Correlato neurobiológico de los síntomas premotores del parkinson: el origen en la teoría de Braak / Neurobiological correlate of parkinson's premotor symptoms: the origin in Braak's theory / Correlação neurobiológica dos sintomas pré-motores de parkinson: a origem na teoria de Braak

El diagnóstico de enfermedad de Parkinson (ED) se basa en las principales manifestaciones motoras: bradicinesia en combinación con temblor en reposo, rigidez o ambos. Cuando se realiza el diagnóstico basado en la sintomatología motora clínica típica ya se han perdido hasta el 60 % de las neuronas dopaminérgicas de la sustancia negra pars compacta mesencefálica. La identificación de los síntomas premotores son un marcador temprano para sospechar la aparición futura de la enfermedad, así como su progresión y gravedad. La hipótesis sobre la patogénesis que mejor expone la progresión de la enfermedad es la teoría de Braak. Esta se basa en la aparición y presencia de cuerpos de Lewy en diferentes estructuras anatómicas, las cuales representadas en cada uno de sus seis estadios y podrían ser la explicación biológica de los síntomas premotores, motores y no motores. La detección temprana de los síntomas premotores puede tener repercusiones positivas en el enfoque, seguimiento, diagnóstico y tratamiento de la EP. El propósito de este artículo es identificar las aproximaciones neurológicas descritas por la teoría de Braak para los síntomas premotores de la enfermedad de Parkinson de acuerdo con la literatura publicada en los últimos 20 años.

The diagnosis of Parkinson's disease (PD) is based on the main motor manifestations: bradykinesia in combination with tremor at rest, rigidity, or both. When the diagnosis is made based on typical clinical motor symptoms, up to 60 % of the dopaminergic neurons of the mesencephalic substantia nigra pars compacta have already been lost. The identification of premotor symptoms is an early marker to suspect the future appearance of the disease, as well as its progression and severity. The hypothesis about the pathogenesis that best exposes the progression of the disease is Braak's theory. It is based on the appearance and presence of Lewy bodies in different anatomical structures, which are represented in each of its six stages and could be the biological explanation biological of premotor, motor, and non-motor symptoms. Early detection of premotor symptoms can have positive repercussions in the approach, follow-up, diagnosis and treatment of PD. The purpose of this article is to identify the neurological approaches described by Braak's theory for the premotor symptoms of Parkinson's disease according to the literature published in the last 20 years.

O diagnóstico da doença de Parkinson (DP) baseia-se nas principais manifestações motoras: bradicinesia combinada com tremor de repouso, rigidez ou ambos. Quando o diagnóstico é feito com base em sintomas clínicos motores típicos, até 60% dos neurônios dopaminérgicos da substância negra pars compacta mesencefálica já foram perdidos. A identificação de sintomas pré-motores é um marcador precoce para suspeitar do futuro aparecimento da doença, bem como da sua progressão e gravidade. A hipótese sobre a patogênese que melhor expõe a progressão da doença é a teoria de Braak. Isto se baseia no aparecimento e presença de corpos de Lewy em diferentes estruturas anatômicas, que estão representados em cada uma de suas seis etapas e podem ser a explicação biológica dos sintomas pré-motores, motores e não motores. A detecção precoce de sintomas pré-motores pode repercutir positivamente na abordagem, acompanhamento, diagnóstico e tratamento da DP. O objetivo deste artigo é identificar as abordagens neurológicas descritas pela teoria de Braak para os sintomas pré-motores da doença de Parkinson de acordo com a literatura publicada nos últimos 20 anos.

When the fever will not stop, stop the pills! A case report

ABSTRACT Neuroleptic malignant syndrome (NMS) is a neurologic emergency potentially fatal. This rare side effect is most commonly associated with first-generation antipsychotics and less frequently with atypical or second-generation antipsychotics. The diagnosis relies on both clinical and laboratory criteria, with other organic and psychiatric conditions being ruled out. CASE REPORT: A 39-year-old female patient, who is institutionalized and completely dependent, has a medical history of recurrent urinary infections and colonization by carbapenem-resistant Klebsiella pneumoniae. Her regular medication regimen included sertraline, valproic acid, quetiapine, risperidone, lorazepam, diazepam, haloperidol, baclofen, and fentanyl. The patient began experiencing dyspnea. Upon physical examination, she exhibited hypotension and a diminished vesicular murmur at the right base during pulmonary auscultation. Initially, after hospitalization, she developed high febrile peaks associated with hemodynamic instability, prompting the initiation of antibiotic treatment. Despite this, her fever persisted without an increase in blood inflammatory parameters, and she developed purulent sputum, necessitating antibiotherapy escalation. The seventh day of hospitalization showed no improvement in symptoms, suggesting NNMS as a differential diagnosis. All antipsychotic and sedative drugs, as well as antibiotherapy, were discontinued, after which the patient showed significant clinical improvement. CONCLUSION: Antipsychotic agents are commonly employed to manage behavioral changes linked to various disorders. However, their severe side effects necessitate a high degree of vigilance, the cessation of all medications, and the implementation of supportive care measures. A prompt and accurate diagnosis of NMS is crucial to alleviating the severe, prolonged morbidity and potential mortality associated with this syndrome.

