RWWC) predicted school age exercise-induced wheeze, emergency department visits, and hospitalizations. These findings were independent of allergic sensitization, and we theorized that increased parasympathetic tone underlay the association. We also reported that increased heart-rate variability (HRV) in infants predicted wheeze in 2–3 year-olds. In a convenience sample of children participating in a birth cohort study, we tested the hypothesis that infants with RWWC would have elevated HRV, indicating increased parasympathetic tone.

Methods

RWWC symptoms since birth were queried for 3-month-old children. At 4-months, HRV was assessed (root mean square of successive differences [RMSSD]) during a standardized infant–mother still-face paradigm, which included 2 minutes of mother/child play immediately followed by 2 minutes of the mother maintaining a still-face.

Results

Among participants (n=38), RWWC was common for girls (32%) and boys (21%). The children with the greatest decrease in RMSSD between play and still-face challenge (lowest tertile) had a higher prevalence of RWWC as compared with children in the higher tertiles (50% vs 16%, P=0.045). In a logistic regression model controlling for sex, age and time between HRV and RWWC assessment, children with greater decrease in HRV between play and still-face (lowest tertile) had greater odds of having RWWC (odds ratio=6.0, P=0.029).

Conclusion

In this relatively small study, we demonstrated greater decreases in HRV in response to a stressor among children with reported RWWC, suggesting that these children might have increased parasympathetic tone and/or overall greater vagal reactivity.

Rationale and Design of a Panel Study Investigating Six Health Effects of Airborne Pollen: The EPOCHAL Study

Background: While airborne pollen is widely recognized as a seasonal cause of sneezing and itchy eyes, its effects on pulmonary function, cardiovascular health, sleep quality, and cognitive performance are less well-established. It is likely that the public health impact of pollen may increase in the future due to a higher population prevalence of pollen sensitization as well as earlier, longer, and more intense pollen seasons, trends attributed to climate change. The effects of pollen on health outcomes have previously been studied through cross-sectional design or at two time points, namely preceding and within the period of pollen exposure. We are not aware of any observational study in adults that has analyzed the dose-response relationship between daily ambient pollen concentration and cardiovascular, pulmonary, cognitive, sleep, or quality of life outcomes. Many studies have relied on self-reported pollen allergy status rather than objectively confirming pollen sensitization. In addition, many studies lacked statistical power due to small sample sizes or were highly restrictive with their inclusion criteria, making the findings less transferable to the "real world." Methods: The EPOCHAL study is an observational panel study which aims to relate ambient pollen concentration to six specific health domains: (1) pulmonary function and inflammation; (2) cardiovascular outcomes (blood pressure and heart rate variability); (3) cognitive performance; (4) sleep; (5) health-related quality of life (HRQoL); and (6) allergic rhinitis symptom severity. Our goal is to enroll 400 individuals with diverse allergen sensitization profiles. The six health domains will be assessed while ambient exposure to pollen of different plants naturally varies. Health data will be collected through six home nurse visits (at approximately weekly intervals) as well as 10 days of independent tracking of blood pressure, sleep, cognitive performance, HRQoL, and symptom severity by participants. Through repeated health assessments, we aim to uncover and characterize dose-response relationships between exposure to different species of pollen and numerous acute health effects, considering (non-)linearity, thresholds, plateaus and slopes. Conclusion: A gain of knowledge in pollen-health outcome relationships is critical to inform future public health policies and will ultimately lead toward better symptom forecasts and improved personalized prevention and treatment.

Sleep disturbances and affecting factors in young children with food allergy and their mothers

OBJECTIVE

To examine sleep patterns and sleep disturbance of children with food allergy (FA) and their mothers.

METHODS

The food allergy group included 71 children with mean age, 2.97±1.52 years, and 58 control children were recruited the study. Mothers of children completed the Childhood Sleep Habits Questionnaire (CSHQ) and The Pittsburgh Sleep Quality Index (PSQI) in order to evaluate sleep disturbance in both children and themselves. Depressive symptomatology of mothers of children with or without food allergy was assessed with Beck-Depression Inventory II (BDI-II).

RESULTS

The mean total scores of CSHQ was 49.33±7.93 (range=31-68) in the FA and 42.39±6.43 (range=30-62) in controls. The total CSHQ scores were significantly higher in children with FA than in controls (p=0.002). The total PSQI score was significantly higher in mothers of children with FA than in mothers of children without FA (7.09±3.11 vs 5.15±2.59, p<0.001) indicating that the mothers of children with FA had worse sleep quality. The mothers of children with FA had more depressive symptoms than mothers of children without FA. The mean total scores of BDI-II were 10.10±6.95 in mothers of children with FA and 7.78±6.64 in mothers of children without FA (p=0.005).

