Study of Cardiovascular Autonomic Dysfunction in Type II Diabetes Mellitus.

Autonomic neuropathy is a common complication of diabetes mellitus which may affect major systems like cardiovascular system that may cause early death in diabetics. In our study attempt was made to asses different cardiovascular autonomic function parameters like change of blood pressure from supine to standing posture (postural BP changes) and ratio of longest and shortest R-R interval during deep expiration and inspiration respectively (E/I ratio) on ECG in type 2 diabetics and age sex matched non diabetic controls. Level of fasting blood glucose (FBG) and glycosylated hemoglobin (HbA1C) were also measured in the same subjects. Diabetics were subdivided into <5 years and >5 years groups. Findings were compared between diabetics and the controls and also between the subgroups of diabetics. Correlation between glycaemic control , duration of disease and autonomic function parameters were tested. We found, a significant difference in postural BP changes and E/I ratios between diabetics and the controls, no significant correlation could be found out between glycaemic control or duration of disease and autonomic function parameters. Therefore, our study concludes that diabetes may lead to autonomic dysfunction that may cause postural hypotension and altered E/I ratio irrespective of the duration of disease and glycemic control.

Sildenafil: eficácia, segurança e efeito sobre a pressão arterial postural em homens com 70 ou mais anos portadores de disfunção erétil / Sildenafil: efficacy, safety and impact on postural blood pressure in men aged 70 years or older with erectile dysfunction

Justificativa e objetivos: Avaliar a segurança, a eficácia e o impacto sobre a pressão arterial postural do citrato de sildenafila (100mg) em homens com 70 ou mais anos portadores de disfunção erétil. Método: Os pacientes iniciaram tratamento com o citrato de sildenafila 100 mg sob demanda. Após seis semanas foram divididos em dois grupos: respondedores e não respondedores ao tratamento. Os respondedores continuaram o mesmo tratamento por mais 12 semanas. Os não respondedores passaram a fazer uso do citrato de sildenafila, 100 mg, em dose diária e foram reavaliados após quatro semanas, quando optaram por descontinuar o estudo ou continuar tomando as doses diárias por mais oito semanas. Em todos os pacientes a avaliação final foi feita após 18 semanas. Resultados: Dos 47 pacientes incluídos, 39 foram avaliados. A idade média foi de 74 anos (70 a 88 anos). O escore do domínio da função erétil do Índice Internacional de Função Erétil aumentou significativamente de 13,4 ± 5,0 (basal) para 23,3 ± 8,0 (P<0.0001) (pós-tratamento). Aproximadamente 25% da amostra apresentaram efeitos colaterais leves que não resultaram em abandono do estudo. Hipotensão postural foi detectada em um paciente (2,6%) no pós-tratamento. Conclusões: O tratamento da disfunção erétil com o citrato de sildenafila em pacientes com 70 ou mais anos resultou em um aumento significativo no escore do domínio da função erétil do Índice Internacional de Função Erétil, efeitos colaterais leves e praticamente nenhum efeito negativo aparente sobre a pressão arterial postural.

Disautonomia na doença de Parkinson. Revisão da literatura / Dysautonomy in Parkinson's disease. Review of the literature

Desde o trabalho original, são conhecidos alguns distúrbios autonômicos associados à doença de Parkinson, tais como, sialorréia, disfagia e constipação intestinal. Nesta revisão, descrevemos as principais alterações gastrointestinais, cardiovasculares, urinárias, sexuais, termorregulatórias e cutâneas. Apesar da alta prevalência (14 a 80%), continuam inadequadamente diagnosticadas.

Since the original manuscript, it has become known that some autonomic disorders are associated with Parkinson´s disease, such as sialorrhea, dysphagia and constipation. In this review we describe the main gastrointestinal, cardiovascular, urinary, sexual, thermoregulatory and cutaneous dysfunctions. Despite the high prevalence of these disorders (14 to 80%), they remain underdiagnosed.