Study of heart rate variability to assess autonomic dysfunction in patients with chronic obstructive pulmonary disease of a tertiary care hospital of West Bengal: A cross-sectional comparative study

Background: Chronic obstructive pulmonary disease (COPD) is one of the major causes of morbidity and mortality throughout the world. COPD and its complications also lead to a large number of deaths every year in our country. Cardiac arrhythmias and sudden cardiac death are the major complications of COPD leading to death and disability. Such cardiac complications are often a result of autonomic dysfunction. Aims and Objectives: This study aims to find out the autonomic dysfunction in moderate COPD patients by comparing their heart rate variability (HRV) parameters with age and sex matched healthy controls. Materials and Methods: After obtaining approval from the Institutional Ethics Committee, 48 patients of moderate COPD and 54 healthy subjects were assessed and compared with respect to their HRV parameters which included Mean RR, Mean HR, SDNN, NN50, pNN50, root mean square of successive differences (RMSSD), high frequency (HF), low frequency (LF), LF/HF ratio, and SD2/SD1 ratio. Results: It was found that in comparison to healthy controls, patients of moderate COPD had significant alteration in the following HRV parameters – Mean HR (P: 0.001), RMSSD (P: 0.002), SDNN (P: 0.015), NN50 (P: 0.001), pNN50 (P: 0.000), HF (NU/normalized unit) [P: 0.033], HF (%) [P: 0.002], LF (NU/normalized unit) [P: 0.033], LF (%) [P: 0.012], and LF/HF (P: 0.033). Conclusion: As there is a significant alteration of several HRV parameters in moderate COPD patients, we conclude that HRV measurement may subserve as a simple and non-invasive tool to assess autonomic dysfunction in patients of COPD at the earliest.

A case of nasopharyngeal carcinoma with autonomic nervous dysfunction and literature review / 中国医师杂志

Objective:A case of advanced nasopharyngeal carcinoma with autonomic dysfunction was reported and its pathophysiological mechanism was discussed.Methods:The diagnosis and treatment of a nasopharyngeal carcinoma patient with autonomic nervous dysfunction such as paroxysmal syncope was summarized, and the pathophysiological mechanism of this case was analyzed by searching related literature.Results:Nasopharyngeal carcinoma characterized by autonomic dysfunction was rare and had a poor prognosis. Autonomic dysfunction caused by nasopharyngeal carcinoma was associated with carotid sinus syndrome, parapharyngeal space syncope syndrome, glossopharyngeal nerve reflex and paraneoplastic neuropathy.Conclusions:Early detection and treatment is a key factor affecting the prognosis of nasopharyngeal carcinoma. Clinicians should consider nasopharyngeal carcinoma as one of the differential diagnoses in the diagnosis and treatment of patients with autonomic nervous dysfunction combined with cranial nerve damage.

Reflex cardioinhibitory syncope potentially related to SARS-CoV-2 infection: a case report / Síncope cardioinibitória reflexa potencialmente relacionada à infecção por SARS-CoV-2: um relato de caso

Autonomic dysfunction related to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is increasingly described in the literature. We report the case of a 30-year-old male with a background of asthma and migraine who experienced a second episode of SARS-CoV-2 infection characterized by mild respiratory symptoms. Twenty-four days after the symptom onset, he developed acute syncope. A tilt test revealed a neuromediated cardioinhibitory response with asystole (Vasovagal Syncope International Study ­ VASIS type 2B). The temporal association between SARS-CoV-2 infection and syncope seems to indicate a probable causal relationship, which requires corroboration by future studies.

Disfunção autonômica relacionada à infecção por coronavírus-2 da síndrome respiratória aguda grave (SARS-CoV-2) vem sendo cada vez mais descrita na literatura. Relatamos o caso de um homem de 30 anos de idade, com histórico de asma e enxaqueca, que apresentou um segundo episódio de infecção por SARS-CoV-2 caracterizado por sintomas respiratórios leves. Vinte e quatro dias após o início dos sintomas, desenvolveu um quadro agudo de síncope. Um teste de inclinação revelou uma resposta cardioinibitória neuromediada com assistolia (Vasovagal Syncope International Study ­ VASIS tipo 2B). A associação temporal entre infecção por SARS-CoV-2 e síncope parece indicar uma provável relação causal, a qual requer corroboração por estudos futuros.