CONCLUSION

The presence of a food allergy in a child may be associated with a deterioration in sleep quality in children and mothers as well as increased depressive symptoms in mothers.

Increased salivary fluid flow in children with newly diagnosed allergic rhinitis

OBJECTIVES

The pathogenesis of allergic rhinitis (AR) may involve dysregulation of the autonomic nervous system (ANS). Salivary fluid flow and salivary alpha-amylase (sAA) secretion are able to reflect the activity of parasympathetic (PNS) and sympathetic nervous system (SNS), respectively. The study aims to address the ANS profile in children with newly diagnosed AR by measuring the salivary secretion pattern.

METHODS

We recruited thirty-three children with newly diagnosed AR and thirty-one age- and sex-matched healthy children as control. Saliva samples were collected in the morning and the salivary parameters, including salivary flow rate (SFR, ml/min) and sAA secretion rate (μg/min), were determined accordingly. We also measured the gene copy number of the sAA gene, AMY1, for each individual.

RESULTS

We detected a significantly higher SFR in AR children compared with healthy control (2.20 ± 0.55 vs. 1.63 ± 0.61; p = 0.0002). Similar sAA secretion rate was observed between the two groups (312.8 ± 124.8 (Healthy) vs. 347.9 ± 114.0 (AR) μg/min; p = 0.2444). Besides, the two groups did not differ in AMY1 gene copy number (7.2 ± 2.3 (Healthy) vs. 7.7 ± 2.2 (AR); p = 0.3493).

CONCLUSIONS

Our results implicate an overactivity of the PNS while normal SNS activity in children with newly diagnosed AR. The findings support a contributing role of the ANS dysfunction in the pathogenesis of AR.

Allergic rhinitis and the associated risk of nocturnal enuresis in children: a population-based cohort study

BACKGROUND

Despite controversy, an association between allergy and nocturnal enuresis (NE) has been reported for almost a century. Allergic rhinitis (AR)-associated sleep-disordered breathing frequently results in microarousals during sleep, decreased sleep efficiency, and change in sleep pattern and behavior. NE is a common sleep disorder in children. Hence, this study aimed to investigate the incidence and risk of NE in children with AR.

METHODS

A population-based cohort study was conducted among 327,928 children with AR and 327,601 non-AR controls between 2000 and 2012 in Taiwan. By the end of 2012, the incidence of NE in both cohorts, and the AR-to-non-AR cohort hazard ratios (HRs) were measured.

RESULTS

The adjusted HR of NE during the study period was 1.7-fold higher in the AR cohort compared to the non-AR cohort. The risk was greater for boys, children younger than 6 years old, those with comorbidities of asthma, atopic dermatitis, and attention deficit/hyperactivity disorder (ADHD), and those who had more than 5 AR-related medical visits per year. The risk of NE in the AR cohort decreased with follow-up time and was the highest within the first year after AR diagnosis.

CONCLUSION

Children with AR had a higher incidence and subsequent risk of NE. The risk of NE was greater for boys, younger children, and those with more frequent health utilization for AR symptoms.

Dynamic Changes in Heart Rate Variability and Nasal Airflow Resistance during Nasal Allergen Provocation Test

Allergic rhinitis is a major chronic respiratory disease and an immunoneuronal disorder. We aimed at providing further knowledge on the function of the neural system in nasal allergic reaction. Here, a method to assess simultaneously the nasal airflow resistance and the underlying function of autonomic nervous system (ANS) is presented and used during the nasal provocation of allergic and nonallergic subjects. Continuous nasal airflow resistance and spectral heart rate variability parameters show in detail the timing and intensity differences in subjects' reactions. After the provocation, the nasal airflow resistance of allergic subjects showed a positive trend, whereas LF/HF (Low Frequency/High Frequency) ratio and LF power showed a negative trend. This could imply a gradual sympathetic withdrawal in allergic subjects after the allergen provocation. The groups differed significantly by these physiological descriptors. The proposed method opens entirely new opportunities to research accurately concomitant changes in nasal breathing function and ANS.

Association between allergic and nonallergic rhinitis and obstructive sleep apnea

PURPOSE OF REVIEW

Allergic rhinitis and nonallergic rhinitis (NAR) are common disorders, which have been considered as potential risk factors for obstructive sleep apnea (OSA). This review summarizes the proposed underlying pathophysiological mechanisms to provide a better understanding of the relationship between these conditions.

