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Clinical Autonomic Research : Official... Jun 2024This work's purpose was to quantify rapid sympathetic activation in individuals with spinal cord injury (SCI), and to identify associated correlations with symptoms of...
PURPOSE
This work's purpose was to quantify rapid sympathetic activation in individuals with spinal cord injury (SCI), and to identify associated correlations with symptoms of orthostatic hypotension and common autonomically mediated secondary medical complications.
METHODS
This work was a cross-sectional study of individuals with SCI and uninjured individuals. Symptoms of orthostatic hypotension were recorded using the Composite Autonomic Symptom Score (COMPASS)-31 and Autonomic Dysfunction following SCI (ADFSCI) survey. Histories of secondary complications of SCI were gathered. Rapid sympathetic activation was assessed using pressure recovery time of Valsalva maneuver. Stepwise multiple linear regression models identified contributions to secondary medical complication burden.
RESULTS
In total, 48 individuals (24 with SCI, 24 uninjured) underwent testing, with symptoms of orthostatic hypotension higher in those with SCI (COMPASS-31, 3.3 versus 0.6, p < 0.01; ADFSCI, 21.2 versus. 3.2, p < 0.01). Pressure recovery time was prolonged after SCI (7.0 s versus. 1.7 s, p < 0.01), though poorly correlated with orthostatic symptom severity. Neurological level of injury after SCI influenced pressure recovery time, with higher injury levels associated with more prolonged time. Stepwise multiple linear regression models identified pressure recovery time as the primary explanation for variance in number of urinary tract infections (34%), histories of hospitalizations (12%), and cumulative secondary medical complication burden (24%). In all conditions except time for bowel program, pressure recovery time outperformed current clinical tools for assessing such risk.
CONCLUSIONS
SCI is associated with impaired rapid sympathetic activation, demonstrated here by prolonged pressure recovery time. Prolonged pressure recovery time after SCI predicts higher risk for autonomically mediated secondary complications, serving as a viable index for more "autonomically complete" injury.
PubMed: 38916658
DOI: 10.1007/s10286-024-01040-5 -
Cureus Jun 2024Spontaneous intracranial hypotension (SIH) is a rare neurological syndrome. We report the case of a 47-year-old woman with acute, severe orthostatic headache after...
Spontaneous intracranial hypotension (SIH) is a rare neurological syndrome. We report the case of a 47-year-old woman with acute, severe orthostatic headache after surgery, chemotherapy, and radiotherapy for breast cancer. The brain and spine magnetic resonance imaging showed signs of intracranial hypotension. We describe the results of a non-targeted epidural blood patch with 10 mL of the patient's blood administered after unsuccessful conservative treatment. After the procedure, the patient reported gradual headache relief. This effect persisted over one year. The case shows that a single non-targeted low-volume epidural blood patch can be an effective treatment option for a patient with SIH when conservative treatment fails.
PubMed: 38915836
DOI: 10.7759/cureus.63059 -
Endocrine Practice : Official Journal... Jun 2024To evaluate the determinants of orthostatic hypotension (OH) in type 2 diabetes (T2D) and the usefulness of ΔHR/ΔSBP, index of cardiac baroreflex function, in...
OBJECTIVES
To evaluate the determinants of orthostatic hypotension (OH) in type 2 diabetes (T2D) and the usefulness of ΔHR/ΔSBP, index of cardiac baroreflex function, in identifying neurogenic OH.
METHODS
In 208 participants with T2D, we performed three heart rate based cardiovascular reflex tests (HR-CARTs) and OH test and assessed clinical history and variables. We defined OH as a systolic blood pressure (BP) fall ≥20 and ≥30 mmHg with supine BP <140 and ≥140 mmHg, respectively, and early and confirmed CAN based on 1 and 2 abnormal HR-CARTs. In participants with OH, we measured ΔHR/ΔSBP, using data from the lying to standing and OH test, and its diagnostic accuracy for neurogenic OH (as OH plus confirmed HR-CAN).
RESULTS
OH was present in 25 participants and associated with lower HR-CARTs (P=0.01), higher HbA1c (P=0.0048), presence of CAN (P=0.0058), retinopathy (P=0.037), and peripheral vascular disease (P=0.0056), absence of hypertension (P=0.0008) and physical activity (P=0.0214), but not with interfering drugs and beta-blockers. In a multiple logistic regression, HR-CAN was the main independent determinant of OH (odds ratio: 4.74) with physical activity and hypertension (odds ratio: 0.16 and 0.23) (R2=0.22). ΔHR/ΔSBP had a good diagnostic accuracy for neurogenic OH (AUC: 0.816±0.087), and at the cut-off of 0.5 bpm/mmHg a sensitivity of 100% and specificity of 63.2%.
