1
|
Frandsen MN, Varnum C, Foss NB, Mehlsen J, Kehlet H. Time-course of heart rate variability after total hip arthroplasty. J Clin Monit Comput 2024; 38:423-432. [PMID: 37052614 PMCID: PMC10995030 DOI: 10.1007/s10877-023-00992-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 03/03/2023] [Indexed: 04/14/2023]
Abstract
Heart rate variability (HRV) is a measure of the autonomic nervous system function and possibly related to postoperative outcome. Despite several HRV studies in different surgical settings, optimal indices and timepoints for measuring have not been adequately determined. Consequently, there is a need for detailed descriptive procedure-specific studies on the time-course of perioperative HRV within a modern fast-track surgical setting. We measured HRV continuously in 24 patients from 4 days before until 9 days after total hip arthroplasty (THA). Statistical methods included mainly ANOVA and t-tests or Kruskal-Wallis and pairwise Wilcoxon test. Patients completed the Orthostatic Discriminant and Severity Scale five times during the study describing autonomic nervous system dysfunction. Standard deviation between normal-to-normal beats and the total power of HRV were reduced for at least 9 days following THA, with a trend towards increased HRV leading up to the day of surgery. The balance between low- and high-frequency power of HRV was reduced in the postoperative evenings. There was increased orthostatic intolerance symptoms on the first postoperative day, with symptoms of pain, fatigue and weakness decreasing after the first postoperative day. Median hospital stay was 1 day. We provide the first detailed description of perioperative time-course of HRV and orthostatic symptoms in fast-track THA, showing reduced HRV after surgery for at least a week, and that HRV changes are sensitive to time of day and timing before and after surgery. These results are helpful in designing future HRV studies in perioperative risk assessment and outcome.
Collapse
Affiliation(s)
- Mikkel Nicklas Frandsen
- Section for Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Claus Varnum
- Department of Orthopedic Surgery, Lillebaelt Hospital, Vejle, Denmark
| | - Nicolai Bang Foss
- Department of Anesthesia and Intensive Care, Hvidovre University Hospital, Hvidovre, Denmark
| | - Jesper Mehlsen
- Section for Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
2
|
Hristovska AM, Andersen LB, Uldall-Hansen B, Kehlet H, Troelsen A, Gromov K, Foss NB. Postoperative orthostatic intolerance following fast-track unicompartmental knee arthroplasty: incidence and hemodynamics-a prospective observational cohort study. J Orthop Surg Res 2024; 19:214. [PMID: 38561817 PMCID: PMC10983746 DOI: 10.1186/s13018-024-04639-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/21/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Early postoperative mobilization is essential for early functional recovery but can be inhibited by postoperative orthostatic intolerance (OI). Postoperative OI is common after major surgery, such as total knee arthroplasty (TKA). However, limited data are available after less extensive surgery, such as unicompartmental knee arthroplasty (UKA). We, therefore, investigated the incidence of OI as well as cardiovascular and tissue oxygenation responses during early mobilization after UKA. METHODS This prospective single-centre observational study included 32 patients undergoing primary UKA. Incidence of OI and cardiovascular and tissue oxygenation responses during mobilization were evaluated preoperatively, at 6 and 24 h after surgery. Perioperative fluid balance, bleeding, surgery duration, postoperative hemoglobin, pain during mobilization and opioid usage were recorded. RESULTS During mobilization at 6 h after surgery, 4 (14%, 95%CI 4-33%) patients experienced OI; however, no patients terminated the mobilization procedure prematurely. Dizziness and feeling of heat were the most common symptoms. OI was associated with attenuated systolic and mean arterial blood pressure responses in the sitting position (all p < 0.05). At 24 h after surgery, 24 (75%) patients had already been discharged, including three of the four patients with early OI. Only five patients were available for measurements, two of whom experienced OI; one terminated the mobilization procedure due to intolerable symptoms. We observed no statistically significant differences in perioperative fluid balance, bleeding, surgery duration, postoperative hemoglobin, pain, or opioid usage between orthostatic intolerant and tolerant patients. CONCLUSIONS The incidence of orthostatic intolerance after fast-track unicompartmental knee arthroplasty is low (~ 15%) and is associated with decreased orthostatic pressure responses. Compared to the previously described orthostatic intolerance incidence of ~ 40% following total knee arthroplasty, early orthostatic intolerance is uncommon after unicompartmental knee arthroplasty, suggesting a procedure-specific component. TRIAL REGISTRATION Prospectively registered at ClinicalTrials.gov; registration number: NCT04195360, registration date: 13.12.2019.
Collapse
Affiliation(s)
- Ana-Marija Hristovska
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Copenhagen, Denmark.
| | - Louise B Andersen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Copenhagen, Denmark
| | - Bodil Uldall-Hansen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Copenhagen, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Anders Troelsen
- Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Kirill Gromov
- Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Copenhagen, Denmark
| |
Collapse
|
3
|
Li Y, Bai B, Wang H, Wu H, Deng Y, Shen C, Zhang Q, Shi L. Plasma metabolomic profile in orthostatic intolerance children with high levels of plasma homocysteine. Ital J Pediatr 2024; 50:52. [PMID: 38486257 PMCID: PMC10941598 DOI: 10.1186/s13052-024-01601-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/27/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Orthostatic intolerance, which includes vasovagal syncope and postural orthostatic tachycardia syndrome, is common in children and adolescents. Elevated plasma homocysteine levels might participate in the pathogenesis of orthostatic intolerance. This study was designed to analyze the plasma metabolomic profile in orthostatic intolerance children with high levels of plasma homocysteine. METHODS Plasma samples from 34 orthostatic intolerance children with a plasma homocysteine concentration > 9 µmol/L and 10 healthy children were subjected to ultra-high-pressure liquid chromatography and quadrupole-time-of-flight mass spectrometry analysis. RESULTS A total of 875 metabolites were identified, 105 of which were significantly differential metabolites. Choline, 1-stearoyl-2-linoleoyl-sn-glycero-3-phosphocholine, 1-(1Z-octadecenyl)-2-(4Z,7Z,10Z,13Z,16Z,19Z-docosahexaenoyl)-sn-glycero-3-phosphocholine, histidine, isocitric acid, and DL-glutamic acid and its downstream metabolites were upregulated, whereas 1-palmitoyl-sn-glycero-3-phosphocholine, 1-stearoyl-sn-glycerol 3-phosphocholine, sphingomyelin (d18:1/18:0), betaine aldehyde, hydroxyproline, and gamma-aminobutyric acid were downregulated in the orthostatic intolerance group compared with the control group. All these metabolites were related to choline and glutamate. Heatmap analysis demonstrated a common metabolic pattern of higher choline, 1-stearoyl-2-linoleoyl-sn-glycero-3-phosphocholine, and DL-glutamic acid, and lower sphingomyelin (d18:1/18:0), 1-stearoyl-sn-glycerol 3-phosphocholine, and 1-palmitoyl-sn-glycero-3-phosphocholine in patients with certain notable metabolic changes (the special group) than in the other patients (the common group). The maximum upright heart rate, the change in heart rate from the supine to the upright position, and the rate of change in heart rate from the supine to the upright position of vasovagal syncope patients were significantly higher in the special group than in the common group (P < 0.05). Choline, 1-stearoyl-2-linoleoyl-sn-glycero-3-phosphocholine, and DL-glutamic acid were positively correlated with the rate of change in heart rate from the supine to the upright position in vasovagal syncope patients (P < 0.05). CONCLUSIONS The levels of choline-related metabolites and glutamate-related metabolites changed significantly in orthostatic intolerance children with high levels of plasma homocysteine, and these changes were associated with the severity of illness. These results provided new light on the pathogenesis of orthostatic intolerance.
Collapse
Affiliation(s)
- Yaqi Li
- Department of Cardiology, Children's Hospital, Capital Institute of Pediatrics, No 2 Yabao Road, Beijing, Chaoyang District, 100020, China
| | - Baoling Bai
- Beijing Municipal Key Laboratory of Child Development and Nutriomics, Capital Institute of Pediatrics, No 2 Yabao Road, Beijing, Chaoyang District, 100020, China
| | - Hui Wang
- Department of Cardiology, Children's Hospital, Capital Institute of Pediatrics, No 2 Yabao Road, Beijing, Chaoyang District, 100020, China
| | - Haojie Wu
- Department of Cardiology, Children's Hospital, Capital Institute of Pediatrics, No 2 Yabao Road, Beijing, Chaoyang District, 100020, China
| | - Yanjun Deng
- Department of Cardiology, Children's Hospital, Capital Institute of Pediatrics, No 2 Yabao Road, Beijing, Chaoyang District, 100020, China
| | - Chen Shen
- Department of Cardiology, Children's Hospital, Capital Institute of Pediatrics, No 2 Yabao Road, Beijing, Chaoyang District, 100020, China
| | - Qin Zhang
- Beijing Municipal Key Laboratory of Child Development and Nutriomics, Capital Institute of Pediatrics, No 2 Yabao Road, Beijing, Chaoyang District, 100020, China.
| | - Lin Shi
- Department of Cardiology, Children's Hospital, Capital Institute of Pediatrics, No 2 Yabao Road, Beijing, Chaoyang District, 100020, China.
| |
Collapse
|
4
|
D'Ippolito I, Menduni M, D'Amato C, Andreadi A, Lauro D, Spallone V. Does the Relationship of the Autonomic Symptoms Questionnaire COMPASS 31 with Cardiovascular Autonomic Tests Differ between Type 1 and Type 2 Diabetes Mellitus? Diabetes Metab J 2024:dmj.2023.0301. [PMID: 38408489 DOI: 10.4093/dmj.2023.0301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/22/2023] [Indexed: 02/28/2024] Open
Abstract
Background The aim was to investigate if autonomic symptoms questionnaire Composite Autonomic Symptom Score (COMPASS) 31 has different association with cardiovascular autonomic neuropathy (CAN) and diagnostic performance between type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). Methods Seventy-nine participants with T1DM and 140 with T2DM completed COMPASS 31 before cardiovascular reflex tests (CARTs) for CAN, and assessment of symptoms, signs, vibration, and thermal perception thresholds for diabetic polyneuropathy (DPN) diagnosis. Results COMPASS 31 total weighted score (TWS) was similar in the two groups, but significantly associated with confirmed CAN only in T1DM (P=0.0056) and not T2DM group (P=0.1768) and correlated with CARTs score more strongly in T1DM (rho=0.356, P=0.0016) than in T2DM group (rho=0.084, P=0.3218) (P=0.016). Only in T1DM and not T2DM group, the area under the receiver operating characteristic curve (AUC) reached a fair diagnostic accuracy (>0.7) for confirmed CAN (0.73±0.07 vs. 0.61±0.08) and DPN (0.75±0.06 vs. 0.68±0.05), although without a significant difference. COMPASS 31 TWS (cut-off 16.44) reached acceptable diagnostic performance in T1DM, with sensitivity for confirmed CAN 81.2% and sensitivity and specificity for DPN 76.3% and 78%, compared to T2DM group (all <70%). AUC for DPN of orthostatic intolerance domain was higher in T1DM compared to T2DM group (0.73±0.05 vs. 0.58±0.04, P=0.027). Conclusion COMPASS 31 is more weakly related to CAN in T2DM than in T1DM, with a fair diagnostic accuracy for confirmed CAN only in T1DM. This difference supports a multifactorial origin of symptoms and should be considered when using COMPASS 31.
Collapse
Affiliation(s)
- Ilenia D'Ippolito
- Endocrinology Section, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Marika Menduni
- Endocrinology Section, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Cinzia D'Amato
- Endocrinology Section, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Aikaterini Andreadi
- Endocrinology Section, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Davide Lauro
- Endocrinology Section, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Vincenza Spallone
- Endocrinology Section, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| |
Collapse
|
5
|
Groppelli A, Rivasi G, Fedorowski A, de Lange FJ, Russo V, Maggi R, Capacci M, Nawaz S, Comune A, Bianchi L, Zambon A, Soranna D, Ungar A, Parati G, Brignole M. Interventions aimed to increase average 24-h systolic blood pressure reduce blood pressure drops in patients with reflex syncope and orthostatic intolerance. Europace 2024; 26:euae026. [PMID: 38262617 PMCID: PMC10849184 DOI: 10.1093/europace/euae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/05/2024] [Indexed: 01/25/2024] Open
Abstract
AIMS Systolic blood pressure (SBP) drops recorded by 24-h ambulatory blood pressure (BP) monitoring (ABPM) identify patients with susceptibility to reflex syncope and orthostatic intolerance. We tested the hypothesis that treatments aimed to increase BP (reassurance, education, and lifestyle measures plus pharmacological strategies) can reduce SBP drops. METHODS AND RESULTS This was a multicentre, observational proof-of-concept study performed in patients with reflex syncope and/or orthostatic intolerance and with SBP drops on a screening ABPM. Among 144 eligible patients, 111 underwent a second ABPM on average 2.5 months after start of treatment. Overall, mean 24-h SBP increased from 114.1 ± 12.1 to 121.4 ± 14.5 mmHg (P < 0.0001). The number of SBP drops <90 and <100 mmHg decreased by 61%, 46% during daytime, and by 48% and 37% during 24-h period, respectively (P < 0.0001 for all). The dose-response relationship between difference in 24-h average SBP increase and reduction in number of SBP drops reached a plateau around ∼15 mmHg increase of 24-h SBP. The reduction in SBP drop rate was consistent and significant in patients who underwent deprescription of hypotensive medications (n = 44) and in patients who received BP-rising drugs (n = 67). CONCLUSION In patients with reflex syncope and/or orthostatic intolerance, an increase in average 24-h SBP, regardless of the implemented strategy, significantly reduced the number of SBP drops and symptom burden. A 13 mmHg increase in 24-h SBP appears to represent the optimal goal for aborting the maximal number of SBP drops, representing a possible target for future interventions. ClincalTrials.gov identifier: NCT05729724.