RECENT FINDINGS

In adults, allergic rhinitis and NAR may be considered as symptoms potentiating, rather than risk potentiating factors in the pathophysiology of OSA, whereas in children, these are considered to be independent predictors for sleep-disordered breathing (SDB) and failure of adeno-tonsillectomy, the recommended first-line therapy for children with OSA. Current advances suggest IL-6 may be important in regulating the sleep-wake cycle, and serum soluble IL-6 receptor (sIL-6R) levels may reflect the severity of OSA. Elevated Th17/Treg ratio correlates positively with apnea-hypopnea index of OSA patients, and Th17 and Treg imbalances caused by allergic rhinitis and OSA, respectively, may possibly promote each other, leading to further imbalance. Moreover, obesity is a strong risk factor for OSA, and leptin plays an important role in ventilatory function and upper airway obstruction. The variant trigeminocardiac reflex and nasotrigeminal reflex may also be involved in the association between rhinitis and OSA.

SUMMARY

Allergic rhinitis/NAR and OSA are closely associated, and each condition can be detrimental to the other. Thus, clinicians should pay attention to the potential presence of allergic rhinitis/NAR in OSA patients and vice versa.

The association between cold hypersensitivity in the hands and feet and chronic disease: results of a multicentre study

Background

Cold hypersensitivity in the hands and feet (CHHF) is a common symptom in Korea and patients with CHHF complain of coldness in the hands and feet in an environment that is not considered cold by unaffected people. In traditional East Asian medicine, CHHF is believed to be accompanied by various diseases and symptoms, and is considered a symptom that needs active treatment. CHHF is used for pattern identification in the cold pattern, yang deficiency, and constitution. This study aimed to examine the differences in frequencies of chronic diseases with respect to the presence of CHHF.

Methods

Disease history, CHHF, body measurements, and blood test survey data from 6149 patients collected by 25 medical institutes in Korea were obtained from the Korean Medicine Data Center. The participants were divided into CHHF (n = 1909) and non-CHHF groups (n = 3017) according to the CHHF survey. The differences in frequencies of 18 diseases were analysed using chi-square tests, and the odds ratios (ORs) for each disease according to CHHF status were examined via logistic regression with adjustment for age, sex, and body mass index (BMI).

Results

Based on chi-square test results, the CHHF group showed a higher frequency of the following diseases: anaemia, hypotension, chronic gastritis, reflux oesophagitis, chronic rhinitis, dysmenorrhoea, and gastroduodenal ulcer. Diseases found in lower frequencies were as follows: hypertension, diabetes mellitus, impaired fasting glucose, dyslipidaemia, stroke, fatty liver, and angina pectoris. In addition, from the logistic regression with adjustment for age, sex, and BMI, the CHHF group showed a lower OR in diabetes mellitus and dyslipidaemia than the non-CHHF group, but a higher OR in degenerative arthritis, chronic gastritis, gastroduodenal ulcer, reflux oesophagitis, and chronic rhinitis.

Conclusions

This study showed that CHHF is associated with chronic disease. Further large-scale prospective studies are needed to validate these associations.

Association between allergic disease, sleep-disordered breathing, and childhood nocturnal enuresis: a population-based case-control study

BACKGROUND

Little is known about the associations between allergic disease, sleep-disordered breathing (SDB), and childhood nocturnal enuresis (NE). We examined whether allergic disease and SDB were associated with childhood NE.

METHODS

Data were assessed from the 2007-2012 Taiwan National Health Insurance Research Database. We enrolled 4308 children aged 5-18 years having NE diagnosis and age- and sex-matched 4308 children as the control group. The odds ratios of NE were calculated to determine an association with preexisting allergic disease and SDB.

RESULTS

A total of 8616 children were included in the analysis. Prevalence of allergic diseases and SDB was significantly higher for the NE group than the control group (all p < 0.001). After adjusting odds ratios for potential confounding factors, except asthma, children with allergic rhinitis, atopic dermatitis, allergic conjunctivitis, and obstructive sleep apnea (OSA) had significantly higher odds of NE compared with children never diagnosed. With stratification for sex, girls with allergic rhinitis, atopic dermatitis, allergic conjunctivitis, OSA, and snoring had significantly higher odds of NE, compared with girls never diagnosed. Only boys with allergic rhinitis and OSA were associated with increased odds of NE. With stratification for age, children aged 5-12 years with allergic rhinitis, atopic dermatitis, allergic conjunctivitis, and OSA had significantly higher odds of NE compared with those never diagnosed. Odds of NE increased with the number of comorbid allergic diseases.

CONCLUSIONS

Allergic diseases and SDB are associated with increased odds of childhood NE. The odds of NE increased with the number of comorbid allergic diseases present.

Rhinitis and sleep disorders: The trigeminocardiac reflex link?