Heart rate turbulence assessed through ergometry after myocardial infarction: a feasibility study

ABSTRACT BACKGROUND: Coronary artery disease is an important cause of morbidity and mortality. The impact of ventricular arrhythmias with impaired cardiac vagal activity is one of the most recently studied prognostic factors. However, there are no studies evaluating the phenomenon of heart rate turbulence (HRT) during physical exertion. OBJECTIVE: To study the behavior of HRT during exercise testing, among individuals after myocardial infarction. DESIGN AND SETTING: Feasibility study conducted in a university hospital among individuals 4-6 weeks after myocardial infarction. METHODS: All subjects underwent 24-hour Holter monitoring and ergometric stress testing. We considered that abnormal HRT was present if the turbulence onset was ≥ 0% or turbulence slope was ≤ 2.5 mm/relative risk interval. RESULTS: All 32 subjects were asymptomatic. Their median age was 58 years (interquartile range 12.8) and 70% were male. Abnormal HRT was associated with ventricular dysfunction in this population. We found no differences regarding the behavior of HRT, in relation to age, gender, smoking, systemic arterial hypertension, diabetes mellitus or dyslipidemia. Ergometric stress testing detected premature ventricular beats (PVB) in approximately 44% of the examinations, and these occurred both during the active phase of effort and in the recovery period. The low occurrence of several isolated PVB in beta-blocked subjects made it difficult to perform statistical analysis to correlate HRT between ergometric and Holter testing. CONCLUSION: The data obtained in this study do not support performing HRT through ergometric stress testing among patients who remain on beta-blockers post-myocardial infarction, for the purpose of assessing cardiac vagal activity.

Comparison of time domain heart rate variability parameters between smokers and non-smokers

Background: Cigarette smoking induced sympathetic overdrive is one of the major independent modifiable risk factors for cardiovascular mortality and morbidity. There is altered autonomic activity with increased adrenergic activity in chronic smoking which also predisposes to cardiovascular morbidity and mortality. There are several tests that can determine the Autonomic Activity. Among them, heart rate variability (HRV), especially the time domain parameters of it, is simple, easy to perform, and non-invasive test for diagnosing autonomic dysfunction in the smokers. Aims and Objectives: The aims of this study were to compare the time domain parameters of HRV in smokers and non-smokers. Materials and Methods: The present study was carried out at autonomic function laboratory and cardiovascular function laboratory, Department of Physiology, Government Medical College, Bhavnagar, among 200 subjects, out of which 100 were smokers and 100 were non-smokers, in age group of 20–50 years. Results: There was a significant increase in mean heart rate, blood pressure, and R-R interval in smokers as compared to the non-smokers. There was also a significant decrease in all time domain parameters of HRV which suggests profound sympathetic overdrive and a decrease in vagal tone due to the actions of nicotine presents in tobacco smoke. Conclusions: Cigarette smoking plays a major role in degradation and decreased function of autonomic nervous system.

To assess the prevalence of clinical and subclinical cardiac autonomic dysfunction in adolescent with family history of hypertension and adolescent with prehypertension; correlating with adolescent anthropometric parameters

Objectives: Hypertension (HTN) is an inherited disorder and these patients manifest with cardiac autonomic dysfunction (CAD). The present study intends to assess the presence of pre HTN, clinical and subclinical CAD in adolescents with a family history of HTN, and to obtain its correlation with anthropometric values. Materials and Methods: After obtaining ethical clearance and informed consent, three groups containing 50 subjects each, of age 17–19 years were included in the study. (Group-I: Normotensives without a family history of HTN; Group-II: Normotensives with a family history of HTN and Group-III: prehypertensives). CAD was done by performing (1) resting tachycardia, (2) loss of sinus arrhythmia, and (3) heart rate response to the Valsalva manoeuvre. If any two of them are positive then the presence of CAD was confirmed. Results: Height, weight, BMI, SBP and DBP was significantly higher in group 3 (prehypertensives). Confirmed CAD findings was seen in 36% of group 2 and 46% of group 3 participants. Of the anthropometric parameters, a significant positive correlation was seen between weight and SBP, DBP and CAD parameters, and height with SBP and DBP. Conclusion: Clinical and subclinical CAD exists in adolescents with risk factors for HTN including heredity, obesity, and pre-HTN values. These risk factors show multiplicative effects for disease genesis and indicate high sympathetic and low parasympathetic drives. Extra care should be taken to curb the onset of clinical HTN and CAD in these young adults. Additional work needs to be done on pathophysiological mechanisms for the same.