Collapse
Affiliation(s)
- Antonella Groppelli
- Faint and Fall Research Centre, Department of Cardiology, IRCCS Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, Naples, Italy
| | - Roberto Maggi
- Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Marco Capacci
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Sara Nawaz
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, Naples, Italy
| | - Lorenzo Bianchi
- Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Antonella Zambon
- Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Davide Soranna
- Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Gianfranco Parati
- Department of Cardiology, IRCCS Istituto Auxologico Italiano, San Luca Hospital, Piazzale Brescia 20, 20149 Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dei daini 2, 20126 Milan, Italy
| | - Michele Brignole
- Faint and Fall Research Centre, Department of Cardiology, IRCCS Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy
| |
Collapse
|
6
|
Lyonga Ngonge A, Nyange C, Ghali JK. Novel pharmacotherapeutic options for the treatment of postural orthostatic tachycardia syndrome. Expert Opin Pharmacother 2024; 25:181-188. [PMID: 38465412 DOI: 10.1080/14656566.2024.2319224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/12/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Postural tachycardia syndrome (POTS) is a disorder characterized by a constellation of symptoms including lightheadedness, fatigue, and palpitations when upright, associated with an increase in the heart rate (HR) of > 30 beats per minute when changing from a lying down to standing position or head-up tilt position and not associated with orthostatic hypotension. The causes as well as the management of POTS are not quite fully understood. AREAS COVERED We performed a literature review on the diagnosis and management of POTS, and this article includes an overview of novel pharmacotherapeutic options for the treatment of (POTS), although an effective treatment has not been established. EXPERT OPINION POTS is a clinical syndrome characterized by a constellation of symptoms that are nonspecific. No single etiology or unified hypothesis could be identified. In fact, multiple pathophysiological mechanisms have been proposed, and none of the suggested medications have been approved by the FDA for this indication. Further understanding of the autonomic nervous system and its adjustment to standing position is needed to provide better management strategies.
Collapse
Affiliation(s)
| | - Christabel Nyange
- Division of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA, USA
| | - Jalal K Ghali
- Division of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA, USA
| |
Collapse
|
7
|
van Campen C(LM, Verheugt FW, Rowe PC, Visser FC. Orthostatic chronotropic incompetence in patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). IBRO Neurosci Rep 2023; 15:1-10. [PMID: 37303862 PMCID: PMC10250802 DOI: 10.1016/j.ibneur.2023.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/25/2023] [Accepted: 04/30/2023] [Indexed: 06/13/2023] Open
Abstract
Background Orthostatic intolerance (OI) is a core diagnostic criterion in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). The majority of ME/CFS patients have no evidence of hypotension or postural orthostatic tachycardia syndrome (POTS) during head-up tilt, but do show a significantly larger reduction in stroke volume index (SVI) when upright compared to controls. Theoretically a reduction in SVI should be accompanied by a compensatory increase in heart rate (HR). When there is an incomplete compensatory increase in HR, this is considered chronotropic incompetence. This study explored the relationship between HR and SVI to determine whether chronotropic incompetence was present during tilt testing in ME/CFS patients. Methods From a database of individuals who had undergone tilt testing with Doppler measurements for SVI both supine and end-tilt, we selected ME/CFS patients and healthy controls (HC) who had no evidence of POTS or hypotension during the test. To determine the relation between the HR increase and SVI decrease during the tilt test in patients, we calculated the 95% prediction intervals of this relation in HC. Chronotropic incompetence in patients was defined as a HR increase below the lower limit of the 95th % prediction interval of the HR increase in HC. Results We compared 362 ME/CFS patients with 52 HC. At end-tilt, tilt lasting for 15 (4) min, ME/CFS patients had a significantly lower SVI (22 (4) vs. 27 (4) ml/m2; p < 0.0001) and a higher HR (87 (11) vs. 78 (15) bpm; p < 0.0001) compared to HC. There was a similar relationship between HR and SVI between ME/CFS patients and HC in the supine position. During tilt ME/CFS patients had a lower HR for a given SVI; 37% had an inadequate HR increase. Chronotropic incompetence was more common in more severely affected ME/CFS patients. Conclusion These novel findings represent the first description of orthostatic chronotropic incompetence during tilt testing in ME/CFS patients.
Collapse
Affiliation(s)
| | | | - Peter C. Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frans C. Visser
- Stichting CardioZorg, Planetenweg 5, 2132 HN Hoofddorp, The Netherlands
| |
Collapse
|
8
|
Idiaquez J, Casar JC, Idiaquez Rios JF, Biaggioni I. Engaging patients in the management of orthostatic intolerance. Clin Auton Res 2023; 33:893-897. [PMID: 37847460 DOI: 10.1007/s10286-023-00990-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/27/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Juan Idiaquez
- Departamento de Neurologia, Pontificia Universidad Catolica de Chile, Santiago de Chile, Chile
| | - Juan Carlos Casar
- Departamento de Neurologia, Pontificia Universidad Catolica de Chile, Santiago de Chile, Chile
| | - Juan Francisco Idiaquez Rios
- Division of Neurology, Department of Medicine, Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Canada
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center and Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
| |
Collapse
|
9
|
Miwa K, Inoue Y. Repetitive transcranial magnetic stimulation ameliorates symptoms in patients with myalgic encephalomyelitis (chronic fatigue syndrome). IBRO Neurosci Rep 2023; 15:335-341. [PMID: 38025661 PMCID: PMC10661112 DOI: 10.1016/j.ibneur.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/01/2023] Open
Abstract
Background Central nervous system dysfunction has been postulated to cause debilitating symptoms in patients with myalgic encephalomyelitis (ME) (originally called "chronic fatigue syndrome"). Repetitive transcranial magnetic stimulation (rTMS) is a newly developed neuromodulatory procedure and has been suggested to facilitate the cortical neural activity. Methods This study enrolled 30 patients with ME (7 men and 23 women) with a mean age of 39 ± 12 years, who received rTMS treatment of both the left dorsolateral prefrontal cortex and the left primary motor area in the brain. The performance status score (0-9) for restricting activities of daily living, orthostatic intolerance (OI) during a 10-min standing test, neurologic disequilibrium diagnosed as unstable standing with their feet together and eyes closed, neuropathic pain or fibromyalgia, and muscle weakness were compared before and after treatment. Results After therapy, favorable effects were observed with a decrease in performance status score or index for restriction of activities of daily living of ≥ 2 points in 20 patients (67%). OI with the inability to complete the 10-min standing test was resolved in 10 (83%) out of 12 patients, and disequilibrium was resolved in 15 (88%) out of 17 patients. Neuropathic pain or fibromyalgia was attenuated in seven (70%) out of 10 patients. Muscle weakness with grip power of < 10 kg was resolved in two (50%) out of four patients. No untoward effects were encountered in all the study patients. Conclusion The treatment with rTMS is effective in alleviating various symptoms, especially OI and disequilibrium, and in improving the activities of daily living in patients with ME.
Collapse
Affiliation(s)
| | - Yukichi Inoue
- Department of Neurology, Toyama Prefectural Rehabilitation Hospital & Support Center for Children with Disabilities, Toyama, Japan
| |
Collapse
|
10
|
Tarbell SE, Olufs EL, Fischer PR, Chelimsky G, Numan MT, Medow M, Abdallah H, Ahrens S, Boris JR, Butler IJ, Chelimsky TC, Coleby C, Fortunato JE, Gavin R, Gilden J, Gonik R, Klaas K, Marsillio L, Marriott E, Pace LA, Pianosi P, Simpson P, Stewart J, Van Waning N, Weese-Mayer DE. Assessment of comorbid symptoms in pediatric autonomic dysfunction. Clin Auton Res 2023; 33:843-858. [PMID: 37733160 DOI: 10.1007/s10286-023-00984-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/08/2023] [Indexed: 09/22/2023]
Abstract
PURPOSE Pediatric patients with autonomic dysfunction and orthostatic intolerance (OI) often present with co-existing symptoms and signs that might or might not directly relate to the autonomic nervous system. Our objective was to identify validated screening instruments to characterize these comorbidities and their impact on youth functioning. METHODS The Pediatric Assembly of the American Autonomic Society reviewed the current state of practice for identifying symptom comorbidities in youth with OI. The assembly includes physicians, physician-scientists, scientists, advanced practice providers, psychologists, and a statistician with expertise in pediatric disorders of OI. A total of 26 representatives from the various specialties engaged in iterative meetings to: (1) identify and then develop consensus on the symptoms to be assessed, (2) establish committees to review the literature for screening measures by member expertise, and (3) delineate the specific criteria for systematically evaluating the measures and for making measure recommendations by symptom domains. RESULTS We review the measures evaluated and recommend one measure per system/concern so that assessment results from unrelated clinical centers are comparable. We have created a repository to apprise investigators of validated, vetted assessment tools to enhance comparisons across cohorts of youth with autonomic dysfunction and OI. CONCLUSION This effort can facilitate collaboration among clinical settings to advance the science and clinical treatment of these youth. This effort is essential to improving management of these vulnerable patients as well as to comparing research findings from different centers.
Collapse
Affiliation(s)
- Sally E Tarbell
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Erin L Olufs
- Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Philip R Fischer
- Mayo Clinic, Rochester, MN, USA
- Sheikh Shakhbout Medical City, Abu Dhabi, UAE
- Khalifa University College of Medicine and Health Sciences, Abu Dhabi, UAE
| | - Gisela Chelimsky
- Children's Hospital of Richmond, Richmond, VA, USA
- Virginia Commonwealth University Health, Richmond, VA, USA
| | | | | | | | | | | | - Ian J Butler
- University of Texas McGovern Medical School, Houston, TX, USA
| | | | | | - John E Fortunato
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Raewyn Gavin
- Starship Children's Hospital, Auckland, New Zealand
| | - Janice Gilden
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Renato Gonik
- University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Lauren Marsillio
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
- Stanley Manne Research Institute, Chicago, IL, USA
| | - Erin Marriott
- American Family Children's Hospital, Madison, WI, USA
| | | | - Paul Pianosi
- University of Minnesota Medical School, Minneapolis, MN, USA
| | | | | | | | - Debra E Weese-Mayer
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
- Stanley Manne Research Institute, Chicago, IL, USA
| |
Collapse
|
11
|
Zawadka-Kunikowska M, Rzepiński Ł, Cieślicka M, Klawe JJ, Tafil-Klawe M. Alterations in short-term blood pressure variability related to disease severity and autonomic symptoms in myasthenia gravis patients. Neurol Sci 2023; 44:4065-4075. [PMID: 37378800 PMCID: PMC10570234 DOI: 10.1007/s10072-023-06927-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/21/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVES We aimed to evaluate beat-to-beat blood pressure variability (BPV) during head-up tilt test (HUTT) in patients with mild and moderate myasthenia gravis (MG) compared to healthy controls (HCs), and its association with the severity of autonomic symptoms. METHODS A total of 50 MG patients and 30 HCs were evaluated. Patients were stratified into 2 groups regarding Myasthenia Gravis Foundation of America (MGFA) classification: mild (I,II MGFA), moderate form (III MGFA). Autonomic symptoms were assessed by COMPASS-31 questionnaire. Cardiovascular parameters, indices of very short-term systolic (SBPV), and diastolic blood pressure (BP) variability (DBPV) were assessed at rest, and during HUTT. RESULTS Moderate MG patients were characterized by an overall shift of sympathovagal balance toward sympathetic predominance, either at rest and during HUTT, as well as lower values of high frequency (HFnu) of DBPV during HUTT, compared to HCs and mild MG. Similarly, moderate MG showed higher resting low frequency (LFnu) of DBPV (p=0.035), higher COMPASS-31 score (p=0.031), and orthostatic intolerance sub-score (p=0.019) than mild MG patients. Compared to HCs, mild MG patients showed lower Δmean BP (p=0.029), Δdiastolic BP (p=0.016). Autonomic symptoms were associated with lower BP values, at rest and during HUTT, and lower LF BPV parameters during HUTT. CONCLUSION MG patients present significant alterations in BPV, both at rest and in response to orthostatic stress, which are related to autonomic symptoms and disease severity. This study confirms the importance of monitoring BPV when evaluating cardiovascular autonomic function and its evolution over the course of MG disease.
Collapse
Affiliation(s)
- Monika Zawadka-Kunikowska
- Department of Human Physiology, Nicolaus Copernicus University, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Karłowicza 24, 85-092, Bydgoszcz, Poland.
| | - Łukasz Rzepiński
- Sanitas-Neurology Outpatient Clinic, Dworcowa 110, 85-010, Bydgoszcz, Poland
- Department of Neurology, 10th Military Research Hospital and Polyclinic, 85-681, Bydgoszcz, Poland
| | - Mirosława Cieślicka
- Department of Human Physiology, Nicolaus Copernicus University, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Karłowicza 24, 85-092, Bydgoszcz, Poland
| | - Jacek J Klawe
- Department of Hygiene, Epidemiology, Ergonomy and Postgraduate Education, Nicolaus Copernicus University in Torun, Ludwik Rydygier Collegium Medicum in Bydgoszcz, M. Sklodowskiej-Curie 9, 85-094, Bydgoszcz, Poland
| | - Małgorzata Tafil-Klawe
- Department of Human Physiology, Nicolaus Copernicus University, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Karłowicza 24, 85-092, Bydgoszcz, Poland
| |
Collapse
|
12
|
Koch SA, Jarjour IT, Evankovich KD. Neurocognitive Profiles in Adolescents With Postural Tachycardia Syndrome and Perceived Brain Fog: A Preliminary Report. Pediatr Neurol 2023; 148:128-132. [PMID: 37703657 DOI: 10.1016/j.pediatrneurol.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 07/17/2023] [Accepted: 08/10/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Postural tachycardia syndrome (POTS) is associated with complaints of cognitive and emotional difficulties that may contribute to severe functional disability. For high-achieving adolescents, these symptoms can result in decreased participation in school and extracurricular activities. There are very limited data comparing subjective symptom reports to neurocognitive profiles in adolescents presenting with POTS, "brain fog," and cognitive difficulties. METHODS A review of medical records and neuropsychological data was conducted for six adolescents diagnosed with POTS at a pediatric neurology clinic. All patients had frequent symptoms of orthostatic intolerance for more than three months. There was heart rate increase of ≥40 beats per minute (bpm) within 10 minutes of active standing or head-up tilt test in five patients and 36 bpm in one patient, who was diagnosed with probable POTS. All were referred for neuropsychological evaluations due to reported debilitating cognitive problems and an inability to function in a regular academic setting. Patients underwent a six-hour neuropsychological evaluation utilizing standardized measures of cognitive and emotional functioning. Clinically reported symptoms included fatigue, poor concentration, and memory impairment as well as "brain fog." RESULTS Subjective complaints differed from patients' performance on standardized neuropsychological measures. Patients performed in the average to superior range across measures of general intelligence, verbal and working memory, processing speed, and sustained attention. CONCLUSIONS Further research is needed to elucidate the basis for perceived "brain fog" and cognitive impairment in POTS, such as better understanding of patient and parental perceptions of initial medical symptoms and diagnosis as well as symptom amplification due to biopsychosocial processes.
