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Annals of Clinical and Translational... Oct 2022Vestibular syncope is a condition in which vertigo-induced hemodynamic changes cause syncope. This study investigated the clinical and laboratory findings of vestibular...
BACKGROUND AND OBJECTIVES
Vestibular syncope is a condition in which vertigo-induced hemodynamic changes cause syncope. This study investigated the clinical and laboratory findings of vestibular syncope and tried to refine our knowledge of the mechanism underlying this newly recognized entity.
METHODS
This study retrospectively analyzed 53 patients (33 women, median age = 63 years [interquartile range = 54-71 years]) with vestibular syncope from January 2017 to December 2021. To explain the mechanism of vestibular syncope, we incorporated a velocity-storage model into the dual reflex pathways comprising the vestibulo-sympathetic reflex and baroreflex and predicted the cardiovascular responses.
RESULTS
Twenty (37.7%) patients had multiple episodes of vestibular syncope, and seven (13.2%) had potentially life-threatening injuries. Meniere's disease (20.8%) and benign paroxysmal positional vertigo (9.4%) were the most common underlying vestibular disorders. Abnormal vestibular function tests included impaired cervical vestibular-evoked myogenic potentials (57.5%) and positive head impulse tests (31.0%). Orthostatic hypotension was found in 19.5% of patients. Dyslipidemia (30.2%) and hypertension (28.3%) were common medical comorbidities. The dual reflex pathways incorporating the function of the velocity-storage circuit in the brainstem and cerebellum suggest that vestibular syncope is a neurally mediated reflex syncope associated with a sudden hemodynamic change during vertigo. This change can be arterial hypertension triggered by a false downward inertial cue, as suggested previously, or hypotension driven by a false upward inertial cue.
CONCLUSIONS
Vestibular syncope is associated with various vestibular disorders and requires careful evaluation and intervention to prevent recurrent falls and significant injuries.
Topics: Aged; Female; Humans; Hypertension; Meniere Disease; Middle Aged; Retrospective Studies; Syncope; Vertigo
PubMed: 36056529
DOI: 10.1002/acn3.51661 -
European Journal of Pediatrics Nov 2023This paper aims to improve the diagnosis of syncope and transient loss of consciousness (TLOC) in children. Diagnostic problems stem, first, from some causes spanning... (Review)
Review
This paper aims to improve the diagnosis of syncope and transient loss of consciousness (TLOC) in children. Diagnostic problems stem, first, from some causes spanning various disciplines, e.g. cardiology, neurology and psychiatry, while the most common cause, vasovagal syncope, is not embraced by any specialty. Second, clinical variability is huge with overlapping signs and symptoms. Third, the approach to TLOC/syncope of the European Society of Cardiology (ESC) is underused in childcare. We explain the ESC guidelines using an additional paediatric literature review. Classification of TLOC and syncope is hierarchic and based on history taking. Loss of consciousness (LOC) is defined using three features: abnormal motor control including falling, reduced responsiveness and amnesia. Adding a < 5 min duration and spontaneous recovery defines TLOC. TLOC simplifies diagnosis by excluding long LOC (e.g. some trauma, intoxications and hypoglycaemia) and focussing on syncope, tonic-clonic seizures and functional TLOC. Syncope, i.e. TLOC due to cerebral hypoperfusion, is divided into reflex syncope (mostly vasovagal), orthostatic hypotension (mostly initial orthostatic hypotension in adolescents) and cardiac syncope (arrhythmias and structural cardiac disorders). The initial investigation comprises history taking, physical examination and ECG; the value of orthostatic blood pressure measurement is unproven in children but probably low. When this fails to yield a diagnosis, cardiac risk factors are assessed; important clues are supine syncope, syncope during exercise, early death in relatives and ECG abnormalities. Conclusions: In adults, the application of the ESC guidelines reduced the number of absent diagnoses and costs; we hope this also holds for children. What is Known: • Syncope and its mimics are very common in childhood, as they are at other ages. • Syncope and its mimics provide considerable diagnostic challenges. What is New: • Application of the hierarchic framework of transient loss of consciousness (TLOC) simplifies diagnosis. • The framework stresses history-taking to diagnose common conditions while keeping an eye on cardiac danger signs.