Assessment of heart rate variability among individuals with different risk levels for type 2 diabetes mellitus

Background: Cardiac autonomic function is altered in type 2 diabetes mellitus (T2DM) individuals. It is evidenced by decreased heart rate variability (HRV). Decreased HRV results in cardiac autonomic neuropathy and increased risk for sudden cardiac death. Identifying individuals with high risk for T2DM can be an important approach to prevent or delay T2DM complications. In India, the Indian Diabetes Risk Score (IDRS) questionnaire was developed for screening Indian population. To the best of our knowledge, there are no data available evaluating HRV among adults with different risk levels for T2DM (categorized using IDRS). Aim and Objective: In our study, we evaluated HRV among adults with different risk levels for T2DM. Materials and Methods: This study was done in the Department of Physiology, MAPIMS. It is a cross-sectional study done on 130 male and female staffs, attenders, and laboratory technicians working in MAPIMS. All the participants will be asked to complete the IRDS questionnaire. Then, based on the IRDS score, they are divided into Groups I, II, and III. In all the three groups, 5 min short-term HRV will be recorded using RMS Polyrite. Data were analyzed by SPSS 20.0 version software. One-way ANOVA was used to find any statistical difference between the groups. Correlations between the variables were done using Pearson correlation test. Results: Statistically significant (P < 0.05) difference in HRV between different risk levels for diabetes was determined by one-way ANOVA and the post hoc (Dunn’s) test revealed that HRV levels were significantly reduced in high risk, moderate risk when compared to mild risk group. Conclusion: HRV levels reduced as the risk for diabetes increased, that is, HRV negatively correlated with the risk score.

Autonomic dysfunction is common in liver cirrhosis and is associated with cardiac dysfunction and mortality: prospective observational study

ABSTRACT BACKGROUND: Although autonomic dysfunction has been shown to be associated with liver cirrhosis, the prevalence and prognostic implications are unclear. Abnormal heart rate variability (HRV), a measure of autonomic function, has not been well investigated in cirrhosis. OBJECTIVE: To evaluate the prevalence of high-risk HRV parameters in a cohort of cirrhotic patients and their association with cardiac dysfunction and mortality. DESIGN AND SETTING: Prospective observational study conducted in the Federal University of São Paulo. METHOD: A cohort of 120 patients, comprising 17 healthy controls and 103 cirrhotic outpatients, was evaluated and followed for 10 months. HRV analysis was based on 24-hour Holter monitoring and defined using time-domain and frequency-domain parameters. RESULTS: The HRV parameters were statistically lower in cirrhotic patients than in healthy subjects. High-risk HRV parameters were prevalent, such that 64% had at least one high-risk parameter. Time-domain parameters correlated with Child scores (P < 0.0001). In regression models, HRV parameters were independent predictors of diastolic dysfunction and mortality. During 10 months of follow-up, there were 11 deaths, all of patients with at least one high-risk HRV parameter. Kaplan-Meier analysis estimated low survival rates among patients with standard deviation of normal-to-normal RR intervals (SDNN) < 100. CONCLUSION: Reduced HRV is prevalent in liver cirrhosis and is related to cardiac dysfunction, severity of liver disease and mortality. Abnormal high-risk HRV parameters are prevalent among cirrhotic patients and are also predictors of mortality. Our findings highlight the need for a more careful cardiac evaluation of cirrhotic patients.

Characteristics of motor and non-motor symptoms in patients with rapid eye movement sleep behavior disorder and early Parkinson disease / 中华行为医学与脑科学杂志