Collapse
Affiliation(s)
- Sarah A Koch
- Pediatric Neuropsychology Program, Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Imad T Jarjour
- Section of Child Neurology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.
| | - Karen D Evankovich
- Section of Child Neurology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas; Sections of Psychology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.
| |
Collapse
|
13
|
Seeley MC, Gallagher C, Ong E, Langdon A, Chieng J, Bailey D, Dennis A, McCaffrey N, Lau DH. Poor health-related quality of life in postural orthostatic tachycardia syndrome in comparison with a sex- and age-matched normative population. Clin Auton Res 2023; 33:469-477. [PMID: 37338634 PMCID: PMC10439037 DOI: 10.1007/s10286-023-00955-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/18/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE The effect of postural orthostatic tachycardia syndrome (POTS) on health-related quality of life (HrQoL) remains poorly studied. Here, we sought to compare the HrQoL in individuals with POTS to a normative age-/sex-matched population. METHODS Participants enrolled in the Australian POTS registry between 5 August 2021 and 30 June 2022 were compared with propensity-matched local normative population data from the South Australian Health Omnibus Survey. The EQ-5D-5L instrument was used to assess HrQoL across the five domains (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) with global health rating assessed with a visual analog scale (EQ-VAS). A population-based scoring algorithm was applied to the EQ-5D-5L data to calculate utility scores. Hierarchical multiple regression analyses were undertaken to explore predictors of low utility scores. RESULTS A total of 404 participants (n = 202 POTS; n = 202 normative population; median age 28 years, 90.6% females) were included. Compared with the normative population, the POTS cohort demonstrated significantly higher burden of impairment across all EQ-5D-5L domains (all P < 0.001), lower median EQ-VAS (p < 0.001), and lower utility scores (p < .001). The lower EQ-VAS and utility scores in the POTS cohort were universal in all age groups. Severity of orthostatic intolerance symptoms, female sex, fatigue scores, and comorbid diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome were independent predictors of reduced HrQoL in POTS. The disutility in those with POTS was lower than many chronic health conditions. CONCLUSIONS This is the first study to demonstrate significant impairment across all subdomains of EQ-5D-5L HrQoL in the POTS cohort as compared with a normative population. TRIAL REGISTRATION ACTRN12621001034820.
Collapse
Affiliation(s)
- Marie-Claire Seeley
- Australian Dysautonomia and Arrhythmia Research Collaborative, The University of Adelaide, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Celine Gallagher
- Australian Dysautonomia and Arrhythmia Research Collaborative, The University of Adelaide, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Eric Ong
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Amy Langdon
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Jonathan Chieng
- Australian Dysautonomia and Arrhythmia Research Collaborative, The University of Adelaide, Adelaide, Australia
| | - Danielle Bailey
- Australian Dysautonomia and Arrhythmia Research Collaborative, The University of Adelaide, Adelaide, Australia
| | - Annabelle Dennis
- Australian Dysautonomia and Arrhythmia Research Collaborative, The University of Adelaide, Adelaide, Australia
| | - Nikki McCaffrey
- Deakin Health Economics, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Melbourne, VIC, Australia
| | - Dennis H Lau
- Australian Dysautonomia and Arrhythmia Research Collaborative, The University of Adelaide, Adelaide, Australia.
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia.
- Department of Cardiology, Royal Adelaide Hospital, 1 Port Road, Adelaide, SA, 5000, Australia.
| |
Collapse
|
14
|
Maier A, Schopen L, Thiel JC, Müller K, Fimm B, Schulz JB. Cognitive functioning in postural orthostatic tachycardia syndrome among different body positions: a prospective pilot study (POTSKog study). Clin Auton Res 2023; 33:459-468. [PMID: 37261636 PMCID: PMC10439038 DOI: 10.1007/s10286-023-00950-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/29/2023] [Indexed: 06/02/2023]
Abstract
PURPOSE Approximately 96% of patients with postural orthostatic tachycardia syndrome (PoTS) report cognitive complaints. We investigated whether cognitive function is impaired during sitting and active standing in 30 patients with PoTS compared with 30 healthy controls (HCs) and whether it will improve with the counter manoeuvre of leg crossing. METHODS In this prospective pilot study, patients with PoTS were compared to HCs matched for age, sex, and educational level. Baseline data included norepinephrine plasma levels, autonomic testing and baseline cognitive function in a seated position [the Montreal Cognitive Assessment, the Leistungsprüfsystem (LPS) subtests 1 and 2, and the Test of Attentional Performance (TAP)]. Cognitive functioning was examined in a randomized order in supine, upright and upright legs crossed position. The primary outcomes were the cognitive test scores between HCs and patients with PoTS at baseline testing, and among the different body positions. RESULTS Patients with PoTS had impaired attention (TAP median reaction time) in the seated position and impaired executive functioning (Stroop) while standing compared with HC. Stroop was influenced by position (supine versus upright versus upright legs crossed) only in the PoTS group. Leg crossing did not result in an improvement in executive function. In patients with PoTS, there was a negative correlation of Stroop with norepinephrine plasma levels while standing. CONCLUSION Compared with HCs, PoTS participants showed impaired cognitive attention and executive function in the upright position that did not improve in the legs crossed position. Data provide further evidence for orthostatic cognitive deterioration in patients with PoTS. TRIAL REGISTRATION INFORMATION The study was registered at ClinicalTrials.gov (NCT03681080).
Collapse
Affiliation(s)
- Andrea Maier
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany.
| | - Lena Schopen
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Joana C Thiel
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Katharina Müller
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
- Department of Gynaecology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Bruno Fimm
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Jörg B Schulz
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Jülich Research Center GmbH and RWTH Aachen University, Aachen, Germany
| |
Collapse
|
15
|
Shigeyasu Y, Okada A, Fujii C, Tanaka C, Sugihara A, Horiuchi M, Yorifuji T, Tsukahara H. Quality of life and physical/psychosocial factors in children and adolescents with orthostatic intolerance. Biopsychosoc Med 2023; 17:23. [PMID: 37308984 DOI: 10.1186/s13030-023-00278-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 05/24/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Orthostatic intolerance (OI), which is common in children and adolescents, negatively impacts their quality of life (QOL) due to physical symptoms that limit work, school, and daily activities. The purpose of this study is to explore the association of physical and psychosocial factors with QOL scores in children and adolescents with OI. METHODS A cross sectional observational study was conducted. The study participants included 95 Japanese pediatric patients of age 9-15 years who were diagnosed with OI from April 2010 to March 2020. The QOL scores and the QOL T-scores of children with OI assessed using the KINDL-R questionnaire at the initial visit were compared with conventional normative data. The associations of physical and psychosocial factors with the QOL T-scores were examined using multiple linear regression. RESULTS Pediatric patients with OI had significantly lower QOL scores than healthy children in both elementary (50.7 ± 13.5 vs. 67.9 ± 13.4, p < 0.001) and junior high schools (51.8 ± 14.6 vs. 61.3 ± 12.6, p < 0.001). This finding was observed in the physical, mental, self-esteem, friends, and school domains. Total QOL scores were significantly associated with school nonattendance (β = - 3.2, 95% confidence interval [CI] = - 5.8 to - 0.5, p = 0.022) and poor relationship with school (β = - 5.0, 95% CI = - 9.8 to - 0.4, p = 0.035). CONCLUSIONS These results suggest that the assessment of QOL, including both physical and psychosocial aspects, especially school factors, needs to be implemented earlier in children and adolescents with OI.
Collapse
Affiliation(s)
- Yoshie Shigeyasu
- Department of Pediatrics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 7008558, Japan.
| | - Ayumi Okada
- Department of Pediatrics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 7008558, Japan
| | - Chikako Fujii
- Department of Pediatrics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 7008558, Japan
| | - Chie Tanaka
- Department of Pediatrics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 7008558, Japan
| | - Akiko Sugihara
- Clinical Psychology section, Department of Medical Support, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 7008558, Japan
| | - Makiko Horiuchi
- Clinical Psychology section, Department of Medical Support, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 7008558, Japan
| | - Takashi Yorifuji
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 7008558, Japan
| | - Hirokazu Tsukahara
- Department of Pediatrics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 7008558, Japan
| |
Collapse
|
16
|
Maciuch J, Jason LA. Alcohol intolerance and myalgic encephalomyelitis/chronic fatigue syndrome. World J Neurol 2023; 9:17-27. [DOI: 10.5316/wjn.v9.i3.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/13/2023] [Accepted: 05/06/2023] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND The literature is mixed about the occurrence of alcohol intolerance among patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Surveys that asked respondents with ME/CFS whether they experienced alcohol intolerance within a recent time frame might produce inaccurate results because respondents may indicate that the symptom was not present if they avoid alcohol due to alcohol intolerance.
AIM To overcome this methodologic problem, participants in the current study were asked whether they have avoided alcohol in the past 6 mo, and if they had, how severe their alcohol intolerance would be if they were to drink alcohol.
METHODS The instrument used was a validated scale called the DePaul symptom questionnaire. Independent t-tests were performed among the alcohol intolerant or not alcohol intolerant group. The alcohol intolerant group had 208 participants, and the not alcohol intolerant group had 96 participants.
RESULTS Using specially designed questions to properly identify those with alcohol intolerance, those who experienced alcohol intolerance vs those who did not experience alcohol intolerance experienced more frequent/severe symptoms and domains. In addition, using a multiple regression analysis, the orthostatic intolerance symptom domain was related to alcohol intolerance.
CONCLUSION The findings from the current study indicated that those with ME/CFS are more likely to experience alcohol intolerance. In addition, those with this symptom have more overall symptoms than those without alcohol intolerance.
Collapse
Affiliation(s)
- Jessica Maciuch
- Center for Community Research, DePaul University, Chicago, IL 60614, United States
| | - Leonard A Jason
- Center for Community Research, DePaul University, Chicago, IL 60614, United States
| |
Collapse
|
17
|
Frandsen MN, Huang L, Petersen RH, Foss NB, Mehlsen J, Kehlet H. Continuous perioperative heart rate variability monitoring in video-assisted thoracoscopic surgery lobectomy-a pilot study. J Clin Monit Comput 2023:10.1007/s10877-023-01016-2. [PMID: 37243951 PMCID: PMC10372135 DOI: 10.1007/s10877-023-01016-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 04/14/2023] [Indexed: 05/29/2023]
Abstract
Heart rate variability (HRV) is a measure of cardiac autonomic modulation and is potentially related to hypotension, postoperative atrial fibrillation, and orthostatic intolerance. However, there is a lack of knowledge on which specific time points and indices to measure. To improve future study design, there is a need for procedure-specific studies in an enhanced recovery after surgery (ERAS) video-assisted thoracic surgery (VATS) lobectomy setting, and for continuous measurement of perioperative HRV. HRV was measured continuously from 2 days before until 9 days after VATS lobectomy in 28 patients. After VATS lobectomy, with median length of stay = 4 days, the standard deviation between normal-to-normal beats and the total power of HRV were reduced for 8 days during the night and day times, while low-to-high frequency variation and detrended fluctuation analysis were stable. This is the first detailed study to show that HRV measures of total variability were reduced following ERAS VATS lobectomy, while other measures were more stable. Further, preoperative HRV measures showed circadian variation. The patch was well tolerated among participants, but actions should be taken to ensure proper mounting of the measuring device. These results demonstrate a valid design platform for future HRV studies in relation to postoperative outcomes.
Collapse
Affiliation(s)
- Mikkel Nicklas Frandsen
- Section for Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Lin Huang
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - René Horsleben Petersen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nicolai Bang Foss
- Department of Anesthesiology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Jesper Mehlsen
- Section for Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
18
|
Gobezie NZ, Endalew NS, Tawuye HY, Aytolign HA. Prevalence and associated factors of postoperative orthostatic intolerance at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2022: cross sectional study. BMC Surg 2023; 23:108. [PMID: 37127603 PMCID: PMC10150513 DOI: 10.1186/s12893-023-02015-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/24/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Postoperative orthostatic intolerance is an inability to maintain an upright position because of symptoms of cerebral hypoperfusion. It is a common problem in the early postoperative period and hinders early mobilization, however, there is limited information about factors associated with it. Thus, the main aim of this study was to determine the prevalence and identify factors associated with postoperative orthostatic intolerance. METHOD Hospital based cross-sectional study was conducted from April 08 to July 20, 2022, at University of Gondar comprehensive Specialized Hospital. A semi-structured questionnaire containing sociodemographic variables and perioperative factors related to anesthesia and surgery was used for data collection. The presence of postoperative orthostatic intolerance during the first ambulation was evaluated with a standardized symptom checklist which contains symptoms of orthostatic intolerance. Binary logistic regression analysis was performed to assess factors associated with postoperative orthostatic intolerance. In multivariable regression, variables with P-value < 0.05 were considered statistically significant. RESULT A total of 420 patients were included in this study with a response rate of 99.06%. Postoperative orthostatic intolerance was experienced in 254 (60.5%) participants. Being female (AOR = 2.27; 95% CI = 1.06-4.86), low BMI (AOR = 0.79; 95% CI = 0.71-0.95), ASA II and above (AOR = 3.34; 95% CI = 1.34-8.28), low diastolic blood pressure (AOR = 0.82; 95% CI = 0.88-0.99), general anesthesia (AOR = 3.26, 95% CI = 1.31-8.12), high intraoperative blood lose (AOR = 0.93, 95% CI = 0.88-0.99), high postoperative fluid intake (AOR = 2.09, 95% CI = 1.23-3.55), pain before ambulation (AOR = 1.99, 95% CI = 1.28-3.11) and pain during ambulation (AOR = 1.82, 95% CI = 1.23-2.69) were the significant factors associated with orthostatic intolerance. CONCLUSION Our study revealed that postoperative orthostatic intolerance was experienced in nearly two-thirds of participants. During the time of ambulation, assessing patients for the presence of orthostatic intolerance is necessary to reduce the adverse effects of postoperative OI. In addition, maintaining preoperative normotension, reducing intraoperative blood loss and optimizing postoperative pain control is recommended to reduce the risk of postoperative orthostatic intolerance.