Rhinitis, allergic or non-allergic, is an inflammatory condition of the nose. It is associated with a wide range of sleep disorders that are generally attributed to nasal congestion and presence of inflammatory mediators like cytokines and interleukins. However, the pathophysiological mechanisms behind these sleep disorders remain unclear. On the other hand, the trigeminocardiac reflex (TCR) has recently been linked to various sleep disorders like obstructive sleep apnea, sleep bruxism and rapid eye movement (REM) sleep apnea. TCR can be incited by stimulation of the trigeminal nerve or the area innervated by its branches including the nasal mucosa. Trigeminal nasal afferents can be activated on exposure to noxious stimuli (mechanical or chemical) like ammonia vapors, carbon-dioxide, nicotine, hypertonic saline, air-puffs and smoke. In rhinitis, there is associated neuronal hyper-responsiveness of sensory nasal afferents due to inflammation (which can be suppressed by steroids). This may further lead to increased occurrence of TCR in rhinitis. Moreover, there is involvement of autonomic nervous system both in rhinitis and TCR. In TCR, parasympathetic over activity and sympathetic inhibition leads to sudden onset bradycardia, hypotension, apnea and gastric motility. Also, the autonomic imbalance reportedly plays a significant role in the pathophysiology of rhinitis. Thus, considering these facts we hypothesize that the TCR could be the link between rhinitis and sleep disorders and we believe that further research in this direction may yield significant development in our understanding of sleep disorders in rhinitis.

Autonomic function in adults with allergic rhinitis and its association with disease severity and duration

BACKGROUND

The association between allergic rhinitis (AR) and the autonomic nervous system (ANS) has recently received substantial attention. However, no studies have assessed how the heart rate variability (HRV) parameters are associated with duration and disease severity in AR.

OBJECTIVE

To compare the difference in autonomic conditions among individuals with AR of various durations and severities and healthy controls.

METHODS

We divided individuals with AR into subgroups based on duration and severity of disease. Next, we measured HRV, and the results were compared among subgroups and healthy controls.

RESULTS

High frequency (HF) and normalized high frequency (NHF) were significantly higher in the intermittent group than in the control group, whereas normalized low frequency (NLF) and the ratio of absolute LF to HF power (LF/HF) were significantly lower in the intermittent group than in the control group. Furthermore, NLF was significantly higher in the persistent group than in the intermittent group. HF and NHF were significantly higher in the mild group than in the control group, whereas NLF and LF/HF were significantly lower in the mild group than in the control group. The total nasal symptom and itchy nose scores were negatively correlated with NHF.

CONCLUSION

Our results indicate that patients with intermittent and mild AR have hypervagal activity and hyposympathetic activity, and the predominance lessens in patients with more persistent AR and severe symptoms. Further investigation of the mechanisms underlying the association between autonomic function and persistent and severe AR is needed.

Concomitant dynamic changes in autonomic nervous system function and nasal airflow resistance during allergen provocation

Allergic rhinitis is a major chronic respiratory disease which more than 500 million people suffer from around the world. It is considered to be an immuno-neuronal disorder, but little is known about the part played by the neural system in nasal allergic reaction. This is due mainly to the lack of objective measurement techniques producing accurate, reliable and continuous measurement data about the dynamic changes in nasal respiratory function. Here, a method to assess the association of nasal airflow resistance and the underlying function of autonomic nervous system (ANS) is presented and used during the birch pollen provocation test. Ten allergic volunteers were challenged with allergen. Continuous nasal airflow resistance and spectral heart rate variability parameters were computed and analyzed for the dynamic changes. The derived signals show in detail the timing and intensity differences in subjects' reactions. After the provocation, the nasal airflow resistance rose gradually, whereas LF power and LF/HF ratio decreased gradually for all subjects. This implies gradually increasing sympathetic withdrawal in allergic patients during the provocation with allergen. The proposed method opens entirely new possibilities to assess accurately the dynamic and short-term changes in non-stationary nasal function and could increase the accuracy and reliability of diagnostics and assessment of the effect of nasal treatments.

Correlation Analysis between Polysomnography Diagnostic Indices and Heart Rate Variability Parameters among Patients with Obstructive Sleep Apnea Hypopnea Syndrome