Objective:To investigate the motor and non-motor symptoms and polysomnographic features in patients with rapid eye movement sleep behavior disorder (RBD), early Parkinson's disease (PD) with and without RBD.Methods:Patients with idiopathic RBD (IRBD) and early PD were collected from the clinics in West China Hospital of Sichuan University from August 2020 to May 2021.All the patients were divided into 3 groups including IRBD group (67 cases), PD with RBD (PD+ RBD) group (19 cases), and PD without RBD (PD-RBD) group (22 cases). Unified Parkinson's disease rating scale part 3 (UPDRS-Ⅲ), Hoehn-Yahr(H-Y) stage, Epworth sleepiness scale (ESS), REM sleep behavior disorder questionnaire-Hong Kong (RBDQ-HK), 17-item Hamilton depression scale(HAMD-17), mini-mental state examination(MMSE), Sniffin’Sticks olfactory function test, visual analogue scale (VAS), and scale for outcomes in Parkinson's disease-AUT(SCOPA-AUT) were used to assess the motor and non-motor symptoms including sleepiness, RBD, depression, cognitive function, olfactory function, pain and autonomic function respectively.All patients were performed to the polysomnography (PSG) examination.One-way ANOVA, Krukal-Wallis test, χ2 test and Fisher accurate test were used to analyze the data of motor and non-motor symptoms and sleep parameters among the 3 groups accordingly. Results:There were statistically significant differences in motor symptoms among the three groups ( F=57.009, P<0.05), and the scores of UPDRS Ⅲ and H-Y stage were higher in the PD+ /- RBD group than those in the IRBD group(both P<0.05). However, there was no significant difference in motor symptoms between PD+ RBD group and PD-RBD group ( P>0.05). There were no significant differences in the scores of ESS, MMSE, olfactory function test and VAS (all P>0.05). But the HAMD-17 score was significantly higher in the PD+ RBD group(2(1, 9)) than that in the IRBD group (0(0, 3)( P<0.05). The SCOPA-AUT scores of autonomic function were significant differences in the three groups, mainly in the digestive system, urinary system, and sexual function ( P<0.05). Notably, the IRBD group (8(4, 14)) and PD+ RBD group (11(7, 14)) had higher scores of SCOPA-AUT compared with PD-RBD group (4(4, 5.75)(all P<0.05), especially in the digestive dysfunction(all P<0.05). The PD+ RBD group(3.47±1.17) had higher scores of sexual function compared with IRBP group(1.78±0.60)( P<0.05), and the urinary system scores also higher than PD-RBD group( P<0.05). The PD-RBD group(21.30 (6.10, 34.00)/h) had a significantly higher oxygen desaturation index in REM sleep compared with that of IRBD group(5.90(2.70, 16.73)/h) ( P<0.05). Conclusions:Early PD with RBD has more severe non-motor symptoms, especially depression and autonomic dysfunction.RBD can be related with the earlier and more widely autonomic dysfunction.

Neuropatia autonômica cardiovascular em pacientes com diabetes mellitus: perspectivas atuais / Cardiovascular autonomic neuropathy in patients with diabetes mellitus: current outlook

A neuropatia autonômica cardíaca (NAC) é uma complicação comum do diabetes mellitus (DM) e frequentemente, subdiagnosticada. A NAC está associada ao aumento da mortalidade, cardiovascular e renal, doença renal crônica e maior morbidade em pacientes com DM. Apesar dessas consequências, muitas vezes, a NAC permanece sem diagnóstico por um período prolongado. Isso geralmente porque a doença é assintomática até a fase avançada, bem como pela falta de informações e de estratégias de triagem. Clinicamente NAC se manifesta por distúrbios funcionais ou condições clínicas que envolvem desajuste das atividades reflexas cardiovasculares, tais como taquicardia em repouso, intolerância ao exercício, hipotensão ortostática, instabilidade cardiovascular intraoperatória, disfunção elétrica do coração traduzida por arritmias e isquemia miocárdica silenciosa. Essas alterações comprometem a qualidade de vida e a sobrevida dos pacientes. A NAC, segundo sua evolução, pode ser subdividida em subclínica (fase em que predominam alterações funcionais reversíveis) e clínica (quando as alterações neuronais estruturais estão plenamente estabelecidas). A avaliação da integridade do sistema nervoso autonômico é realizada por meio de exploração da atividade parassimpática, analisando o comportamento da frequência cardíaca (FC) em resposta à respiração profunda, ortostatismo ou manobra de Valsalva. A atividade simpática é explorada por meio de aferição da pressão arterial em resposta a mudança de postura (ortostatismo) e esforço isométrico. A análise da variabilidade da frequência cardíaca (VFC), no domínio do tempo, no domínio da frequência e por métodos gráficos complementam essa avaliação. Neste artigo de revisão, analisamos recentes informações sobre a epidemiologia, manifestações clínicas, diagnóstico, e tratamentos da NAC

Cardiac autonomic neuropathy (CAN) is a common and often-underdiagnosed complication of diabetes mellitus (DM). CAN is associated with increased mortality, cardiovascular disease, chronic kidney disease, and morbidity in patients with DM, but despite these significant consequences CAN often remains undiagnosed for a prolonged period. This is commonly due to the disease being asymptomatic until the later stages, as well as a lack of easily available screening strategies. Clinically, CAN is manifested by functional disorders or clinical conditions that involve maladjustment of cardiovascular reflex activities, such as tachycardia at rest, exercise intolerance, orthostatic hypotension, intraoperative cardiovascular instability, electrical dysfunction of the heart translated by arrhythmias and silent myocardial ischemia. These changes compromise patients' quality of life and survival. CAN, according to its evolution, can be subdivided into subclinical (phase in which reversible functional changes predominate) and clinical (when structural neuronal changes are fully established). The assessment of the integrity of the autonomic nervous system is performed by exploring parasympathetic activity, analyzing the heart rate in response to deep breathing, orthostatism or Valsalva maneuver. Sympathetic activity is explored by measuring blood pressure in response to a change in posture (orthostatism) and isometric effort. The analysis of heart rate variability (HRV), in the time domain, in the frequency domain and by graphic methods, complement this assessment. In this article, we review the latest developments in the epidemiology, pathogenesis, diagnosis, consequences, and treatments of CAN in patients with DM.