Collapse
Affiliation(s)
- Negesse Zurbachew Gobezie
- Department of Anesthesia, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia.
| | - Nigussie Simeneh Endalew
- Department of Anesthesia, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Hailu Yimer Tawuye
- Department of Anesthesia, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Habtu Adane Aytolign
- Department of Anesthesia, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| |
Collapse
|
19
|
Miwa K. Orthostatic Intolerance and Chronotropic Incompetence in Patients With Myalgic Encephalomyelitis or Chronic Fatigue Syndrome. Circ Rep 2023; 5:55-61. [PMID: 36818521 PMCID: PMC9908528 DOI: 10.1253/circrep.cr-22-0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 01/25/2023] Open
Abstract
Background: Orthostatic intolerance markedly affects the day-to-day activities of patients with myalgic encephalomyelitis (ME) or chronic fatigue syndrome. Chronotropic incompetence (CI), defined as an impaired chronotropic response or reduced increases in heart rate during exercise and resulting in lower exercise capacity, may also be observed during orthostasis in patients with ME. Methods and Results: In this study, the recordings of 101 adult patients with ME (36 men, 65 women; mean [±SD] age 37±12 years) who underwent conventional active 10-min standing tests at least 3 times to determine the presence of CI were analyzed. Recordings were selected for 13 patients who experienced tests both with and without exhibiting postural orthostatic tachycardia syndrome (POTS; an increase in heart rate of ≥30 beats/min or an actual heart rate of ≥120 beats/min) while also both successfully completing and failing to complete 10-min standing on different occasions. Subjects in whom failure without POTS was observed in any test(s) while success was associated with POTS on other occasions were considered positive for CI during orthostasis. Of the 13 patients, 12 (92%) were CI positive, 5 (38%) of whom exclusively failed the tests without experiencing POTS. Conclusions: Some patients with ME were CI positive during standing tests, suggesting impaired sympathetic activation. The presence of POTS appears to be essential for maintaining orthostasis in these patients.
Collapse
|
20
|
Bogle JM. The role of otolith reflexes in orthostatic intolerance. Clin Auton Res 2022; 32:395-8. [PMID: 36255648 DOI: 10.1007/s10286-022-00902-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/08/2022] [Indexed: 01/31/2023]
|
21
|
Rahmouni K. Energy metabolism and syncope. Clin Auton Res 2022; 32:391-393. [PMID: 36326945 DOI: 10.1007/s10286-022-00906-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Kamal Rahmouni
- Department of Neuroscience and Pharmacology, University of Iowa Carver College of Medicine, Iowa City, IA, 52242, USA. .,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA. .,Fraternal Order of Eagles Diabetes Research Center, University of Iowa Carver College of Medicine, Iowa City, IA, USA. .,Obesity Research and Education Initiative, University of Iowa Carver College of Medicine, Iowa City, IA, USA. .,Iowa Neuroscience Institute, University of Iowa Carver College of Medicine, Iowa City, IA, USA. .,Veterans Affairs Health Care System, Iowa City, IA, USA.
| |
Collapse
|
22
|
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a complex multisystem disorder characterized by orthostatic intolerance and tachycardia and may be triggered by viral infection. Recent reports indicate that 2%-14% of coronavirus disease 2019 (COVID-19) survivors develop POTS and 9%-61% experience POTS-like symptoms, such as tachycardia, orthostatic intolerance, fatigue, and cognitive impairment within 6-8 months of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Pathophysiological mechanisms of post-COVID-19 POTS are not well understood. Current hypotheses include autoimmunity related to SARS-CoV-2 infection, autonomic dysfunction, direct toxic injury by SARS-CoV-2 to the autonomic nervous system, and invasion of the central nervous system by SARS-CoV-2. Practitioners should actively assess POTS in patients with post-acute COVID-19 syndrome symptoms. Given that the symptoms of post-COVID-19 POTS are predominantly chronic orthostatic tachycardia, lifestyle modifications in combination with the use of heart rate-lowering medications along with other pharmacotherapies should be considered. For example, ivabradine or β-blockers in combination with compression stockings and increasing salt and fluid intake has shown potential. Treatment teams should be multidisciplinary, including physicians of various specialties, nurses, psychologists, and physiotherapists. Additionally, more resources to adequately care for this patient population are urgently needed given the increased demand for autonomic specialists and clinics since the start of the COVID-19 pandemic. Considering our limited understanding of post-COVID-19 POTS, further research on topics such as its natural history, pathophysiological mechanisms, and ideal treatment is warranted. This review evaluates the current literature available on the associations between COVID-19 and POTS, possible mechanisms, patient assessment, treatments, and future directions to improving our understanding of post-COVID-19 POTS.
Collapse
Affiliation(s)
- Cameron K Ormiston
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, California; Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland
| | - Iwona Świątkiewicz
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, California; Department of Cardiology and Internal Medicine, Nicolaus Copernicus University Torun, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
| | - Pam R Taub
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, California.
| |
Collapse
|
23
|
崔 雅, 杜 军, 张 清, 廖 莹, 刘 平, 王 瑜, 齐 建, 闫 辉, 徐 文, 刘 雪, 孙 燕, 孙 楚, 张 春, 陈 永, 金 红. [A 10-year retrospective analysis of spectrums and treatment options of orthostatic intolerance and sitting intolerance in children]. Beijing Da Xue Xue Bao Yi Xue Ban 2022; 54:954-960. [PMID: 36241239 PMCID: PMC9568388 DOI: 10.19723/j.issn.1671-167x.2022.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Indexed: 09/15/2023]
Abstract
OBJECTIVE To analyze the disease spectrums underlying orthostatic intolerance (OI) and sitting intolerance (SI) in Chinese children, and to understand the clinical empirical treatment options. METHODS The medical records including history, physical examination, laboratory examination, and imagological examination of children were retrospectively studied in Peking University First Hospital from 2012 to 2021. All the children who met the diagnostic criteria of OI and SI were enrolled in the study. The disease spectrums underlying OI and SI and treatment options during the last 10 years were analyzed. RESULTS A total of 2 110 cases of OI and SI patients were collected in the last 10 years, including 943 males (44.69%) and 1 167 females (55.31%) aged 4-18 years, with an average of (11.34±2.84) years. The overall case number was in an increasing trend over the year. In the OI spectrum, postural tachycardia syndrome (POTS) accounted for 826 cases (39.15%), followed by vasovagal syncope (VVS) (634 cases, 30.05%). The highest proportion of SI spectrum was sitting tachycardia (STS) (8 cases, 0.38%), followed by sitting hypertension (SHT) (2 cases, 0.09%). The most common comorbidity of OI and SI was POTS coexisting with STS (36 cases, 1.71%). The highest proportion of treatment options was autonomic nerve function exercise (757 cases, 35.88%), followed by oral rehydration salts (ORS) (687 cases, 32.56%), metoprolol (307 cases, 14.55%), midodrine (142 cases, 6.73%), ORS plus metoprolol (138 cases, 6.54%), and ORS plus midodrine (79 cases, 3.74%). The patients with POTS coexisting with VVS were more likely to receive pharmacological intervention than the patients with POTS and the patients with VVS (41.95% vs. 30.51% vs. 28.08%, χ2= 20.319, P < 0.01), but there was no significant difference in the proportion of treatment options between the patients with POTS and the patients with VVS. CONCLUSION POTS and VVS in children are the main underlying diseases of OI, while SI is a new disease discovered recently. The number of children with OI and SI showed an increasing trend. The main treatment methods are autonomic nerve function exercise and ORS. Children with VVS coexisting with POTS were more likely to take pharmacological treatments than those with VVS or POTS only.
Collapse
Affiliation(s)
- 雅茜 崔
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - 军保 杜
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
- 教育部分子心血管学重点实验室, 北京 100191Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing 100191, China
| | - 清友 张
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - 莹 廖
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - 平 刘
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - 瑜丽 王
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - 建光 齐
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - 辉 闫
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - 文瑞 徐
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - 雪芹 刘
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - 燕 孙
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - 楚凡 孙
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - 春雨 张
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - 永红 陈
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - 红芳 金
- 北京大学第一医院儿科, 北京 100034Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| |
Collapse
|
24
|
儿童直立不耐受和坐位不耐受的疾病谱及治疗方式十年回顾. Beijing Da Xue Xue Bao Yi Xue Ban 2022; 54. [PMID: 36241239 DOI: 10.19723/j.issn.1671-167X.2022.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To analyze the disease spectrums underlying orthostatic intolerance (OI) and sitting intolerance (SI) in Chinese children, and to understand the clinical empirical treatment options. METHODS The medical records including history, physical examination, laboratory examination, and imagological examination of children were retrospectively studied in Peking University First Hospital from 2012 to 2021. All the children who met the diagnostic criteria of OI and SI were enrolled in the study. The disease spectrums underlying OI and SI and treatment options during the last 10 years were analyzed. RESULTS A total of 2 110 cases of OI and SI patients were collected in the last 10 years, including 943 males (44.69%) and 1 167 females (55.31%) aged 4-18 years, with an average of (11.34±2.84) years. The overall case number was in an increasing trend over the year. In the OI spectrum, postural tachycardia syndrome (POTS) accounted for 826 cases (39.15%), followed by vasovagal syncope (VVS) (634 cases, 30.05%). The highest proportion of SI spectrum was sitting tachycardia (STS) (8 cases, 0.38%), followed by sitting hypertension (SHT) (2 cases, 0.09%). The most common comorbidity of OI and SI was POTS coexisting with STS (36 cases, 1.71%). The highest proportion of treatment options was autonomic nerve function exercise (757 cases, 35.88%), followed by oral rehydration salts (ORS) (687 cases, 32.56%), metoprolol (307 cases, 14.55%), midodrine (142 cases, 6.73%), ORS plus metoprolol (138 cases, 6.54%), and ORS plus midodrine (79 cases, 3.74%). The patients with POTS coexisting with VVS were more likely to receive pharmacological intervention than the patients with POTS and the patients with VVS (41.95% vs. 30.51% vs. 28.08%, χ2= 20.319, P < 0.01), but there was no significant difference in the proportion of treatment options between the patients with POTS and the patients with VVS. CONCLUSION POTS and VVS in children are the main underlying diseases of OI, while SI is a new disease discovered recently. The number of children with OI and SI showed an increasing trend. The main treatment methods are autonomic nerve function exercise and ORS. Children with VVS coexisting with POTS were more likely to take pharmacological treatments than those with VVS or POTS only.
Collapse
|
25
|
Govindapala D, Senarath US, Wijewardena D, Nakkawita D, Undugodage C. An unusual presentation of anaphylaxis with severe hypertension: a case report. J Med Case Rep 2022; 16:327. [PMID: 36008817 PMCID: PMC9413925 DOI: 10.1186/s13256-022-03528-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 07/16/2022] [Indexed: 11/10/2022] Open
Abstract
Background Low blood pressure and associated postural symptoms are well-recognized manifestations of anaphylaxis. Nonetheless, anaphylaxis can present with high blood pressure and is rarely reported in the literature. We report an unusual presentation of anaphylaxis with severe supine hypertension and orthostatic intolerance. Case presentation A 43-year-old Asian female presented to the emergency department with generalized itching, hives, and postural dizziness after taking a slow-release diclofenac sodium 100 mg tablet. On admission, the patient was tachycardic with a supine blood pressure of 200/100 mmHg. She had urticaria and bilateral rhonchi. A clinical diagnosis of anaphylaxis was made. She was treated with intravenous hydrocortisone and chlorpheniramine, but intramuscular adrenaline was withheld owing to her high blood pressure. She was kept in the supine position, and her vital parameters were closely monitored. Although the respiratory and cutaneous symptoms improved with treatment, her blood pressure remained elevated. Forty minutes later, the postural dizziness recurred as she sat up on the bed and her blood pressure plummeted from 198/100 mmHg to 80/60 mmHg. She was put back in the supine position immediately, and the blood pressure was restored with three doses of intramuscular adrenaline and a fluid bolus. Her postural symptoms completely resolved after adrenaline, but her blood pressure remained elevated. Two weeks after the initial presentation, a diagnosis of essential hypertension was made, which probably had been undetected. In anaphylaxis, where the cardiovascular system is involved, a blood pressure reduction from baseline is expected in patients with preexisting hypertension. Despite cardiovascular involvement, our patients’ blood pressure on presentation to the emergency department was much higher than her pretreatment ambulatory blood pressure, thus making this presentation unusual. Conclusions Diagnosis and treatment of anaphylaxis can be delayed in patients presenting with high blood pressure. Postural symptoms should alert the clinician to cardiovascular involvement despite elevated supine blood pressure. Early treatment with adrenaline should be considered in these patients with extreme caution.