Heart rate variability (HRV) can reflect the changes in the autonomic nervous system (ANS) that are affected by apnea or hypopnea events among patients with obstructive sleep apnea hypopnea syndrome (OSAHS). To evaluate the possibility of using HRV to screen for OSAHS, we investigated the relationship between HRV and polysomnography (PSG) diagnostic indices using electrocardiography (ECG) and PSG data from 25 patients with OSAHS and 27 healthy participants. We evaluated the relationship between various PSG diagnostic indices (including the apnea hypopnea index [AHI], micro-arousal index [MI], oxygen desaturation index [ODI]) and heart rate variability (HRV) parameters using Spearman's correlation analysis. Moreover, we used multiple linear regression analyses to construct linear models for the AHI, MI, and ODI. In our analysis, the AHI was significantly associated with relative powers of very low frequency (VLF [%]) (r = 0.641, P = 0.001), relative powers of high frequency (HF [%]) (r = -0.586, P = 0.002), ratio between low frequency and high frequency powers (LF/HF) (r = 0.545, P = 0.049), normalized powers of low frequency (LF [n.u.]) (r = 0.506, P = 0.004), and normalized powers of high frequency (HF [n.u.]) (r = -0.506, P = 0.010) among patients with OSAHS. The MI was significantly related to standard deviation of RR intervals (SDNN) (r = 0.550, P = 0.031), VLF [%] (r = 0.626, P = 0.001), HF [%] (r = -0.632, P = 0.001), LF/HF (r = 0.591, P = 0.011), LF [n.u.] (r = 0.553, P = 0.004), HF [n.u.] (r = -0.553, P = 0.004), and absolute powers of very low frequency (VLF [abs]) (r = 0.525, P = 0.007) among patients with OSAHS. The ODI was significantly correlated with VLF [%] (r = 0.617, P = 0.001), HF [%] (r = -0.574, P = 0.003), LF [n.u.] (r = 0.510, P = 0.012), and HF [n.u.] (r = -0.510, P = 0.012) among patients with OSAHS. The linear models for the PSG diagnostic indices were AHI = -38.357+1.318VLF [%], MI = -13.389+11.297LF/HF+0.266SDNN, and ODI = -55.588+1.715VLF [%]. However, the PSG diagnostic indices were not related to the HRV parameters among healthy participants. Our analysis suggests that HRV parameters are powerful tools to screen for OSAHS patients in place of PSG monitoring.

Patterns of heart rate variability and cardiac autonomic modulations in controlled and uncontrolled asthmatic patients

BACKGROUND

Previous heart rate variability (HRV) studies in asthmatic subjects (AS) demonstrate predominance of parasympathetic drive concomitant with low HRV, which is against the general belief that enhanced parasympathetic modulation improves HRV. The aim of this study was to compare patterns of HRV and cardiac autonomic modulations of AS to healthy control subjects (HS).

METHODS

Eighty AS and forty HS were enrolled in the study. Asthma control test and spirometry were used to discriminate uncontrolled (UA) from controlled (CA) asthmatic patients. Natural logarithmic (Ln) scale of total power (TP), very low frequency (VLF), low frequency (LF) and high frequency (HF) were used to evaluate HRV. Normalized low frequency (LF Norm) and high frequency (HF Norm) were used to determine sympathetic and parasympathetic autonomic modulations respectively.

RESULTS

CA patients achieved significantly higher LnTP, LnLF, LnHF and HF Norm but lower LF Norm and LnLF/HF compared with UA patients (p < 0.05). Although CA patients showed increased HRV and augmented vagal modulation compared with HS, these findings were no longer significant following adjustment for mean heart rates and anti-asthma treatment. All measured HRV parameters were not significantly different in UA patients compared with the HS (p > 0.05).

CONCLUSIONS

CA is associated with enhanced parasympathetic modulations and higher HRV compared with UA. However, neither CA nor UA patients had different autonomic modulations and/or HRV compared with HS.

Extraintestinal manifestations in children with gastrointestinal food allergy

OBJECTIVES

The presence of extraintestinal manifestations (EIM) in children with gastrointestinal (GI) food allergy (GIFA) is greatly debated. In the present study we assessed the prevalence of EIM in children with GIFA and investigated whether their presence is helpful in the allergy-focused history-taking process.

METHODS

The medical records of all children with a proven diagnosis of GIFA were reviewed along with those of children diagnosed as having inflammatory bowel disease (IBD) as controls. Data regarding age at onset, age at diagnosis, atopic family history, atopic comorbidities, GI symptoms, and EIM were recorded.

RESULTS

Data from 436 children with GIFA and 74 children with IBD were included in the analysis. EIM were documented in 368 children with GIFA, including fatigue (53.0%), allergic shiners (49.1%), mouth ulcers (39.0%), joint pain/hypermobility (35.8%), poor sleep (34.4%), night sweats (34.4%), headache (22.7%), and bed-wetting (17.7%). The proportion of patients with EIM was higher in the GIFA group compared with that in the IBD group (368/436 [84.4%] vs 40/74 [54.1%]; P < 0.001). Segregating the GIFA group into children with and without atopic comorbidities, both atopic (276/30; 89.9%) and nonatopic (93/130; 71.5%) children showed higher proportion of EIM than children with IBD ([40/74; 54.1%], P < 0.01 and <0.05, respectively).