Correlation of Cardiac Autonomic Dysfunction with CD4 Count in Human Immunodeficiency Virus Patients

Background: Almost all organs and systems in thebody are affected by Human Immunodeficiency Virus(HIV) infection. Autonomic nervous systeminvolvement and cardiac autonomic dysfunction isknown to affect severely the quality of life in HIVpatients due to fatal consequences in later stages of thedisease. Aim and Objectives: Assessment of cardiacautonomic dysfunction on HIV infection/AcquiredImmunodeficiency Disease Syndrome (AIDS)patients and to correlate the degree of dysfunction withCluster of Differentiation 4 (CD4) count. Material andMethods: Fifty one human HIV sero-positive patientswith 20 HIV sero-positive patients without AIDS and31 with AIDS and 51 controls were studied for cardiacautonomic dysfunction in a tertiary care medicalcollege hospital. The assessment of cardiac autonomicfunction was done by series of autonomic functiontests. The number of abnormal test results correlatedwith CD4 count. Results: In patients with HIV,abnormal cardiac autonomic functions were observedin 5.6% of patients without AIDS and 37.5% of patientswith AIDS. Significant differences between HIVpatients and controls was observed for systolic bloodpressure response to standing (p<0.001), diastolicblood pressure response to persistent handgrip(p<0.001), heart rate variability to standing (p<0.001),Valsalva maneuver (p<0.001) and to deep breathing(p=0.001). Abnormalities in cardiac autonomicfunction occurred at all levels of CD4 counts. Ourstudy showed an increase in incidence of cardiacautonomic dysfunction as the CD4 count decreased.Conclusion: The affection of various organs andsystems is a consequence of autonomic dysfunction inHIV infection and often invasive procedures arerequired for diagnostic and therapeutic decisions.When HIV patients present with symptoms likedizziness and headache which can be present in manyconditions, cardiac autonomic dysfunction should befirst ruled out by performing simple autonomicdysfunction tests before resource consumingexpensive and invasive tests were performed later onlyif needed.

Prevalence of cardiac autonomic dysfunction in patients with metabolic syndrome: a cross-sectional, observational study

Background: Cardiovascular autonomic neuropathy (CAN) is a distinguished disorder associated with diabetes mellitus and metabolic syndrome. The pathogenesis of CAN in patients with metabolic syndrome still remains unclear. This study was undertaken to assess the prevalence of cardiac autonomic dysfunction in patients with metabolic syndrome and to correlate different parameters of metabolic syndrome with cardiac autonomic dysfunction.Methods: In this cross-sectional observational study, total 100 consecutive cases meeting the inclusion criteria and attending the Department of Medicine in Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi were enrolled. 50 subjects who satisfied the IDF criteria of metabolic syndrome were taken as cases and remaining 50 subjects (age and gender matched) who did not satisfy the IDF criteria were taken as controls. Comparison of categorical variables was made using chi-square or Fisher’s exact test. P-value <0.05 was considered as statistically significant.Results: Majority of study population (i.e., 42%) belonged to the age group of 41-50 years. Overall prevalence of cardiac autonomic dysfunction (CAD) was 25%. Prevalence of CAD among cases and controls was 38% and 12%, respectively. Overall distribution of various parameters like waist circumference, fasting blood glucose, blood pressure, HDL-C and serum triglycerides was assessed in all subjects with respect to CAD. Statistically significant association of these parameters was seen with CAD (p-value ≤0.01).Conclusions: In this study, strong association was found between CAD and central obesity, impaired fasting glucose, high blood pressure and dyslipidemia. Thus, the metabolic disorders are good predictors of CAD.

Prevalence of Asthma symptoms and risk factors in adolescents / Prevalência de sintomas de asma e fatores de risco em adolescentes

INTRODUCTION: Asthma is a chronic disease of the airways, which is increasing its prevalence among teenagers recently. The trigger-related factors are numerous, including environmental factors, genetic, food among others. OBJECTIVE: Investigate the prevalence of asthma symptoms and possible risk factors in adolescents. METHODS: This is a cross-sectional, descriptive and quantitative study conducted in 104 adolescents aged between 13 to 14 years old of both sexes from four educational institutions: three private and one public. Participants answered two questionnaires: one on risk factors for allergic diseases (EISL) and the other on asthma symptoms (ISAAC asthma module). RESULTS: 104 adolescents answered the questionnaire: 54.8% girls and 45.2% boys. Male subjects had the most active asthma (64%) than female (20%) (p = 0.01) and also had more physician-diagnosed asthma (34.4%) than girls (6.1%) (p = 0.04), more wheezing after exercise (34.4%; 12.1%) (p = 0.03). Regarding the association between the symptoms and the risk factors we observed a statistically significant relationship between the presence of wheezing and hospitalization for public schools girls (p = 0.05). CONCLUSION: There is a higher prevalence of asthma symptoms in males than in females unlike other studies was observed.