Collapse
Affiliation(s)
- Dumitha Govindapala
- Department of Clinical Sciences, Faculty of Medicine, General Sir John Kotelawala Defence University, Ratmalana, Sri Lanka.
| | - Uththara Sachinthanie Senarath
- Department of Clinical Sciences, Faculty of Medicine, General Sir John Kotelawala Defence University, Ratmalana, Sri Lanka
| | - Dasun Wijewardena
- Department of Clinical Sciences, Faculty of Medicine, General Sir John Kotelawala Defence University, Ratmalana, Sri Lanka
| | - Dilini Nakkawita
- Department of Paraclinical Sciences, Faculty of Medicine, General Sir John Kotelawala Defence University, Ratmalana, Sri Lanka
| | - Chandimani Undugodage
- Department of Physiology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda, Sri Lanka
| |
Collapse
|
26
|
Soroken C, Posfay-Barbe KM, Caflisch M, Z'Graggen WJ. Postural tachycardia syndrome among adolescents. Arch Pediatr 2022; 29:398-403. [PMID: 35523634 DOI: 10.1016/j.arcped.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/20/2022] [Accepted: 03/26/2022] [Indexed: 12/01/2022]
Abstract
Postural tachycardia syndrome (PoTS) is a polymorphic clinical syndrome that is underdiagnosed, especially in adolescents. It is a form of dysautonomia, but its exact physiopathology remains elusive. Several pathologies can mimic PoTS; it is characterized by heterogeneous symptoms that accompany a disproportionate tachycardia upon the upright position. It can significantly impact the patients' quality of life. Only a Schellong test is useful for making the diagnosis. Treatment in PoTS is primarily symptomatic with the main goal being to restore the patient's condition as quickly as possible. We report here the diagnosis and management of seven adolescents, aged 11-16, who have been followed up since 2015.
Collapse
Affiliation(s)
- C Soroken
- Department of Pediatrics, Geneva University Hospitals, Willy-Donzé Street 6, 1205 Geneva, Switzerland.
| | - K M Posfay-Barbe
- Department of Pediatrics, Geneva University Hospitals, Willy-Donzé Street 6, 1205 Geneva, Switzerland
| | - M Caflisch
- Department of Pediatrics, Geneva University Hospitals, Willy-Donzé Street 6, 1205 Geneva, Switzerland
| | - W J Z'Graggen
- Departments of Neurology and Neurosurgery, Inselspital, Bern University Hospital, Freiburgstrasse 16, 3010 Bern, Switzerland
| |
Collapse
|
27
|
Snapper H, Cheshire WP. Oral and intravenous hydration in the treatment of orthostatic hypotension and postural tachycardia syndrome. Auton Neurosci 2022; 238:102951. [PMID: 35123367 DOI: 10.1016/j.autneu.2022.102951] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 12/07/2021] [Accepted: 01/25/2022] [Indexed: 01/21/2023]
Abstract
Hydration with water and salt is the mainstay of treatment for autonomic nervous system disorders that impair orthostatic tolerance. The goal is to expand intravascular volume to compensate for the downward displacement of blood volume that occurs when standing and thereby sustain cerebral perfusion and restore quality of life. Despite strong consensus recommendations for salt supplementation as standard treatment of these disorders, published evidence of benefit is relatively weak, and no randomized clinical trials have occurred. This review summarizes the physiological rationale for hydration and evaluates the literature on oral and intravenous hydration in the treatment of neurogenic orthostatic hypotension, postural tachycardia syndrome, and recurrent vasovagal syncope. We conclude that oral salt replacement is indicated for treatment of neurogenic orthostatic hypotension because these patients have excessive renal sodium excretion, and for treatment of chronic orthostatic intolerance because these patients are often hypovolemic. As not all patients are able to tolerate sufficient oral hydration, there is also a role for intravenous volume-loading in severe cases of postural tachycardia syndrome. We offer guidance, based on review of the literature and the clinical judgment of a cardiologist and neurologist with experience treating autonomic disorders, regarding the option of ongoing intravenous hydration for treatment of severe, refractory cases of postural tachycardia syndrome.
Collapse
Affiliation(s)
- Howard Snapper
- Department of Cardiology, Wellstar Healthcare System, Marietta, GA 30060, USA.
| | - William P Cheshire
- Division of Autonomic Disorders, Department of Neurology, Mayo Clinic, Jacksonville, FL 32224, USA
| |
Collapse
|
28
|
Agnihotri SP, Luis CVS, Kazamel M. Autonomic neuropathy as post-acute sequela of SARS-CoV-2 infection: a case report. J Neurovirol 2022; 28:158-161. [PMID: 35181863 PMCID: PMC8856878 DOI: 10.1007/s13365-022-01056-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/13/2022] [Accepted: 01/27/2022] [Indexed: 01/01/2023]
Abstract
Symptoms of autonomic dysfunction, particularly those of orthostatic intolerance, continue to represent a major component of the currently recognized post-acute sequelae of SARS-CoV-2 infections. Different pathophysiologic mechanisms can be involved in the development of orthostatic intolerance including hypovolemia due to gastrointestinal dysfunction, fatigue-associated deconditioning, and hyperadrenergic state due to pandemic-related anxiety. Additionally, there has been a well-established association of a common primary autonomic disorder like postural orthostatic tachycardia syndrome, a subtype of orthostatic intolerance, with antecedent viral infections. Here we report a case of neuropathic type postural orthostatic tachycardia syndrome as a form of autonomic neuropathy that developed following COVID-19 infection.
Collapse
Affiliation(s)
- Shruti P Agnihotri
- Department of Neurology, University of Alabama at Birmingham, 1720 2nd Ave. South, SC271, Birmingham, AL, 35294-0017, USA
| | - Carmela V San Luis
- Department of Neurology, University of Alabama at Birmingham, 1720 2nd Ave. South, SC271, Birmingham, AL, 35294-0017, USA
| | - Mohamed Kazamel
- Department of Neurology, University of Alabama at Birmingham, 1720 2nd Ave. South, SC271, Birmingham, AL, 35294-0017, USA.
| |
Collapse
|
29
|
Okyar Baş A, Güner Oytun M, Kahyaoğlu Z, Çöteli S, Ceylan S, Boğa İ, Doğu BB, Cankurtaran M, Halil MG. Orthostatic intolerance: a frailty marker for older adults. Eur Geriatr Med 2022. [PMID: 35147907 DOI: 10.1007/s41999-022-00618-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/27/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Frailty, orthostatic blood pressure changes (OBPC), and orthostatic intolerance syndrome (OIS) are common in geriatric patients. However, the results of the studies evaluating the relationship between these entities are discordant. We aimed to investigate the association between frailty and OIS with or without OBPC. METHODS Comprehensive geriatric assessment (CGA), frailty assessment, OBPC evaluations in the active-standing test (1st, 3rd, 5th, and 10th min), OIS investigation both in history before the test (self-reported OIS) and emerged during the active-standing test, and sarcopenia assessment via BIA and handgrip strength (HGS) were performed in 102 geriatric outpatients. RESULTS Patients were divided into three categories according to their frailty status (non-frail, prefrail, and frail) by Modified Fried Frailty Index (FFI) and Clinical Frailty Scale (CFS). Prevalence of self-reported OIS and OIS during the test were statistically higher in the frail group assessed by both frailty scales (P value: 0.001 for CFS, P value < 0.0001 for FFI, and P value: 0.001 for CFS, P value: 0.007 for FFI, respectively). Logistic regression analysis showed that OIS significantly increased frailty assessed both by FFI and CFS, when adjusted for age, sex, comorbidities, CGA, and sarcopenia (For FFI, OR: 19.37; 95% CI: 2.38-157.14; P value: 0.006 and for CFS OR: 4.32; 95% CI: 1.184-11.47; P value: 0.003, respectively). CONCLUSION To the best of our knowledge, this is the first study defining OIS as symptoms both self-reported and provoked during the test, and showed a strong correlation between OIS and frailty. OIS may be defined as a multifactorial and independent marker for frailty, regardless of OBPC. Further prospective investigations are warranted to support the relationships between OIS and frailty.
Collapse
|
30
|
Jenkins ZM, Castle DJ, Eikelis N, Phillipou A, Lambert GW, Lambert EA. Autonomic nervous system function in women with anorexia nervosa. Clin Auton Res 2022; 32:29-42. [PMID: 34762216 DOI: 10.1007/s10286-021-00836-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/28/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE Abnormalities in autonomic function have been observed in people with anorexia nervosa. However, the majority of investigations have utilised heart rate variability as the sole assessment of autonomic activity. The current study utilised a variety of methodologies to assess autonomic nervous system function in women with a current diagnosis of anorexia, a past diagnosis of anorexia who were weight-restored, and healthy controls. METHODS The sample included 37 participants: 10 participants with anorexia, 17 weight-restored participants (minimum body mass index > 18.5 for minimum of 12 months) and 10 controls. Assessments of autonomic function included muscle sympathetic nerve activity (MSNA) using microneurography, heart rate variability, baroreflex sensitivity, blood pressure variability, head-up tilt table test, sudomotor function and assessment of plasma catecholamines. RESULTS MSNA (bursts/min) was significantly decreased in both anorexia (10.22 ± 6.24) and weight-restored (17.58 ± 1.68) groups, as compared to controls (23.62 ± 1.01, p < 0.001 and p = 0.033, respectively). Participants with anorexia had a significantly lower standard deviation in heart rate, lower blood pressure variability and decreased sudomotor function as compared to controls. Weight-restored participants demonstrated decreased baroreflex sensitivity in response to head-up tilt as compared to controls. CONCLUSION Women with a current or previous diagnosis of anorexia have significantly decreased sympathetic activity, which may reflect a physiological response to decreased energy intake. During the state of starvation, women with anorexia also displayed decreased sudomotor function. The consequences of a sustained decrease in MSNA are unknown, and future studies should investigate autonomic function in long-term weight-restored participants to determine whether activity returns to normal.
Collapse
Affiliation(s)
- Zoe M Jenkins
- Iverson Health Innovation Research Institute and School of Health Sciences, Swinburne University of Technology, Melbourne, Australia. .,Department of Mental Health, St Vincent's Hospital Melbourne, PO Box 2900, Fitzroy, VIC, 3065, Australia. .,Department of Psychiatry, University of Melbourne, Melbourne, Australia.
| | - David J Castle
- Department of Mental Health, St Vincent's Hospital Melbourne, PO Box 2900, Fitzroy, VIC, 3065, Australia.,Centre for Complex Interventions, Centre for Addictions and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Nina Eikelis
- Iverson Health Innovation Research Institute and School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
| | - Andrea Phillipou
- Department of Mental Health, St Vincent's Hospital Melbourne, PO Box 2900, Fitzroy, VIC, 3065, Australia.,Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Centre for Mental Health and School of Health Sciences, Swinburne University of Technology, Melbourne, Australia.,Department of Mental Health, Austin Health, Melbourne, Australia
| | - Gavin W Lambert
- Iverson Health Innovation Research Institute and School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
| | - Elisabeth A Lambert
- Iverson Health Innovation Research Institute and School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
| |
Collapse
|
31
|
Williams EL, Raj SR, Schondorf R, Shen WK, Wieling W, Claydon VE. Salt supplementation in the management of orthostatic intolerance: Vasovagal syncope and postural orthostatic tachycardia syndrome. Auton Neurosci 2021; 237:102906. [PMID: 34823150 DOI: 10.1016/j.autneu.2021.102906] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/23/2021] [Accepted: 11/06/2021] [Indexed: 02/07/2023]
Abstract
Salt supplementation is a common non-pharmacological approach to the management of recurrent orthostatic syncope or presyncope, particularly for patients with vasovagal syncope (VVS) or postural orthostatic tachycardia syndrome (POTS), although there is limited consensus on the optimal dosage, formulation and duration of treatment. Accordingly, we reviewed the evidence for the use of salt supplementation to reduce susceptibility to syncope or presyncope in patients with VVS and POTS. We found that short-term (~3 months) salt supplementation improves susceptibility to VVS and associated symptoms, with little effect on supine blood pressure. In patients with VVS, salt supplementation is associated with increases in plasma volume, and an increase in the time taken to provoke a syncopal event during orthostatic tolerance testing, with smaller orthostatic heart rate increases, enhanced peripheral vascular responses to orthostatic stress, and improved cerebral autoregulation. Responses were most pronounced in those with a baseline sodium excretion <170 mmol/day. Salt supplementation also improved symptoms, plasma volume, and orthostatic responses in patients with POTS. Salt supplementation should be considered for individuals with recurrent and troublesome episodes of VVS or POTS without cardiovascular comorbidities, particularly if their typical urinary sodium excretion is low, and their supine blood pressure is not elevated. The efficacy of the response, in terms of the improvement in subjective and objective markers of orthostatic intolerance, and any potential deleterious effect on supine blood pressure, should be routinely monitored in individuals on high salt regimes.
Collapse
Affiliation(s)
- E L Williams
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - S R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - R Schondorf
- Department of Neurology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - W K Shen
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - W Wieling
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - V E Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada.
| |
Collapse
|
32
|
Jorge-Galarza E, Torres-Tamayo M, Martínez-Alvarado MDR, Peña-Aparicio B, González-Salazar C, Reyes-Barrera J, Sierra-Beltrán M, Fajardo-Flores E, Kostin A, González-Hermosillo JA. Cardiovascular autonomic responses during head-up tilt test in newly diagnosed type 2 diabetes. Ir J Med Sci 2021; 191:2077-2084. [PMID: 34750734 DOI: 10.1007/s11845-021-02825-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 10/21/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Autonomic dysfunction is commonly observed in patients with long-standing type 2 diabetes. Previous studies have confirmed the value of both subjectively assessed symptoms and objective measurements of autonomic nervous system function in diagnosing cardiovascular autonomic neuropathy. However, the head-up tilt test (HUTT) has been rarely used to investigate cardiovascular autonomic responses in subjects with high risk of newly diagnosed type 2 diabetes (nT2D). OBJECTIVE To evaluate autonomic cardiovascular responses through passive orthostatic challenge along the diabetes continuum. METHODS The study population was stratified as normoglycemic (n = 16), prediabetes (n = 20), and nT2D (n = 20). The prevalence of orthostatic intolerance and autonomic cardiovascular responses was evaluated with the Task Force Monitor during a 30-min passive HUTT. Spectral indices of heart rate and blood pressure variability and baroreceptor effectiveness index (BEI) were calculated through the HUTT. BEI was obtained by the sequence method. RESULTS There were no differences in the prevalence of orthostatic intolerance or in the indices of heart rate and blood pressure variability among the three groups of study. The BEI was attenuated in the nT2D group in supine rest and throughout HUTT compared with normoglycemic and prediabetes groups. The multivariable linear regression analysis showed that BEI was associated with fasting glucose (β = - 0.52, p < 0.001) and HbA1c (β = - 0.57, p < 0.001) independently of cardiovascular risk factors. CONCLUSION Cardiovascular autonomic neuropathy, expressed as blunted BEI, is the only abnormal autonomic nervous test detected in nT2D, and it was independently associated with fasting glucose and HbA1c values.