CONCLUSIONS

GIFA are commonly associated with a wide range of EIM, which appear to represent important and specific clinical features of this group of conditions. Their recognition in taking an allergy-focused history may play an important role for both diagnosis and management.

Autonomic functions in acrocyanosis assessed by heart rate variability

OBJECTIVE

To evaluate the autonomic activity of patients with acrocyanosis by using heart rate variability indices.

MATERIAL AND METHODS

The study group consisted of 24 patients with acrocyanosis and the control group contained 22 sex- and age-matched healthy subjects. All subjects underwent 24-hour Holter monitoring. Among the heart rate variability (HRV) parameters, time-domain and frequency-domain indices were analysed.

RESULTS

The time-domain indices of HRV indicating global autonomic functions were found to be increased, and indices indicating parasympathetic activity showed a significant decrease in the patient group. Power-spectral analysis of HRV revealed that the low frequency and high frequency power were higher in the patient group than in controls. However, the ratio of Low Frequency/High Frequency was found to be lower in the patient group than in controls.

CONCLUSION

In acrocyanosis, both sympathetic and parasympathetic systems seem to be disrupted. Therefore, we may conclude that acrocyanosis may be resulted of systemic autonomic imbalance rather than pure sympathetic over-activation. Also, these results suggest that acrocyanosis is not a localised disorder; on the contrary, it is associated with various abnormalities of the systemic autonomic nervous system.

Heart rate variability in patients with atrial septal defect and healthy children

OBJECTIVE

Heart rate variability (HRV) measures are altered in various cardiac and non-cardiac situations in children. The autonomic nervous system is assumed to have a role in the pathophysiology of atrial septal defect (ASD). In this study, we evaluated the autonomic system by measuring HRV in children with ASD.

METHODS

Twenty-eight patients with ASD and 32 healthy children (mean ages: 6.6±2.1 years and 6.4±2.2 years, respectively) were enrolled in the study. Twenty-four-hour ambulatory electrocardiographic recordings were obtained and the seven time-domain (SDNN, SDANN, rMSSD, SD, SDNN index, PNN50, and mean RR) and four frequency-domain (VLF, LF, HF, and LF/HF ratio) indices of HRV were analyzed.

RESULTS

A significant decrease in calculated HRV variables was observed in children with ASD as compared to controls. The HRV alteration was found in both time-domain and frequency-domain parameters.

CONCLUSIONS

Our results indicate that HRV is decreased in children with ASD, which implies parasympathetic withdrawal and sympathetic predominance.

Heart rate variability analysis in patients with allergic rhinitis

BACKGROUND

Very few studies investigate the role of the autonomic nervous system in allergic rhinitis. In this study, we evaluated the autonomic nervous system in allergic rhinitis patients using heart rate variability (HRV) analysis.

METHODS

Eleven patients with allergic rhinitis and 13 healthy controls, aged between 19 and 40 years old, were enrolled in the study. Diagnosis of allergic rhinitis was based on clinical history, symptoms, and positive Phadiatop test. Electrocardiographic recordings on the sitting and supine positions were obtained for HRV analysis.

RESULTS

In the supine position, there were no significant statistical differences in very-low-frequency power (VLF, ≤0.04 Hz), low-frequency power (LF, 0.04-0.15 Hz), high-frequency power (HF, 0.15-0.40 Hz), and the ratio of LF to HF (LF/HF) between the patient and control groups. The mean RR intervals significantly increased, while LF% and LF/HF significantly decreased in the patient group in the sitting position. Moreover, mean RR intervals, LF, and LF/HF, which were significantly different between the two positions in the control group, did not show a significant change with the posture change in the patient group.

CONCLUSION

These suggest that patients with allergic rhinitis may have poor sympathetic modulation in the sitting position. Autonomic dysfunction may therefore play a role in the pathophysiology of allergic rhinitis.

Pupillometric assessment of autonomic nervous system in children with allergic rhinitis

OBJECTIVE

The purpose of this study was to investigate autonomic nervous system dysfunction by measuring pupil sizes in pediatric patients with allergic rhinitis.

SUBJECTS AND METHODS

The study group consisted of 60 children (28 girls and 32 boys) who were age and gender matched with the control group, which also consisted of 60 children (26 girls and 34 boys). The diagnosis of allergic rhinitis was based on the history, physical examination and skin prick test performed by an allergologist. Pupil diameter measurements were performed using the pupillometer incorporated in the NİDEK OPD-Scan.

RESULTS

In the allergic rhinitis group, mean photopic and mesopic pupil diameters were 3.52 ± 0.07 and 5.98 ± 0.21, respectively, while in the control group, corresponding measurements were 4.03 ± 0.18 and 6.55 ± 0.16. There was a significant difference for photopic and mesopic pupil diameter between the groups (p < 0.001).