INTRODUÇÃO: A asma é a doença crônica das vias aéreas que vem apresentando um aumento na sua prevalência entre os adolescentes nas últimas décadas. Os fatores relacionados com o seu desencadeamento são inúmeros, passando por fatores ambientais, genéticos, alimentares dentre outros. OBJETIVO: Analisar a prevalência dos sintomas da asma e possíveis fatores de risco associados em adolescentes. MÉTODO: Trata-se de um estudo transversal, descritivo e quantitativo realizado em 104 adolescentes de 13 e 14 anos, de ambos os sexos, de quatro instituições de ensino: três privadas e uma pública. Os participantes responderam a dois questionários: um sobre os fatores de risco para doenças alérgicas e o outro sobre os sintomas da asma (ISAAC módulo asma). RESULTADOS: Responderam ao questionário 104 adolescentes: 54,8% meninas e 45,2% meninos. Os voluntários do sexo masculino apresentaram mais asma ativa (64,%) que as voluntárias (20%) (p = 0,01) e também tiveram mais asma diagnosticada (34,4%) do que as voluntárias (6,1%) (p = 0,04), além de mais chiado no peito após exercício (34,4%; 12,1%) (p = 0,03). Com relação à associação entre os sintomas e os fatores de riscos observou-se uma relação estatisticamente significante entre presença de sibilos e hospitalizações para as meninas de escolas públicas (p=0,05). CONCLUSÃO: Houve maior frequência de adolescentes do sexo masculino com asma ativa, asma diagnostica e sibilos após exercício físico. Por outro lado, as meninas da escola pública apresentaram um maior risco de hospitalização na presença de sibilos. Os demais fatores de riscos não apresentaram associações estatisticamente significantes com os sintomas da asma.

ANSiscope™: Can it be the crystal ball of cardiac anesthesia?

Background: Autonomic dysfunction (AD) is infrequently evaluated preoperatively despite having profound perioperative implications. The ANSiscope™ is a monitoring device that quantifies AD. This study aims to determine the potential of the device to predict hypotension following anesthetic induction, occurrence of arrhythmias, and inotrope requirement for patients undergoing off-pump coronary artery bypass surgery (OPCAB). Study Design: Prospective observational double-blinded study. Materials and Methodology: Seventy-five patients undergoing OPCAB had their autonomic function assessed by ANSiscope™. They were classified into four groups based on their AD and compared to perioperative adverse events. Results: Patients with diabetes had a higher ANSindex (P = 0.0263). They had a greater decrease in systolic blood pressure (P = 0.001) and mean arterial pressure (P = 0.004) postinduction, had an increased incidence of arrhythmias (P = 0.009), required higher inotropic support immediately (P = 0.010) and at 24 h after surgery (P = 0.018), and longer duration of postoperative ventilation (P < 0.001). They also had a higher incidence of emergency conversion of OPCAB to on-pump surgery (P = 0.009). Conclusions: An increased association between AD as quantified by the ANSiscope™ and perioperative adverse outcomes was observed. An increased rate of emergency conversion of OPCAB to on-pump surgery with higher dysfunction was noted. The authors opine that the threshold for conversion must be lower in patients deemed to be at a higher risk. Proper evaluation of the autonomic nervous system empowers the anesthesiologist to anticipate and adequately prepare for complications.

Quantitative autonomic function test in differentiation of multiple system atrophy from idiopathic Parkinson disease / 中华医学杂志(英文版)