Collapse
Affiliation(s)
- Esteban Jorge-Galarza
- Endocrinology Department, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
| | - Margarita Torres-Tamayo
- Endocrinology Department, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
| | | | - Berenice Peña-Aparicio
- Endocrinology Department, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
| | - Carmen González-Salazar
- Endocrinology Department, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
| | - Juan Reyes-Barrera
- Endocrinology Department, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
| | - Manuel Sierra-Beltrán
- Dysautonomic Clinic, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
| | - Erika Fajardo-Flores
- Dysautonomic Clinic, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
| | - Andrey Kostin
- Dysautonomic Clinic, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
| | - J Antonio González-Hermosillo
- Dysautonomic Clinic, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico. .,, Mexico City, Mexico.
| |
Collapse
|
33
|
González-Hermosillo JA, Rubio-Vega A, González-Olvera KAF, Sierra-Beltrán M, Kostine A, Lerma C. Early Cerebral Hypoperfusion in Patients with Orthostatic Intolerance Without Tachycardia During Head-Up Tilt Test is Independent of Vasovagal Response. Rev Invest Clin 2021; 73. [PMID: 34129596 DOI: 10.24875/ric.21000199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/20/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Cerebral hypoperfusion before syncope has been shown in patients with chronic orthostatic intolerance (OI) without tachycardia, but it is unknown if an initial decrease of cerebral blood flow velocity (CBFv) could be related to the vasovagal response (VVR) to head-up tilt test (HUTT). OBJECTIVE The objective of the study was to compare cardiovascular, cerebrovascular, and autonomic variables during HUTT in OI patients with or without a VVR. METHODS We included 74 subjects (58% female, mean age 33 ± 12 years) who underwent a 30-min HUTT and were divided into three groups: OI with VVR positive (VVR+), OI without VVR negative (VVR-), and asymptomatic healthy subjects with negative HUTT (control group). Cardiovascular, cerebrovascular, and autonomic variables were assessed beat-to-beat during HUTT with a Task Force monitor and a trans-cranial Doppler. Mean values were evaluated at baseline and throughout the first 10 min of tilting. RESULTS Cardiovascular variables were similar in the three groups. Systolic, diastolic, and mean CBFv were similar in VVR+ and VVR-, but both groups had lower CBFv than the control group. Systolic and diastolic CBFv decreased from baseline since min 1 in VVR+ and VVR- and since min 5 in the control group. The mean CBFv had a significant decrease since min 1 compared to baseline in all groups. Spectral indices of heart rate and blood pressure variability showed a similar autonomic response to HUTT in all groups. CONCLUSION Patients with chronic OI without tachycardia have early postural cerebral hypoperfusion, regardless of the VVR during HUTT.
Collapse
Affiliation(s)
| | - Alan Rubio-Vega
- Department of Cardiovascular Dysautonomia, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Karla A F González-Olvera
- Department of Cardiovascular Dysautonomia, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Manuel Sierra-Beltrán
- Department of Cardiovascular Dysautonomia, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Andrei Kostine
- Department of Cardiovascular Dysautonomia, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Claudia Lerma
- Department of Electromechanical Instrumentation, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| |
Collapse
|
34
|
van Campen CLMC, Rowe PC, Visser FC. Cerebral blood flow remains reduced after tilt testing in myalgic encephalomyelitis/chronic fatigue syndrome patients. Clin Neurophysiol Pract 2021; 6:245-55. [PMID: 34667909 DOI: 10.1016/j.cnp.2021.09.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/16/2021] [Accepted: 09/05/2021] [Indexed: 01/06/2023] Open
Abstract
Cerebral blood flow in ME/CFS patients remains abnormal 5 min post-tilt test. Post cerebral blood flow abnormalities do not depend on hemodynamic results and on end-tidal carbon dioxide pressures during the tilt-test. Post cerebral blood flow abnormalities are most severe in more severely diseased ME/CFS patients.
Objective Orthostatic symptoms in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) may be caused by an abnormal reduction in cerebral blood flow. An abnormal cerebral blood flow reduction was shown in previous studies, without information on the recovery pace of cerebral blood flow. This study examined the prevalence and risk factors for delayed recovery of cerebral blood flow in ME/CFS patients. Methods 60 ME/CFS adults were studied: 30 patients had a normal heart rate and blood pressure response during the tilt test, 4 developed delayed orthostatic hypotension, and 26 developed postural orthostatic tachycardia syndrome (POTS) during the tilt. Cerebral blood flow measurements, using extracranial Doppler, were made in the supine position pre-tilt, at end-tilt, and in the supine position at 5 min post-tilt. Also, cardiac index measurements were performed, using suprasternal Doppler imaging, as well as end-tidal PCO2 measurements. The change in cerebral blood flow from supine to end-tilt was expressed as a percent reduction with mean and (SD). Disease severity was scored as mild (approximately 50% reduction in activity), moderate (mostly housebound), or severe (mostly bedbound). Results End-tilt cerebral blood flow reduction was −29 (6)%, improving to −16 (7)% at post-tilt. No differences in either end-tilt or post-tilt measurements were found when patients with a normal heart rate and blood pressure were compared to those with POTS, or between patients with normocapnia (end-tidal PCO2 ≥ 30 mmHg) versus hypocapnia (end-tidal PCO2 < 30 mmHg) at end-tilt. A significant difference was found in the degree of abnormal cerebral blood flow reduction in the supine post-test in mild, moderate, and severe ME/CFS: mild: cerebral blood flow: −7 (2)%, moderate: −16 (3)%, and severe :-25 (4)% (p all < 0.0001). Cardiac index declined significantly during the tilt test in all 3 severity groups, with no significant differences between the groups. In the supine post-test cardiac index returned to normal in all patients. Conclusions During tilt testing, extracranial Doppler measurements show that cerebral blood flow is reduced in ME/CFS patients and recovery to normal supine values is incomplete, despite cardiac index returning to pre-tilt values. The delayed recovery of cerebral blood flow was independent of the hemodynamic findings of the tilt test (normal heart rate and blood pressure response, POTS, or delayed orthostatic hypotension), or the presence/absence of hypocapnia, and was only related to clinical ME/CFS severity grading. We observed a significantly slower recovery in cerebral blood flow in the most severely ill ME/CFS patients. Significance The finding that orthostatic stress elicits a post-stress cerebral blood flow reduction and that disease severity greatly influences the cerebral blood flow reduction may have implications on the advice of energy management after a stressor and on the advice of lying down after a stressor in these ME/CFS patients.
Collapse
Key Words
- BMI, Body Mass Index
- BSA, Body Surface Area
- CBF, Cerebral blood flow
- CI, Cardiac Index
- Cardiac Index
- Cerebral blood flow
- DBP, Diastolic Blood pressure
- Extracranial Doppler echography
- HR, Heart rate
- ICC, International Consensus Criteria
- ME/CFS
- ME/CFS, Myalgic encephalomyelitis/chronic fatigue syndrome
- NormHRBP, normal heart rate and blood pressure response
- Normal heart rate and blood pressure response
- Orthostatic intolerance
- PET, end-tidal pressure
- POTS, Postural orthostatic tachycardia syndrome
- Post exertional malaise
- Postural Orthostatic Tachycardia Syndrome
- Recovery
- SBP, Systolic Blood pressure
- Tilt table testing
- VTI, Time velocity integral
- dOH, delayed orthostatic hypotension
Collapse
|
35
|
Hwang CL, Okazaki K, Shibata S, Liu YL, Fu Q. Menstrual cycle effects on sympathetic neural burst amplitude distribution during orthostasis in young women. Clin Auton Res 2021; 31:767-773. [PMID: 34669075 DOI: 10.1007/s10286-021-00832-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/12/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Fluctuations in ovarian hormones during the menstrual cycle impact muscle sympathetic nerve activity burst frequency and burst incidence at rest. The purpose of this study was to investigate menstrual cycle effects on sympathetic neural burst amplitude distribution during an orthostatic challenge in young women. METHODS This study included 11 healthy women (33 ± 10 years [mean ± standard deviation]). Muscle sympathetic nerve activity was measured in the supine position as baseline measurement and during 5 min of 60° upright tilting, during the early follicular phase (low estrogen and progesterone) and mid-luteal phase (high estrogen and progesterone) of the menstrual cycle. Relative burst amplitude distribution of muscle sympathetic nerve activity was characterized by the mean, median, skewness, and kurtosis. RESULTS From the supine to upright position, mean and median values of relative burst amplitude increased (both P < 0.05), regardless of phases of the menstrual cycle (P = 0.5 and P = 0.7, respectively). In comparison, during the early follicular phase, skewness and kurtosis remained unchanged (P = 0.6 and P = 0.3, respectively) and kurtosis decreased (1.25 ± 1.11 supine vs. - 0.03 ± 0.73 upright; P = 0.02); there was no change in skewness during the mid-luteal phase (P = 0.4). CONCLUSIONS In response to orthostasis, while the symmetry and tailedness/peakness of burst amplitude distribution do not change during the early follicular phase, the distribution during the mid-luteal phase becomes flatter with a lower but broader peak. The latter result suggests that the firing probability of large axon action potentials in response to orthostatic challenge is higher when estrogen and progesterone levels are elevated. The role of changes in sympathetic neural burst amplitude distribution in orthostatic tolerance remains to be determined.
Collapse
Affiliation(s)
- Chueh-Lung Hwang
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA.,Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Kazunobu Okazaki
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA.,The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Shigeki Shibata
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA.,The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yu-Lun Liu
- The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Qi Fu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA. .,The University of Texas Southwestern Medical Center, Dallas, TX, USA.
| |
Collapse
|
36
|
Starling CT, Nguyen QBD, Butler IJ, Numan MT, Hebert AA. Cutaneous manifestations of orthostatic intolerance syndromes. Int J Womens Dermatol 2021; 7:471-477. [PMID: 34621961 PMCID: PMC8484984 DOI: 10.1016/j.ijwd.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 02/05/2021] [Accepted: 03/05/2021] [Indexed: 11/27/2022] Open
Abstract
Dysautonomia refers to a group of autonomic nervous system disorders that affect nearly 70 million people worldwide. One subset of dysautonomia includes syndromes of orthostatic intolerance (OI), which primarily affect adolescents and women of childbearing age. Due to the variability in disease presentation, the average time from symptom onset to diagnosis of dysautonomia is 6 years. In general, there is a paucity of dermatological research articles describing patients with dysautonomia. The objective of this review is to summarize the existing literature on cutaneous manifestations in dysautonomia, with an emphasis on syndromes of OI. A PubMed database of the English-language literature (1970–2020) was searched using the terms “dysautonomia”, “orthostatic intolerance”, “cutaneous”, “skin”, “hyperhidrosis”, “hypohidrosis”, “sweat”, and other synonyms. Results showed that cutaneous manifestations of orthostatic intolerance are common and varied, with one paper citing up to 85% of patients with OI having at least one cutaneous symptom. Recognition of dermatological complaints may lead to an earlier diagnosis of orthostatic intolerance, as well as other comorbid conditions.
Collapse
Affiliation(s)
| | - Quoc-Bao D Nguyen
- Department of Dermatology, UTHealth McGovern Medical School at Houston, Houston, Texas
| | - Ian J Butler
- Department of Pediatrics, UTHealth McGovern Medical School at Houston, Houston, Texas
| | - Mohammed T Numan
- Department of Pediatrics, UTHealth McGovern Medical School at Houston, Houston, Texas
| | - Adelaide A Hebert
- Department of Dermatology, UTHealth McGovern Medical School at Houston, Houston, Texas.,Department of Pediatrics, UTHealth McGovern Medical School at Houston, Houston, Texas
| |
Collapse
|
37
|
Riberholt CG, Olsen MH, Berg RMG, Mehlsen J, Møller K. Dynamic cerebral autoregulation during early orthostatic exercise in patients with severe traumatic brain injury: Further exploratory analyses from a randomized clinical feasibility trial. J Clin Neurosci 2021; 92:39-44. [PMID: 34509259 DOI: 10.1016/j.jocn.2021.07.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/25/2021] [Accepted: 07/25/2021] [Indexed: 01/10/2023]
Abstract
In patients with severe traumatic brain injury, there is limited evidence of the clinical effect of early orthostatic exercise, although such exercise may strengthen systemic or cerebral hemodynamic responses to head-up tilt, thereby minimizing orthostatic intolerance. We measured dynamic cerebral autoregulation (dCA) and the occurrence of orthostatic intolerance after four weeks of regular orthostatic exercise by head-up tilt using a tilt table with integrated stepping using the ERIGO® tilt-table and comparing it to standard care. Thirty-four patients with severe traumatic brain injury admitted to a neurocritical care unit were included in this randomized clinical trial. Middle cerebral artery blood flow velocity (MCAv), non-invasive mean arterial pressure, heart rate and PaCO2 were recorded; dCA was measured by the non-invasive mean flow index (nMxa). Transition from the supine position to head-up tilt triggered a 10-16% decrease in MCAv and increased nMxa in both groups at all time points (P < 0.05), with no differences between groups. There was no difference in the number of episodes with orthostatic intolerance (5 vs 3; 1 vs 2; 1 vs 0) at baseline, two weeks and four weeks, respectively, and no association between changes in PaCO2-adjusted nMxa and the occurrence of orthostatic reactions (P = 0.35). Early orthostatic exercise does not affect dynamic cerebral autoregulation and does not protect against orthostatic intolerance in patients with severe traumatic brain injury. Trial registration: ClinicalTrials.gov identifier: NCT02924649. Registered on 3rd October 2016.