CONCLUSION
CAN is still the main determinant of OH in T2D but does not explain all its variance with contribution of comorbidities and physical inactivity. The index ΔHR/ΔSBP might represent a useful clinical tool to identify neurogenic OH.
PubMed: 38908717
DOI: 10.1016/j.eprac.2024.06.008 -
Gait & Posture Jun 2024In a more clinical setting, abrupt posture change may be used to determine the presence of orthostatic hypotension, a hemodynamic response with relationships to physical...
UNLABELLED
In a more clinical setting, abrupt posture change may be used to determine the presence of orthostatic hypotension, a hemodynamic response with relationships to physical function. Certain gait features and physical function performance are also associated with risk of falling in older adults. However, the extent to which posture change is associated with subsequent gait and physical function has received little attention in the literature. This study aims to determine the effects of posture change on spatiotemporal parameters of gait and Timed Up-and-Go (TUG) performance.
METHODS
Forty-two volunteers (age 73.21 ± 6.22 years) participated in the study. A custom Tekscan Strideway (Tekscan, Boston, MA.) gait system was used to measure gait velocity (VEL), cadence (CAD), stride length (SL), and percent of time spent in active propulsion (AP). Dependent t-tests were used to compare TUG time, VEL, CAD, SL and AP after at least 10 mins of seated rest and supine rest.
RESULTS
Time to complete the TUG was significantly slower after supine rest compared to seated (11.47 ± 0.51 and 10.01 ± 0.33 s, respectively, p<0.001); VEL was significantly slower after supine rest compared to seated (0.888 ± 0.042 and 1.049 ± 0.033 m/s, respectively, p=0.003); CAD was significantly slower after supine rest compared to seated (111.21 ± 2.87 and 120.97 ± 2.56spm, respectively, p=0.001); and AP was significantly lower after supine rest compared to seated (56.87 ± 4.76 and 70.79 ± 4.05 %, respectively, p<0.001). No significant differences were detected in stride length between conditions.
CONCLUSIONS
Among this sample of older adults, standing from a supine posture is associated with spatiotemporal gait parameters consistent with a risk for falling and aging. Additionally, TUG performance worsens significantly after supine rest. Future studies could explore the sensitivity and specificity of falls risk screening after supine rest.
PubMed: 38905853
DOI: 10.1016/j.gaitpost.2024.06.009 -
Immunological Medicine Jun 2024Postural orthostatic tachycardia syndrome (POTS) is characterized by exaggerated orthostatic tachycardia in the absence of orthostatic hypotension. The pathophysiology... (Review)
Review
Postural orthostatic tachycardia syndrome (POTS) is characterized by exaggerated orthostatic tachycardia in the absence of orthostatic hypotension. The pathophysiology of POTS may involve hypovolemia, autonomic neuropathy, a hyperadrenergic state, and cardiovascular deconditioning, any of which can co-occur in the same patient. Furthermore, there is growing evidence of the role of autoimmunity in a subset of POTS cases. In recent years, investigators have described an increased rate of autoimmune comorbidities as evidenced by the finding of several types of neural receptor autoantibody and non-specific autoimmune marker in patients with POTS. In particular, the association of the disease with several types of anti-G protein-coupled receptor (GPCR) antibodies and POTS has frequently been noted. A previous study reported that autoantibodies to muscarinic AChRs may play an important role in POTS with persistent, gastrointestinal symptoms. To date, POTS is recognized as one of the sequelae of coronavirus disease 2019 (COVID-19) and its frequency and pathogenesis are still largely unknown. Multiple autoantibody types occur in COVID-related, autonomic disorders, suggesting the presence of autoimmune pathology in these disorders. Herein, we review the association of anti-GPCR autoantibodies with disorders of the autonomic nervous system, in particular POTS, and provide a new perspective for understanding POTS-related autoimmunity.