Background@#Differential diagnosis of idiopathic Parkinson disease (IPD) and multiple system atrophy-Parkinson type (MSA-P) is challenging since they share clinical features with parkinsonism and autonomic dysfunction. To distinguish MSA-P from IPD when the symptoms are relatively mild, we investigated the usefulness of the quantitative fractionalized autonomic indexes and evaluated the correlations of autonomic test indexes and functional status.@*Methods@#Thirty-six patients with parkinsonism (22 with IPD and 14 with MSA-P) in Soonchunhyang University Bucheon Hospital from February 2014 to June 2015 were prospectively enrolled in the study. We compared fractionalized autonomic indexes and composite autonomic scoring scale between patients with IPD and MSA-P with Hoehn and Yahr (H&Y) score ≤3. Parasympathetic indexes included expiratory/inspiratory ratio during deep breathing, Valsalva ratio (VR), and regression slope of systolic blood pressure (BP) in early phase II (vagal baroreflex sensitivity) during Valsalva maneuver. Sympathetic adrenergic indexes were pressure recovery time (PRT) and adrenergic baroreflex sensitivity (BRSa) (BP decrement associated with phase 3 divided by the PRT), sympathetic index 1, sympathetic index 3, early phase II mean BP drop, and pulse pressure reduction rate. Additionally, we compared the unified multiple system atrophy rating scale (UMSARS) and H&Y scores and the autonomic indexes in all patients.@*Results@#PRT was significantly different between the IPD and MSA-P groups (P = 0.004) despite the similar BP drop during tilt. Cutoff value of PRT was 5.5 s (sensitivity, 71.4%; specificity, 72.7%). VR (r = -0.455, P = 0.009) and BRSa (r = -0.356, P = 0.036) demonstrated a significant correlation with UMSARS and H&Y scores.@*Conclusions@#Among the cardiovascular autonomic indexes, PRT can be a useful parameter in differentiating the early stage of MSAP from that of IPD. Moreover, VR, and BRSa may be the optimal indexes in determining functional symptom severity.

Nosocomial treatment-induced neuropathy of diabetes: An important cause of painful and autonomic neuropathy in hospitalized diabetes mellitus patients

@#Treatment-induced neuropathy of diabetes (TIND) is an acute painful autonomic small-fiber neuropathy that develops following an abrupt improvement in glycaemia control. Recent reports suggest TIND is a significant problem in tertiary neuropathy clinics. TIND in hospitalized patients with poor initial glycaemia control, that we refer to as nosocomial TIND, has not been well-studied. We describe the demographic, clinical features and indices of glycaemia control in 5 consecutive nosocomial TIND patients. TIND was defined using recently published criteria. Pre-meal capillary blood glucose recordings performed during the period of HbA1c decline was used to calculate glycaemic variability. All the nosocomial TIND patients were hospitalized for prolonged periods for serious medical conditions that warranted good glycaemia control, namely severe sepsis, diabetic ketoacidosis, stroke, heart failure and traumatic head injury. They had raised, double-digit, HbA1c levels at admission that subsequently dropped precipitously with tight in-patient glycaemia control protocols. These patients had multiple, largely asymptomatic, hypoglycaemic episodes. Glycaemic variability also appeared to be high in this cohort. TIND may be a significant cause of morbidity in hospitalized diabetic patients with poor glycaemia control. Not all patients developed both autonomic and painful neuropathies, raising the possibility of forme-fruste TIND

Second Dose of Scorpion Antivenom in Children with Indian Red Scorpion (Mesobuthus tamulus) Sting Envenomation

Objective: To study the effect of the second dose of scorpion antivenom in children with nonresolving or worsening scorpion sting envenomation. Methods: 72 children aged ?12 yearswith scorpion sting envenomation grade 2 and above were enrolled. 61 received the first doseof three vials of antivenom at admission (group A). Children with persistent/worseningenvenomation within 6 hours received the second dose (group B). The time required forresolution of autonomic symptoms, myocardial dysfunction, predictors of the second doseand side effects were studied. Results: The mean time taken for resolution of autonomicsymptoms were comparable in Group A and B (4.1 vs. 5.3 h, P=0.4), and of myocardialdysfunction was shorter in Group A (10.8 vs. 37.6 h, P=0.02). On regression analysis,abnormal echocardiography at admission was found to be a significant predictor of thesecond dose (OR=27.6, 95% CI, 4.7–162.5; P=<0.001). Conclusion: Children with severescorpion sting envenomation with abnormal echocardiography may require a higher dose ofscorpion antivenom. Trial registration: CTRI/2015/03/005652.

Autonomic Dysfunction in Dizziness Clinic / 대한평형의학회지

Orthostatic dizziness is a common type of dizziness. In general, orthostatic dizziness is provoked by standing or tilting, and subsided by supine position. The patient with orthostatic intolerance complains multiple symptoms such as dizziness, palpitation, lightheadness, fatigue and rarely syncope. Common orthostatic intolerance is orthostatic hypotension (classic, initial, transient, and delayed orthostatic hypotension) and postural orthostatic tachycardia syndrome. Transcranial Doppler is a noninvasive technique that provides real-time measurement of cerebral blood flow velocity. It can be useful for understanding the relationship between orthostatic symptoms and cerebral autoregulatory function. The reciprocal causal relationship between vestibular and autonomic dysfunction should always be kept in mind.