Collapse
|
38
|
Buoite Stella A, Furlanis G, Frezza NA, Valentinotti R, Ajcevic M, Manganotti P. Autonomic dysfunction in post-COVID patients with and witfhout neurological symptoms: a prospective multidomain observational study. J Neurol 2021; 269:587-596. [PMID: 34386903 PMCID: PMC8359764 DOI: 10.1007/s00415-021-10735-y] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023]
Abstract
The autonomic nervous system (ANS) can be affected by COVID-19, and dysautonomia may be a possible complication in post-COVID individuals. Orthostatic hypotension (OH) and postural tachycardia syndrome (POTS) have been suggested to be common after SARS-CoV-2 infection, but other components of ANS function may be also impaired. The Composite Autonomic Symptom Scale 31 (COMPASS-31) questionnaire is a simple and validated tool to assess dysautonomic symptoms. The aim of the present study was to administer the COMPASS-31 questionnaire to a sample of post-COVID patients with and without neurological complaints. Participants were recruited among the post-COVID ambulatory services for follow-up evaluation between 4 weeks and 9 months from COVID-19 symptoms onset. Participants were asked to complete the COMPASS-31 questionnaire referring to the period after COVID-19 disease. Heart rate and blood pressure were manually taken during an active stand test for OH and POTS diagnosis. One-hundred and eighty participants were included in the analysis (70.6% females, 51 ± 13 years), and OH was found in 13.8% of the subjects. Median COMPASS-31 score was 17.6 (6.9-31.4), with the most affected domains being orthostatic intolerance, sudomotor, gastrointestinal and pupillomotor dysfunction. A higher COMPASS-31 score was found in those with neurological symptoms (p < 0.01), due to more severe orthostatic intolerance symptoms (p < 0.01), although gastrointestinal (p < 0.01), urinary (p < 0.01), and pupillomotor (p < 0.01) domains were more represented in the non-neurological symptoms group. This study confirms the importance of monitoring ANS symptoms as a possible complication of COVID-19 disease that may persist in the post-acute period.
Collapse
Affiliation(s)
- Alex Buoite Stella
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Trieste University Hospital-ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Giovanni Furlanis
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Trieste University Hospital-ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Nicolò Arjuna Frezza
- School of Medicine and Surgery, Department of Medicine, Surgery and Health Sciences, Trieste University Hospital-ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Romina Valentinotti
- Infectious Diseases, Trieste University Hospital-ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Milos Ajcevic
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Trieste University Hospital-ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
- Department of Engineering and Architecture, University of Trieste, Via Alfonso Valerio 10, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Trieste University Hospital-ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy.
| |
Collapse
|
39
|
van Campen CLMC, Rowe PC, Visser FC. Deconditioning does not explain orthostatic intolerance in ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome). J Transl Med 2021; 19:193. [PMID: 33947430 PMCID: PMC8097965 DOI: 10.1186/s12967-021-02819-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/08/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Orthostatic intolerance (OI) is a frequent finding in individuals with myalgic encephalomyelitis /chronic fatigue syndrome (ME/CFS). Published studies have proposed that deconditioning is an important pathophysiological mechanism in various forms of OI, including postural orthostatic tachycardia syndrome (POTS), however conflicting opinions exist. Deconditioning can be classified objectively using the predicted peak oxygen consumption (VO2) values from cardiopulmonary exercise testing (CPET). Therefore, if deconditioning is an important contributor to OI symptomatology, one would expect a relation between the degree of reduction in peak VO2during CPET and the degree of reduction in CBF during head-up tilt testing (HUT). METHODS AND RESULTS In 22 healthy controls and 199 ME/CFS patients were included. Deconditioning was classified by the CPET response as follows: %peak VO2 ≥ 85% = no deconditioning, %peak VO2 65-85% = mild deconditioning, and %peak VO2 < 65% = severe deconditioning. HC had higher oxygen consumption at the ventilatory threshold and at peak exercise as compared to ME/CFS patients (p ranging between 0.001 and < 0.0001). Although ME/CFS patients had significantly greater CBF reduction than HC (p < 0.0001), there were no differences in CBF reduction among ME/CFS patients with no, mild, or severe deconditioning. We classified the hemodynamic response to HUT into three categories: those with a normal heart rate and blood pressure response, postural orthostatic tachycardia syndrome, or orthostatic hypotension. No difference in the degree of CBF reduction was shown in those three groups. CONCLUSION This study shows that in ME/CFS patients orthostatic intolerance is not caused by deconditioning as defined on cardiopulmonary exercise testing. An abnormal high decline in cerebral blood flow during orthostatic stress was present in all ME/CFS patients regardless of their %peak VO2 results on cardiopulmonary exercise testing.
Collapse
Affiliation(s)
| | - Peter C Rowe
- Department of Paediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frans C Visser
- Stichting CardioZorg, Planetenweg 5, 2132 HN, Hoofddorp, Netherlands
| |
Collapse
|
40
|
Christopoulos EM, Tran J, Hillebrand SL, Lange PW, Iseli RK, Meskers CGM, Maier AB. Initial orthostatic hypotension and orthostatic intolerance symptom prevalence in older adults: A systematic review. Int J Cardiol Hypertens 2021; 8:100071. [PMID: 33884364 PMCID: PMC7803043 DOI: 10.1016/j.ijchy.2020.100071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/13/2020] [Accepted: 12/04/2020] [Indexed: 11/25/2022] Open
Abstract
Background Initial orthostatic hypotension is a clinically relevant syndrome in older adults which has been associated with symptoms of orthostatic intolerance. The aim of this systematic review was to determine the prevalence of orthostatic intolerance symptoms in older adults with initial orthostatic hypotension. Methods MEDLINE (from 1946), EMBASE (from 1974) and Cochrane were searched to December 6th, 2019 using the terms "initial orthostatic hypotension", "postural hypotension" and "older adults". Study selection involved the following criteria: published in English; mean or median age ≥ 65 years and diagnosis of initial orthostatic hypotension encompassed a decrease in systolic blood pressure by ≥ 40 mmHg and/or diastolic blood pressure by ≥ 20 mmHg within a maximum of 1 min following a postural change. Results Of 8311 articles, 12 articles reporting initial orthostatic hypotension prevalence in 3446 participants with a mean age of 75 (6 SD) years (56.5% female) were included. Five initial orthostatic hypotension definition variations were utilised and symptoms were reported in six articles (968 participants, mean age 73.4 (6.1 SD) years, 56% female). The prevalence of symptoms in older adults with initial orthostatic hypotension ranged from 24 to 100% and was dependent on variations in timing or the inclusion of symptoms in the initial orthostatic hypotension definition. Conclusions Where orthostatic intolerance symptoms were reported, a large proportion of older adults with a diagnosis of initial orthostatic hypotension were symptomatic. However, the literature on initial orthostatic hypotension and orthostatic intolerance symptoms is scarce and a variety of definitions of initial orthostatic hypotension are utilised.
Collapse
Affiliation(s)
- Elena M Christopoulos
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Jennifer Tran
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Sarah L Hillebrand
- Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, VU University Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Peter W Lange
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Rebecca K Iseli
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Carel G M Meskers
- Department of Rehabilitation Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Andrea B Maier
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia.,Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, VU University Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| |
Collapse
|
41
|
Shouman K, Vanichkachorn G, Cheshire WP, Suarez MD, Shelly S, Lamotte GJ, Sandroni P, Benarroch EE, Berini SE, Cutsforth-Gregory JK, Coon EA, Mauermann ML, Low PA, Singer W. Autonomic dysfunction following COVID-19 infection: an early experience. Clin Auton Res 2021; 31:385-94. [PMID: 33860871 DOI: 10.1007/s10286-021-00803-8] [Citation(s) in RCA: 157] [Impact Index Per Article: 52.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/25/2021] [Indexed: 11/25/2022]
Abstract
Purpose Post-COVID-19 syndrome is a poorly understood aspect of the current pandemic, with clinical features that overlap with symptoms of autonomic/small fiber dysfunction. An early systematic analysis of autonomic dysfunction following COVID-19 is lacking and may provide initial insights into the spectrum of this condition. Methods We conducted a retrospective review of all patients with confirmed history of COVID-19 infection referred for autonomic testing for symptoms concerning for para-/postinfectious autonomic dysfunction at Mayo Clinic Rochester or Jacksonville between March 2020 and January 2021. Results We identified 27 patients fulfilling the search criteria. Symptoms developed between 0 and 122 days following the acute infection and included lightheadedness (93%), orthostatic headache (22%), syncope (11%), hyperhidrosis (11%), and burning pain (11%). Sudomotor function was abnormal in 36%, cardiovagal function in 27%, and cardiovascular adrenergic function in 7%. The most common clinical scenario was orthostatic symptoms without tachycardia or hypotension (41%); 22% of patients fulfilled the criteria for postural tachycardia syndrome (POTS), and 11% had borderline findings to support orthostatic intolerance. One patient each was diagnosed with autoimmune autonomic ganglionopathy, inappropriate sinus tachycardia, vasodepressor syncope, cough/vasovagal syncope, exacerbation of preexisting orthostatic hypotension, exacerbation of sensory and autonomic neuropathy, and exacerbation of small fiber neuropathy. Conclusion Abnormalities on autonomic testing were seen in the majority of patients but were mild in most cases. The most common finding was orthostatic intolerance, often without objective hemodynamic abnormalities on testing. Unmasking/exacerbation of preexisting conditions was seen. The temporal association between infection and autonomic symptoms implies a causal relationship, which however cannot be proven by this study.
Collapse
|
42
|
Sinn DI, Shaik R, Miglis MG, Muppidi S, Jaradeh S. Orthostatic intolerance with Klippel-Trenaunay syndrome. Clin Auton Res 2021; 31:577-579. [PMID: 33655381 DOI: 10.1007/s10286-021-00791-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 02/19/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Dong In Sinn
- Stanford Autonomic Disorders Program, Department of Neurology, Stanford University, Palo Alto, CA, USA.
| | - Ruba Shaik
- Stanford Autonomic Disorders Program, Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Mitchell G Miglis
- Stanford Autonomic Disorders Program, Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Srikanth Muppidi
- Stanford Autonomic Disorders Program, Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Safwan Jaradeh
- Stanford Autonomic Disorders Program, Department of Neurology, Stanford University, Palo Alto, CA, USA
| |
Collapse
|
43
|
Kermansaravi M, Chiappetta S, Lainas P, Kassir R. Orthostatic Intolerance after Bariatric Surgery: a Systematic Review. Obes Surg 2021; 31:2250-2254. [PMID: 33655427 DOI: 10.1007/s11695-021-05266-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/26/2021] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
Predisposing factors of new-onset orthostatic intolerance (OI) after bariatric surgery (BS) are unknown. The purpose of this study is to summarize current existing data on new-onset OI after BS. Materials and methods were considered for a search of articles that were published by the 30th of July 2020. A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and in line with the protocol agreed by all authors was conducted. Of the 604 initially identified articles, four studies were found to match the established criteria and were extracted for eligibility. 83.3% were female. Hypertension, type 2 diabetes mellitus, and obstructive sleep apnea syndrome were the most frequently reported comorbidities. Surgical intervention such as revision, conversion, or reversal was not documented in these studies. Awareness of this issue must be raised due to the possibility of reduced quality of life and the risk of syncope.
Collapse
Affiliation(s)
- Mohammad Kermansaravi
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Sonja Chiappetta
- Department of Obesity and Metabolic Surgery, Ospedale Evangelico Betania, Naples, Italy
| | - Panagiotis Lainas
- Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, Assistance Publique-Hôpitaux de Paris, F-92140, Clamart, France.,Paris-Saclay University, F-91405, Orsay, France
| | - Radwan Kassir
- Department of Digestive Surgery, Félix Guyon University Hospital, 97400, Saint-Denis, La Réunion, France. .,La Réunion University, UFR Santé, La Réunion, France.
| |
Collapse
|
44
|
Gilmore S, Hart J, Geddes J, Olsen CH, Mehlsen J, Gremaud P, Olufsen MS. Classification of orthostatic intolerance through data analytics. Med Biol Eng Comput 2021; 59:621-632. [PMID: 33582941 DOI: 10.1007/s11517-021-02314-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 01/15/2021] [Indexed: 11/25/2022]
Abstract
Imbalance in the autonomic nervous system can lead to orthostatic intolerance manifested by dizziness, lightheadedness, and a sudden loss of consciousness (syncope); these are common conditions, but they are challenging to diagnose correctly. Uncertainties about the triggering mechanisms and the underlying pathophysiology have led to variations in their classification. This study uses machine learning to categorize patients with orthostatic intolerance. We use random forest classification trees to identify a small number of markers in blood pressure, and heart rate time-series data measured during head-up tilt to (a) distinguish patients with a single pathology and (b) examine data from patients with a mixed pathophysiology. Next, we use Kmeans to cluster the markers representing the time-series data. We apply the proposed method analyzing clinical data from 186 subjects identified as control or suffering from one of four conditions: postural orthostatic tachycardia (POTS), cardioinhibition, vasodepression, and mixed cardioinhibition and vasodepression. Classification results confirm the use of supervised machine learning. We were able to categorize more than 95% of patients with a single condition and were able to subgroup all patients with mixed cardioinhibitory and vasodepressor syncope. Clustering results confirm the disease groups and identify two distinct subgroups within the control and mixed groups. The proposed study demonstrates how to use machine learning to discover structure in blood pressure and heart rate time-series data. The methodology is used in classification of patients with orthostatic intolerance. Diagnosing orthostatic intolerance is challenging, and full characterization of the pathophysiological mechanisms remains a topic of ongoing research. This study provides a step toward leveraging machine learning to assist clinicians and researchers in addressing these challenges. Graphical abstract Machine learning tools utilized to analyze heart rate (HR) and blood pressure (BP) time-series data from syncope and control patients. Results show that machine learning can provide accurate classification of disease groups for 98% of patients and we identified two subgroups within the control patients differentiated by their BP response.