Topics: Adult; Adolescent; Child; Humans; Hypotension, Orthostatic; Syncope; Syncope, Vasovagal; Unconsciousness; Heart Diseases
PubMed: 37470792
DOI: 10.1007/s00431-023-05114-w -
Drugs in Context 2021Despite being a common problem in childhood, functional constipation is often difficult to manage. This article provides a narrative updated review on the evaluation,... (Review)
Review
BACKGROUND
Despite being a common problem in childhood, functional constipation is often difficult to manage. This article provides a narrative updated review on the evaluation, diagnosis and management of childhood functional constipation.
METHODS
A PubMed search was performed with Clinical Queries using the key term 'functional constipation'. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. The search was restricted to the English literature and to the paediatric population. The information retrieved from the above search was used in the compilation of the present article.
RESULTS
A detailed history and thorough physical examination are important in the evaluation of a child with constipation to establish the diagnosis of functional constipation as per the Rome IV criteria and to catch 'red flags' suggestive of organic causes of constipation. These 'red flags' include delayed passage of meconium, ribbon stool, rectal bleeding/blood in the stool unless attributable to an anal fissure, failure to thrive, severe abdominal distension, absent anal wink/cremasteric reflex, tight and empty rectum on digital examination and explosive expulsion of liquid stool and gas on withdrawal of the finger, hair tuft/dimple/lipoma/haemangioma in the lumbosacral area, and an anteriorly displaced anus. For functional constipation, pharmacological therapy consists of faecal disimpaction and maintenance therapy. This can be effectively accomplished with oral medications, rectal medications or a combination of both. The most commonly used and most effective laxative is polyethylene glycol. Non-pharmacological management consists of education, behavioural modification and dietary interventions. The combination of pharmacological therapy and non-pharmacological management increases the chance of success.
CONCLUSION
Polyethylene glycol is the medication of first choice for both disimpaction and maintenance therapy. If polyethylene glycol is not available or is poorly tolerated, lactulose is the preferred alternative. Other laxatives may be considered as second-line therapy if treatment with osmotic laxatives fails or is insufficient. Maintenance treatment should be continued for at least 2 months. Early treatment will result in a faster and shorter treatment course.
PubMed: 33828605
DOI: 10.7573/dic.2020-11-2 -
Turkish Archives of Otorhinolaryngology Jun 2021As the aerospace industry has grown rapidly over the years, aviators and astronauts have been exposed to some abnormal physiological changes arising from the dynamics of... (Review)
Review
As the aerospace industry has grown rapidly over the years, aviators and astronauts have been exposed to some abnormal physiological changes arising from the dynamics of the aerospace environment. The vestibular system, encoding linear and angular movements of the head, is one of the main affected systems in which those abnormal changes can occur during flight. Despite the intricate and solid organization, vestibular units are such delicate structures that they can easily be deceived by aerial dynamics and gravity changes. Therefore, it is of vital importance for the continuity of flight safety to be aware of the detrimental alterations and impairments regarding the vestibular system and its reflex pathways. The aim of this paper was to present a review about how a healthy vestibular system is negatively affected within the aerospace environment and how some vestibular disorders become exaggerated or impaired during aviation and space activities.
PubMed: 34386801
DOI: 10.4274/tao.2021.2021-3-3 -
Endoscopy Feb 2021ESGE recommends the "pull" technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE...
ESGE recommends the "pull" technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer ("push") technique for PEG placement in cases where the "pull" method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed "blindly" at the patient's bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 - 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 - 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.
Topics: Adult; Endoscopy, Gastrointestinal; Enteral Nutrition; Gastrostomy; Humans
PubMed: 33348410
DOI: 10.1055/a-1331-8080 -
JACC. Clinical Electrophysiology Feb 2022This study sought to evaluate the role of cardiac afferent reflexes in atrial fibrillation (AF).
OBJECTIVES
This study sought to evaluate the role of cardiac afferent reflexes in atrial fibrillation (AF).
BACKGROUND
Efferent autonomic tone is not associated with atrial remodeling and AF persistence. However, the role of cardiac afferents is unknown.