CONCLUSION

This study showed that the pupil size in response to a light stimulus in children with allergic rhinitis was smaller than that of the control group and may indicate parasympathetic hyperactivity and sympathetic hypoactivity.

OVA-induced airway hyperresponsiveness alters murine heart rate variability and body temperature

Altered autonomic (ANS) tone in chronic respiratory disease is implicated as a factor in cardiovascular co-morbidities, yet no studies address its impact on cardiovascular function in the presence of murine allergic airway (AW) hyperresponsiveness (AHR). Since antigen (Ag)-induced AHR is used to model allergic asthma (in which ANS alterations have been reported), we performed a pilot study to assess measurement feasibility of, as well as the impact of allergic sensitization to ovalbumin (OVA) on, heart rate variability (HRV) in a murine model. Heart rate (HR), body temperature (T_B), and time- and frequency-domain HRV analyses, a reflection of ANS control, were obtained in chronically instrumented mice (telemetry) before, during and for 22 h after OVA or saline aerosolization in sensitized (OVA) or Alum adjuvant control exposed animals. OVA mice diverged significantly from Alum mice with respect to change in HR during aerosol challenge (P < 0.001, Two-Way ANOVA; HR max change Ctrl = +80 ± 10 bpm vs. OVA = +1 ± 23 bpm, mean ± SEM), and displayed elevated HR during the subsequent dark cycle (P = 0.006). Sensitization decreased the T_B during aerosol challenge (P < 0.001). Sensitized mice had decreased HRV prior to challenge (SDNN: P = 0.038; Low frequency (LF) power: P = 0.021; Low/high Frequency (HF) power: P = 0.042), and increased HRV during Ag challenge (RMSSD: P = 0.047; pNN6: P = 0.039). Sensitized mice displayed decreased HRV subsequent to OVA challenge, primarily in the dark cycle (RMSSD: P = 0.018; pNN6: P ≤ 0.001; LF: P ≤ 0.001; HF: P = 0.040; LF/HF: P ≤ 0.001). We conclude that implanted telemetry technology is an effective method to assess the ANS impact of allergic sensitization. Preliminary results show mild sensitization is associated with reduced HRV and a suppression of the acute T_B-response to OVA challenge. This approach to assess altered ANS control in the acute OVA model may also be beneficial in chronic AHR models.

Serum and nasal lavage fluid Clara cell protein decreases in children with allergic rhinitis

BACKGROUND

Allergic rhinitis is among the most common chronic disorders of childhood with prevalence of up to 40% in children. Clara cell secretory protein (CCSP) is secreted by Clara cells in the lining fluid of airways. It has an immune-modulatory and anti-inflammatory activity.

AIM OF WORK

Study aimed at evaluating CCSP as a biomarker in serum and nasal lavage fluid of children with allergic rhinitis.

METHODS

A case-control study was conducted on sera and nasal lavage fluid samples from 15 children with allergic rhinitis and 15 healthy children as a control group.

RESULTS

Children with allergic rhinitis had a male to female ratio 2 to 1, with a mean age of 9.47±2.75 years, while among the healthy group, six were males and nine were females, with a mean age of 8.63±2.28 years. Rhinorrhea and nasal obstruction were the most frequent symptoms (100%) followed by itching (93.3%) then sneezing (73.3%). Among allergic rhinitis patients serum CCSP mean±SD was 2.03±0.59μg/l; it was reliable to predict allergic rhinitis (P<0.0001); while nasal lavage CCSP mean±SD was 12.73±8.25μg/l and it was not reliable to predict allergic rhinitis. Its best cut-off value was 3.75μg/l with a sensitivity of 100%, specificity 80%, with a diagnostic accuracy of 90%.

CONCLUSION

Clara cell secretory protein is a new peripheral sensitive marker of airway injury. Furthermore, serum CCSP level is a predictor of allergic rhinitis but not nasal lavage fluid CCSP.

Autonomic dysfunction and clinical severity of disease in children with allergic rhinitis

OBJECTIVES

The involvement of autonomic imbalance has been reported in the pathogenesis of allergic diseases.

PURPOSE

To investigate the association between the clinical severity of childhood allergic rhinitis and autonomic nervous system (ANS) dysfunction, to define whether the severity of disease correlates with ANS activity.

METHODS

In this cross-sectional, case-control study, we evaluated the ANS testing by measuring sympathetic skin response (SRR) and heart rate (R-R) interval variation (RRIV) in 55 children with perennial allergic rhinitis (PAR), aged 7-12 yrs without any chronic co-morbidity, and the results were compared with 40 sex- and age-matched control subjects. The patients were divided into two groups according to the severity of allergic rhinitis.