PubMed: 38900132
DOI: 10.1080/25785826.2024.2370079 -
Journal of Clinical Medicine May 2024Syncope is a common condition encountered in the emergency department (ED), accounting for about 0.6-3% of all ED visits. Despite its high frequency, a widely accepted... (Review)
Review
Syncope is a common condition encountered in the emergency department (ED), accounting for about 0.6-3% of all ED visits. Despite its high frequency, a widely accepted management strategy for patients with syncope in the ED is still missing. Since syncope can be the presenting condition of many diseases, both severe and benign, most research efforts have focused on strategies to obtain a definitive etiologic diagnosis. Nevertheless, in everyday clinical practice, a definitive diagnosis is rarely reached after the first evaluation. It is thus troublesome to aid clinicians' reasoning by simply focusing on differential diagnoses. With the current review, we would like to propose a management strategy that guides clinicians both in the identification of conditions that warrant immediate treatment and in the management of patients for whom a diagnosis is not immediately reached, differentiating those that can be safely discharged from those that should be admitted to the hospital or monitored before a final decision. We propose the mnemonic acronym RED-SOS: Recognize syncope; Exclude life-threatening conditions; Diagnose; Stratify the risk of adverse events; Observe; decide on the Setting of care. Based on this acronym, in the different sections of the review, we discuss all the elements that clinicians should consider when assessing patients with syncope.
PubMed: 38892942
DOI: 10.3390/jcm13113231 -
GeroScience Jun 2024Orthostatic hypotension (OH) is prevalent in older adults and can cause falls and hospitalization. Diagnostic intermittent blood pressure (BP) measurements are only a...
Orthostatic hypotension (OH) is prevalent in older adults and can cause falls and hospitalization. Diagnostic intermittent blood pressure (BP) measurements are only a proxy for cerebral perfusion and do not reflect daily-life BP fluctuations. Near-infrared spectroscopy (NIRS)-measured cerebral oxygenation potentially overcomes these drawbacks. This study aimed to determine feasibility, face validity, and reliability of NIRS in the home environment. Ten participants with OH (2 female, mean age 77, SD 3.7) and 11 without OH (5 female, mean age 78, SD 6.7) wore a NIRS sensor at home on two different days for 10-11 h per day. Preceded by a laboratory-situated test, cerebral oxygenation was measured during three standardized supine-stand tests per day and during unsupervised daily life activities. Data availability, quality, and user experience were assessed (feasibility), as well as differences in posture-related oxygenation responses between participants with and without OH and between symptomatic (dizziness, light-headedness, blurred vision) and asymptomatic postural changes (face validity). Reliability was assessed through repetitive supine-stand tests. Up to 80% of the standardized home-based supine-stand tests could be analyzed. Oxygenation recovery values were lower for participants with OH (p = 0 .03-0.15); in those with OH, oxygenation showed a deeper maximum drop for symptomatic than asymptomatic postural changes (p = 0.04). Intra-class correlation coefficients varied from 0.07 to 0.40, with no consistent differences over measurements. This proof-of-concept study shows feasibility and face validity of at-home oxygenation monitoring using NIRS, confirming its potential value for diagnosis and monitoring in OH and OH-related symptoms. Further data are needed for conclusions about reliability.
PubMed: 38890204
DOI: 10.1007/s11357-024-01241-w -
Expert Opinion on Drug Metabolism &... Jun 2024Dopamine (D)-receptor antagonists (RAs) were the first antiemetics used in the prophylaxis of chemotherapy-induced nausea and vomiting (CINV). (Review)
Review
INTRODUCTION
Dopamine (D)-receptor antagonists (RAs) were the first antiemetics used in the prophylaxis of chemotherapy-induced nausea and vomiting (CINV).
AREAS COVERED
Eight D-RAs, amisulpride, domperidone, droperidol, haloperidol, metoclopramide, metopimazine, olanzapine and prochlorperazine are reviewed focusing on pharmacokinetics, pharmacodynamics, antiemetic effect and side effects.
EXPERT OPINION
Since the introduction of D-RAs, antiemetics such as corticosteroids, 5-hydroxytryptamine (5-HT)-RAs and neurokinin (NK)-RAs have been developed. The classical D-RAs are recommended in the prophylaxis of CINV from low emetic risk chemotherapy, but not as a fixed component of an antiemetic regimen for moderately or highly (HEC) emetic risk chemotherapy. D-RAs are also used in patients with breakthrough nausea and vomiting. It should be emphasized, that most of these drugs are not selective for dopamine receptors.The multi-receptor targeting agent, olanzapine, is recommended in the prophylaxis of HEC-induced CINV as part of a four-drug antiemetic regimen, including a 5-HT-RA, dexamethasone and a NK-RA. Olanzapine is the most effective agent to prevent chemotherapy-induced nausea.Side effects differ among various D-RAs. Metopimazine and domperidone possess a low risk of extrapyramidal side effects. Domperidone and metoclopramide are prokinetics, whereas metopimazine delays gastric emptying and haloperidol does not influence gastric motility. Many D-RAs increase the risk of prolonged QTc interval; other side effects include sedation and orthostatic hypotension.