METHODS
Individuals with nonpermanent AF (n = 48) were prospectively studied (23 in the in-AF group and 25 in sinus rhythm [SR]) with 12 matched control subjects. We performed: 1) low-level lower body negative pressure (LBNP), which decreases cardiac volume, offloading predominantly cardiac afferent (volume-sensitive) low-pressure baroreceptors; 2) Valsalva reflex (predominantly arterial high-pressure baroreceptors); and 3) isometric handgrip reflex (both baroreceptors). We measured beat-to-beat mean arterial pressure (MAP) and heart rate (HR). LBNP elicits reflex vasoconstriction, estimated using venous occlusion plethysmography-derived forearm blood flow (∝1/vascular resistance), maintaining MAP. To assess reversibility, we repeated LBNP (same day) after 1-hour low-level tragus stimulation (in n = 5 in the in-AF group and n = 10 in the in-SR group) and >6 weeks post-cardioversion (n = 7).
RESULTS
The 3 groups were well matched for age (59 ± 12 years, 83% male), body mass index, and risk factors (P = NS). The in-AF group had higher left atrial volume (P < 0.001) and resting HR (P = 0.01) but similar MAP (P = 0.7). The normal LBNP vasoconstriction (-49 ± 5%) maintaining MAP (control subjects) was attenuated in the in-SR group (-12 ± 9%; P = 0.005) and dysfunctional in the in-AF group (+11 ± 6%; P < 0.001), in which MAP decreased and HR was unchanged. Valsalva was normal throughout. Handgrip MAP response was lowest in the in-AF group (P = 0.01). Interestingly, low-level tragus stimulation and cardioversion improved LBNP vasoconstriction (-48 ± 15%; P = 0.04; and -32 ± 9%; P = 0.02, respectively).
CONCLUSIONS
Cardiac afferent (volume-sensitive) reflexes are abnormal in AF patients during SR and dysfunctional during AF. This could contribute to AF progression, thus explaining "AF begets AF." (Characterisation of Autonomic function in Atrial Fibrillation [AF-AF Study]; ACTRN12619000186156).
Topics: Aged; Atrial Fibrillation; Female; Hand Strength; Heart Atria; Humans; Lower Body Negative Pressure; Male; Middle Aged; Pressoreceptors
PubMed: 35210071
DOI: 10.1016/j.jacep.2021.10.010 -
Ideggyogyaszati Szemle May 2022Neurological symptoms and complications associated with coronavirus 2019 (COVID-19) are well known. It was aimed to evaluate the brainstem and trigeminal/facial nerves...
BACKGROUND AND PURPOSE
Neurological symptoms and complications associated with coronavirus 2019 (COVID-19) are well known. It was aimed to evaluate the brainstem and trigeminal/facial nerves and the pathways between these structures in COVID-19 using the blink reflex test.
METHODS
Thirty patients with post COVID-19 (16 males, 14 females) and 30 healthy individuals (17 males, 13 females) were included in this prospective study. Individuals who previously had a positive nose swap polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 and whose previously clinical features were compatible with COVID-19 were included in the post COVID-19 patient group. Neurological examination of the participants should be normal. Blink reflex test was performed on all participants. R1, ipsilateral R2 (IR2), and contralateral R2 (CR2) waves obtained from the test were analyzed.
RESULTS
The mean ages of healthy individuals and post COVID-19 patients were 34.0±6.4 and 38.4±10.6 years, respectively. Both age and gender were matched between the groups. R1, IR2, and CR2 latencies/amplitudes were not different between the two groups. The side-to-side R1 latency difference was 0.5±0.3 and 1.0±0.8 ms in healthy individuals and post COVID-19 patients, respectively (p=0.011). One healthy individual and 12 patients with post COVID-19 had at least one abnormal blink reflex parameter (p=0.001).
CONCLUSION
This study showed that COVID-19 may cause subclinical abnormalities in the blink reflex, which includes the trigeminal nerve, the seventh nerve, the brainstem, and pathways between these structures.
Topics: Adult; Blinking; COVID-19; Facial Nerve; Female; Humans; Male; Neurologic Examination; Prospective Studies
PubMed: 35819340
DOI: 10.18071/isz.75.0199