RESULTS

There were significant increase in calculated RRIV variables during at rest and deep breathing in children with PAR compared to controls, which reflect parasympathetic nervous system (PNS) activity (p<0.005). The mean amplitude of SSR in patients, which reflect sympathetic nervous system (SNS) activity was smaller compared with the controls, but this difference was not significant (0.61±0.35 μV vs controls 0.94±0.46, p>0.05). Lower RRIV and the prolonged SSR latencies in children with AR were closely correlated with disease severity (r=-0.65, p<0.05, and r=-0.59, p<0.05 respectively).

CONCLUSION

Combined use of these two tests, allows separate testing of PNS and SNS function, and are very sensitive methods in assessing of severity of disease in children with PAR.

Autonomic nervous system dysfunction and their relationship with disease severity in children with atopic asthma

The involvement of autonomic imbalance has been reported in the pathogenesis of allergic diseases. The aim of this study was to investigate the association between the clinical severity of childhood asthma with autonomic nervous system (ANS) dysfunction and to define whether the severity of asthma correlates with ANS activity. In this case-control study, we evaluated the ANS activity by testing heart rate variability (HRV) and sympathetic skin response (SRR) in 77 asthmatic children, age 7-12 yrs, who had no co-morbidity and compared them with 40 gender- and age-matched control subjects. According to the severity of their asthma, study subjects were further divided into three groups: I (mild asthmatics), II (moderate asthmatics), and III (severe asthmatics). Inter-group ANS scale scores differed significantly (p<0.01) between Groups I and III and between Groups II and III. Combined use of HRV and SSR provides a higher degree of sensitivity for assessing disease severity in cases of pediatric asthma.

Effect of pseudoephedrine on cardiac rhythm of children with rhinitis

OBJECTIVE

To investigate the effect of pseudoephedrine on heart rhythm of children with rhinitis.

METHODS

The study included 25 children diagnosed with rhinitis from March 2009 through February 2010 in the Department of Pediatrics. Holter records were obtained for 24 h before and at the fourth day of pseudoephedrine treatments.

RESULTS

Study group consisted of 18 girls (72%) and 7 boys (28%) with a mean age of 8.7 ± 3.4 (4-17.9 years). Common complaints of the patients were rhinorrhea (100%), cough (68%) fatigue (48%), sore throat (36%), and headache (28%). Of the 25 patients whose Holter recordings were evaluated, rare supraventricular extrasystoles were observed in one prior to the administration of pseudoephedrine, which were not repeated on this patient's follow-up recording on day four. There were two ventricular extrasystoles in the day four Holter recording of another patient. None of the patients complained of chest pain or palpitation. There were no observations of supraventricular tachycardia, ventricular tachycardia or ventricular fibrillation. No statistical differences could be found (p > 0.05) in the values before treatment and those on day four of treatment of either the time-dependent Heart rate variability (HRV) parameters SDNN, SDNN index, SDANN and RMSSD, or the frequency-dependent parameters (TP, HF, LF). No statistical difference could be determined between heart rate values of the patients before treatment and those on day four of treatment (p > 0.05).

CONCLUSIONS

This study has established that therapeutic doses of pseudoephedrine do not cause an additional dysrhythmia risk for children with no health problem except rhinitis.

Cardiac autonomic functions in obese children

OBJECTIVE

The autonomic nervous system is assumed to have a role in the pathophysiology of obesity. In this study, we evaluated the autonomic system by measuring heart rate variability (HRV) in obese children.

METHODS

Thirty-two obese and 30 healthy children (mean ages: 11.6±2.0 years and 11.0±2.9 years, respectively) were enrolled in the study. Obesity was defined as a body mass index higher than 97th percentile for age- and gender-specific reference values. All participants were free of any disease and none of them was receiving any medication. Twenty-four-hour ambulatory electrocardiographic recordings were obtained and the time-domain and frequency-domain indices of HRV were analyzed. The study group was evaluated with respect to insulin resistance by HOMA-IR values.

RESULTS

A significant decrease in calculated HRV variables was observed in obese children as compared to controls. The HRV alteration was found in both time-domain and frequency-domain parameters. The subgroup analysis of the study group revealed a significant decrease in all investigated HRV parameters in the insulin-resistant obese children compared to the non-insulin-resistant obese ones.

CONCLUSIONS

Our results indicate that HRV is decreased in obese children, which implies parasympathetic withdrawal and sympathetic predominance. A marked decrease in HRV was observed in insulin-resistant obese children compared to their non-insulin-resistant counterparts. We propose that autonomic imbalance pertaining especially to insulin resistance may be involved in the pathogenesis of obesity in pediatric patients.