Topics: Humans; Nausea; Vomiting; Antiemetics; Antineoplastic Agents; Dopamine Antagonists; Animals; Dopamine D2 Receptor Antagonists; Receptors, Dopamine D3
PubMed: 38878283
DOI: 10.1080/17425255.2024.2367593 -
Journal of Neurosurgery. Spine Jun 2024Spontaneous intracranial hypotension (SIH) is an important cause of orthostatic headaches caused by spinal CSF leaks. It has a strong negative impact on patients'...
OBJECTIVE
Spontaneous intracranial hypotension (SIH) is an important cause of orthostatic headaches caused by spinal CSF leaks. It has a strong negative impact on patients' socioeconomic status and health-related quality of life (HRQOL). This study aimed to analyze the impact of surgical and endovascular treatments on patients' HRQOL.
METHODS
The authors conducted a prospective, observational cohort study that included all patients treated for SIH with microsurgery or embolization, depending on the type of CSF leak, at their institution between April 2022 and May 2023. Patients were asked to complete a specifically designed questionnaire, as well as the 15D HRQOL questionnaire, before and 3 months after treatment.
RESULTS
A total of 21 patients (14 female; mean age 51.7 years) were treated in the study period. There were 12 (57%) type 1 leaks, 3 (14%) type 2, and 6 (29%) type 3. While 20 (95.2%) leaks were localized in the thoracic spine, only 1 (4.8%) was found in the lumbar spine. All patients completed the questionnaires. Fifteen (71.4%) patients underwent microsurgery and 6 (28.6%) endovascular embolization. The mean 15D score improved from 0.802 before to 0.889 after treatment (p = 0.013). Compared with an age- and sex-matched general population, HRQOL was significantly impaired in patients with SIH before treatment. After treatment, the authors found no significant difference in the overall HRQOL between patients and the healthy population. Mean headache intensity on a numeric rating scale improved from 8.1 before treatment to 2.3 after treatment (p = 0.003). Patients reported that SIH had a notable impact on their social and working life.
CONCLUSIONS
SIH has a considerable negative impact on HRQOL. Microsurgery or embolization can dramatically improve HRQOL, subjective perception of health, and headache intensity. Therefore, surgical or endovascular treatment should be considered given the improvement observed in HRQOL for patients with SIH.
PubMed: 38875729
DOI: 10.3171/2024.4.SPINE231232 -
Cureus May 2024Post-dural puncture headache (PDPH) is a common complication of epidural and spinal anaesthesia in obstetric medicine. In rare cases, PDPH can be associated with...
Post-dural puncture headache (PDPH) is a common complication of epidural and spinal anaesthesia in obstetric medicine. In rare cases, PDPH can be associated with complications such as cerebral venous thrombosis (CVT) as well. We discuss a recent case of a young female who developed PDPH and CVT concurrently after undergoing epidural anaesthesia for initially uncomplicated labour and delivered via an emergency caesarean section. She developed an orthostatic headache a few hours post administration of the epidural anaesthetic, which was initially treated as a suspected PDPH by giving simple analgesia and caffeine. Her symptoms did not improve and she underwent further neuroimaging, which revealed the development of a CVT. Despite the prompt administration of enoxaparin, the headache persisted and did not respond to increased doses of analgesia. After deliberation and inter-departmental discussion, an epidural blood patch was performed, leading to the prompt resolution of the headache. This report highlights a rare concurrence of PDPH and CVT, causing a diagnostic dilemma that resulted in treatment delays for the patient. Treating both conditions raises difficult practical questions, especially regarding the use of an epidural blood patch as opposed to anticoagulation. Given the risk of fatal complications such as venous cerebral infarction, seizures, and subdural hematoma, prompt treatment of both PDPH and CVT is strongly recommended. The multifactorial mechanism by which CVT develops with intracranial hypotension and PDPH also makes it essential for clinicians to keep an open mind when managing post-caesarean headaches, requiring inter-departmental cooperation to ensure optimal patient outcomes.
PubMed: 38868268
DOI: 10.7759/cureus.60183