Collapse
Affiliation(s)
- Steven Gilmore
- North Carolina State University, Raleigh, NC, 27695, USA
| | - Joseph Hart
- Sandia National Laboratories, Albuquerque, NM, 87123, USA
| | - Justen Geddes
- North Carolina State University, Raleigh, NC, 27695, USA
| | | | - Jesper Mehlsen
- Rigshospitalet, University of Copenhagen, 2100, Copenhagen Ø, Denmark
| | - Pierre Gremaud
- North Carolina State University, Raleigh, NC, 27695, USA
| | | |
Collapse
|
45
|
Zou R, Wang S, Li F, Lin P, Zhang J, Wang Y, Xu Y, Wang C. Clinical characteristics and hemodynamic responses to head-up tilt test in children and adolescents with unexplained sighing. Neurol Sci 2021; 42:3343-3347. [PMID: 33411193 DOI: 10.1007/s10072-020-04956-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/01/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Sighing is a common symptom in children and adolescents. In this study, we explored the clinical characteristics and hemodynamic responses to head-up tilt test (HUTT) in children and adolescents with unexplained sighing. METHODS One hundred ninety-two children and adolescents complaining of unexplained sighing were enrolled as study group after excluding chest wall, lung, heart diseases, and psychogenic disorders. Sixty-nine healthy individuals were enrolled as control group. All the subjects underwent HUTT. RESULTS Nitroglycerin-stimulated HUTT positive rate was higher in the study group than the control group (24.0% vs 10.1%, P = 0.014). In total, 32.3% of patients with sighing had positive responses to HUTT, which was higher than that of healthy individuals (32.3% vs 15.9%, P = 0.009). Among 62 cases with positive responses to HUTT in the study group, 48 cases were vasoinhibitory type vasovagal syncope (VVS), 5 cases were mixed type VVS, 3 cases were cardioinhibitory type VVS, 5 cases were postural tachycardia syndrome, and one case was orthostatic hypertension. Sighing patients with positive responses to HUTT had female dominance (54.8% vs39.2%, P = 0.045), older mean age (9.6 ± 2.8 vs 8.1 ± 2.7 years old, P = 0.001), higher basic systolic blood pressure (104.8 ± 10.4 vs 101.1 ± 9.9 mmHg, P = 0.019), and higher diastolic blood pressure (66.0 ± 7.5 vs 62.9 ± 9.2 mmHg, P = 0.021) compared with those of negative responses. CONCLUSIONS : Nearly one-third of children and adolescents with unexplained sighing had positive responses to HUTT, demonstrating that sighing was related to dysfunction of the autonomic nervous system. Elder female patients with higher systolic and diastolic blood pressure were more likely to have positive responses to HUTT.
Collapse
Affiliation(s)
- Runmei Zou
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Shuo Wang
- Jishou University School of Medicine, Jishou, 416000, Hunan, China
| | - Fang Li
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Ping Lin
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Juan Zhang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Yuwen Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Yi Xu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Cheng Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.
| |
Collapse
|
46
|
Boris JR, Bernadzikowski T. Prevalence of joint hypermobility syndromes in pediatric postural orthostatic tachycardia syndrome. Auton Neurosci 2021; 231:102770. [PMID: 33388686 DOI: 10.1016/j.autneu.2020.102770] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/12/2020] [Accepted: 12/23/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Patients with postural orthostatic tachycardia syndrome (POTS) have been shown to exhibit comorbid joint hypermobility manifested as Ehlers-Danlos syndrome (EDS) or hypermobility spectrum disorder (HSD). The prevalence of EDS and HSD in POTS has been demonstrated in smaller studies combining adult and pediatric patients. We examined a large series of pediatric patients to determine their prevalence in children with POTS. MATERIALS AND METHODS Patients 18 years old, or less, at initial evaluation at our clinic were included. POTS was diagnosed based on at least six months of frequent debilitating symptoms of orthostatic intolerance, plus a consistent heart rate increase of at least 40 beats per minute without orthostatic hypotension on standing test. Patients with a Beighton score of at least 5/9 plus other systemic findings suggestive of EDS were further evaluated in Connective Tissue Disorders clinics. RESULTS There were 362 patients meeting inclusion criteria, of which 82 patients had EDS (22.7%) and 141 patients had HSD (39.0%). Patients with EDS had an earlier median age at symptom onset (12.1 vs. 13.5 years, p=0.004) and longer median symptom duration (2.5 vs. 1.5 years, p=0.0008) compared to patients without hypermobility. CONCLUSIONS Our evaluation of a large series of pediatric patients with POTS revealed that over one-fifth of patients had EDS and over one-third of patients had HSD. The awareness of the prevalence of comorbidities such as hypermobility disorders may help inform providers diagnosing and caring for these patients.
Collapse
|
47
|
|
48
|
Loughlin EA, Judge CS, Gorey SE, Costello MM, Murphy RP, Waters RF, Hughes DS, Kenny RA, O'Donnell MJ, Canavan MD. Increased Salt Intake for Orthostatic Intolerance Syndromes: A Systematic Review and Meta-Analysis. Am J Med 2020; 133:1471-1478.e4. [PMID: 32603788 DOI: 10.1016/j.amjmed.2020.05.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Guidelines recommend increased salt intake as a first-line recommendation in the management of symptomatic orthostatic hypotension and recurrent syncope. There have been no systematic reviews of this intervention. We sought to summarize the evidence for increased salt intake in patients with orthostatic intolerance syndromes. METHODS We conducted a systematic review and meta-analysis of studies in PubMed, EMBASE, and CINAHL. Interventional studies that increased salt intake in individuals with orthostatic intolerance syndromes were included. Primary outcome measures included incidence of falls and injuries, and rates of syncope and presyncope. Secondary outcome measures included other orthostatic intolerance symptoms, blood pressure, and heart rate. RESULTS A total of 14 studies were eligible, including participants with orthostatic hypotension, syncope, postural orthostatic tachycardia syndrome, and idiopathic orthostatic tachycardia (n = 391). Mean age was 35.6 (± 15) years. All studies were small and short-term (<60 mins-90 days). No study reported on the effect of increased salt intake on falls or injuries. Meta-analysis demonstrated that during head-up tilt, mean time to presyncope with salt intake increased by 1.57 minutes (95% confidence interval [CI], 1.26-1.88), mean systolic blood pressure increased by 12.27 mm Hg (95% CI, 10.86-13.68), and mean heart rate decreased by -3.97 beats per minute (95% CI, -4.08 to -3.86), compared with control. Increased salt increased supine blood pressure by 1.03 mm Hg (95% CI, 0.81 to 1.25). Increased salt intake resulted in an improvement or resolution of symptoms in 62.3% (95% CI, 51.6 to 72.6) of participants in short-term follow-up studies (mean follow-up of 44.3 days, 6 studies; n=91). Methodological quality of studies were low with high statistical heterogeneity in all meta-analyses. CONCLUSIONS Our meta-analysis provides low-quality evidence of a short-term improvement in orthostatic intolerance with increased salt intake. There were no clinical trials demonstrating the efficacy and safety of increased salt intake on long-term clinical outcomes. Overall, there is a paucity of clinical trial evidence to support a cornerstone recommendation in the management of orthostatic intolerance syndromes.
Collapse
Affiliation(s)
- Elaine A Loughlin
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland.
| | - Conor S Judge
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland; Wellcome Trust - HRB, Irish Clinical Academic Training, Dublin, Ireland
| | - Sarah E Gorey
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland
| | - Maria M Costello
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland
| | - Robert P Murphy
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland
| | - Ruairi F Waters
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland
| | - Diarmaid S Hughes
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland
| | - Rose Ann Kenny
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dubline, Ireland
| | - Martin J O'Donnell
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland
| | - Michelle D Canavan
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Galway University Hospital, Newcastle Road, Galway, Ireland
| |
Collapse
|
49
|
Kharraziha I, Holm H, Bachus E, Melander O, Sutton R, Fedorowski A, Hamrefors V. Monitoring of cerebral oximetry in patients with postural orthostatic tachycardia syndrome. Europace 2020; 21:1575-1583. [PMID: 31384930 PMCID: PMC6877984 DOI: 10.1093/europace/euz204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 07/11/2019] [Indexed: 11/14/2022] Open
Abstract
AIMS Postural orthostatic tachycardia syndrome (POTS) is a disorder of unknown aetiology characterized by orthostatic intolerance and tachycardia with diverse other symptoms, including neurocognitive deficits. Cerebral oximetry non-invasively measures cerebral tissue saturation (SctO2) and has been shown to be informative in syncope evaluation. We aimed to assess SctO2 in POTS patients and those with normal response to orthostatic provocation, relative to haemodynamic parameters and symptoms. METHODS AND RESULTS Thirty-four patients with POTS (29.1 ± 9.5 years; 26 females) and 34 age-/sex-matched controls with normal head-up tilt tests (HUTs) were included. SctO2 at rest and during HUT were compared between POTS and controls. The relation between SctO2, systolic blood pressure (SBP), and heart rate (HR) during HUT was linearly assessed. SctO2 values were related to dizziness or syncope during HUT. The minimum SctO2-value during HUT was lower (65.4 ± 5.6 vs. 68.2 ± 4.2%, P = 0.023) and changes in SctO2 from supine to minimum HUT value were more pronounced in POTS patients (-5.7 ± 2.9% vs. -4.3 ± 2.1%, P = 0.028). Decrease in SBP from supine to minimum HUT value (P = 0.004) and increase in HR from supine to HUT value at 3 min (P = 0.022) correlated with more pronounced SctO2 decrease in POTS but not controls. SctO2 did not predict syncope or dizziness during HUT. CONCLUSION Postural orthostatic tachycardia syndrome patients have lower cerebral tissue saturation during orthostatic provocation compared with those subjects having normal haemodynamic response to tilt. Orthostatic decrease in cerebral saturation only weakly correlates with HR increase and does not predict vasovagal reflex in POTS. Other hitherto unknown factors may affect cerebral tissue saturation in POTS.
Collapse
Affiliation(s)
| | - Hannes Holm
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Erasmus Bachus
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| |
Collapse
|
50
|
Lee J, Vernon SD, Jeys P, Ali W, Campos A, Unutmaz D, Yellman B, Bateman L. Hemodynamics during the 10-minute NASA Lean Test: evidence of circulatory decompensation in a subset of ME/CFS patients. J Transl Med 2020; 18:314. [PMID: 32799889 PMCID: PMC7429890 DOI: 10.1186/s12967-020-02481-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 08/07/2020] [Indexed: 11/17/2022] Open
Abstract
Background Lightheadedness, fatigue, weakness, heart palpitations, cognitive dysfunction, muscle pain, and exercise intolerance are some of the symptoms of orthostatic intolerance (OI). There is substantial comorbidity of OI in ME/CFS (Myalgic Encephalomyelitis/Chronic Fatigue Syndrome). The 10-minute NASA Lean Test (NLT) is a simple, point-of-care method that can aid ME/CFS diagnosis and guide management and treatment of OI. The objective of this study was to understand the hemodynamic changes that occur in ME/CFS patients during the 10-minute NLT. Methods A total of 150 ME/CFS patients and 75 age, gender and race matched healthy controls (HCs) were enrolled. We recruited 75 ME/CFS patients who had been sick for less than 4 years (< 4 ME/CFS) and 75 ME/CFS patients sick for more than 10 years (> 10 ME/CFS). The 10-minute NLT involves measurement of blood pressure and heart rate while resting supine and every minute for 10 min while standing with shoulder-blades on the wall for a relaxed stance. Spontaneously reported symptoms are recorded during the test. ANOVA and regression analysis were used to test for differences and relationships in hemodynamics, symptoms and upright activity between groups. Results At least 5 min of the 10-minute NLT were required to detect hemodynamic changes. The < 4 ME/CFS group had significantly higher heart rate and abnormally narrowed pulse pressure compared to > 10 ME/CFS and HCs. The < 4 ME/CFS group experienced significantly more OI symptoms compared to > 10 ME/CFS and HCs. The circulatory decompensation observed in the < 4 ME/CFS group was not related to age or medication use. Conclusions Circulatory decompensation characterized by increased heart rate and abnormally narrow pulse pressure was identified in a subgroup of ME/CFS patients who have been sick for < 4 years. This suggests inadequate ventricular filling from low venous pressure. The 10-minute NLT can be used to diagnose and treat the circulatory decompensation in this newly recognized subgroup of ME/CFS patients. The > 10 ME/CFS group had less pronounced hemodynamic changes during the NLT possibly from adaptation and compensation that occurs over time. The 10-minute NLT is a simple and clinically useful point-of-care method that can be used for early diagnosis of ME/CFS and help guide OI treatment.
Collapse
Affiliation(s)
- Jihyun Lee
- The Bateman Horne Center of Excellence, 24 South 1100 East, Suite 205, Salt Lake City, UT, 84102, USA
| | - Suzanne D Vernon
- The Bateman Horne Center of Excellence, 24 South 1100 East, Suite 205, Salt Lake City, UT, 84102, USA.
| | - Patricia Jeys
- The Bateman Horne Center of Excellence, 24 South 1100 East, Suite 205, Salt Lake City, UT, 84102, USA
| | - Weam Ali
- The Bateman Horne Center of Excellence, 24 South 1100 East, Suite 205, Salt Lake City, UT, 84102, USA
| | - Andrea Campos
- The Bateman Horne Center of Excellence, 24 South 1100 East, Suite 205, Salt Lake City, UT, 84102, USA
| | - Derya Unutmaz
- Jackson Laboratory for Genomic Medicine and University of Connecticut School of Medicine, Farmington, CT, 06032, USA
| | - Brayden Yellman
- The Bateman Horne Center of Excellence, 24 South 1100 East, Suite 205, Salt Lake City, UT, 84102, USA
| | - Lucinda Bateman
- The Bateman Horne Center of Excellence, 24 South 1100 East, Suite 205, Salt Lake City, UT, 84102, USA
| |
Collapse
|