Hipotensión ortostática: un actor solapado en la vida de los ancianos frágiles / Orthostatic hypotension: a sneaky player in the life of the frail elderly

Se investigó la presencia de hipotensión ortostática (HO) y su relación con parámetros demográficos, funcionales, cognitivos, antecedentes y patologías activas, medicación, internaciones en el último año y fallecimiento durante el seguimiento a seis meses, en 69 ancianos residentes en el Sector Geriatría del Hospital Italiano de Buenos Aires, sede San Justo. Se definió la HO como la reducción de la presión arterial (PA) sistólica ≥ a 20 mmHg y/o de la PA diastólica ≥ de 10 mmHg medidas entre 1 y 3 minutos del cambio postural.La HO afectó al 40% de la población. La PA (sistólica/diastólica) disminuyó -26/-7 mmHg al sentarse y -34/-13 mmHg al pararse, en el grupo con HO, y solo -3/-1 mmHg y 3/-1 mmHg, respectivamente, en el grupo sin HO. La respuesta cronotrópica no fue diferente entre los grupos. No encontramos asociación estadísticamente significativa entre HO y enfermedad de Parkinson, demencia, depresión, diabetes, historia de caídas, fractura de cadera, postración, uso de silla de ruedas, trastorno de la deglución, incontinencia urinaria, ni con la medicación utilizada. Durante el seguimiento fallecieron 6 pacientes, de los cuales 4 tenían HO.En conclusión, aunque en nuestros ancianos institucionalizados la HO es frecuente, su asociación con las patologías o medicamentos que clásicamente afectan el ajuste circulatorio postural no alcanzó significancia estadística. La condición de anciano frágil podría ser en sí misma una causa suficiente de HO.

Autonomic failure in primary amyloidosis.

Amyloidosis is an uncommon plasma cell dyscrasia affecting Multisystem, characterized by deposition of amyloid proteins in extracellular spaces and the tissues. Reported incidence of amyloidosis is 8 cases per million per year. Deposition of amyloid fibrils occurs in peripheral nerves in 20% of the cases in Primary Amyloidosis. Though. polyneuropathy is one of the presenting manifestations in cases of Primary Amyloidosis, pure autonomic failure without involving peripheral nerves is not a documented entity. Here, we present a case of Primary Amyloidosis presenting as Pure Autonomic Failure (Dysautonomia).

Approach to a case of autonomic peripheral neuropathy.

Autonomic neuropathy is the term used to describe autonomic disturbances resulting from diseases of the peripheral autonomic nervous system. This is a group of disorders in which the small, lightly myelinated and unmyelinated autonomic nerve fibers are selectively targeted. Most often, autonomic neuropathies occur in conjunction with a somatic neuropathy (i.e. with motor weakness and/or sensory loss), but they can occur in isolation. Causes of autonomic neuropathies are immune-mediated, paraneoplastic, infectious, toxic and drug-induced, hereditary, nutritional and idiopathic. Amongst all, diabetes mellitus is the most common cause. Autonomic features, which involve the cardiovascular, gastrointestinal, urogenital, sudomotor, and pupillomotor systems, occur in varying combination in these disorders. Orthostatic hypotension is often the first recognized and most disabling symptom. Noninvasive, well-validated clinical tests of autonomic functions along with a host of laboratory tests are of immense value to diagnose the presence and to demonstrate the distribution of autonomic failure. Treatment aims to treat specific cause of the autonomic neuropathy (if possible) and to control symptoms of autonomic dysfunction. Present review attempts to outline clinical approach to a case of autonomic peripheral neuropathy.

Síncope / Diagnosis and prognosis of syncope

El síncope es motivo de consulta frecuente y corresponde al médico tratar de hacer un diagnóstico etiológico rápido con elobjeto de distinguir los de origen neurocardiogénico de buen pronóstico de los cardíacos que pueden provocar la muerte. El diagnóstico inicial se puede basar en la historia clínica, el examen físico y el electrocardiograma, completando luego con otros estudios. No siempre se llega a un diagnóstico certero. En oportunidades se pueden tratar con drogas o marcapasos con buen resultado.

Hipotensión ortostática: una manifestación sugerente de feocromocitoma / Orthostatic hypotension: as an unusual manifestation of pheochromocytoma

Pheochromocytoma, though an uncommon cause of hipertension, can be a lethal condition. Because of this it is mandatory to diagnose it or rule it out in presence of suggestive symptoms. Typical symptoms are palpitations, sweating, severe headaches and hypertension. However, there are other suggestive symptoms of this dangerous endocrine entity, one of which is the orthostatic hypotension. We report the case of a 65 years old female patient with long standing hypertension in whom the pheochromocytoma was suspected after episodes of orthostatic hypotension. Although this manifestation was described almost fifty years ago, its frequency and pathophysiology has not yet been well established and fully elucidated. Moreover, it has meaningful implications in relation to preoperatory management and the timing of surgery (Rev Méd Chile 2003; 131: 1429-33).

Relative adrenal insufficiency in post-transplant lymphoproliferative disorder.

Post-transplant lymphoproliferative disorder is treated with rapid decrement of immunosuppressive therapy. This cannot be achieved with ease in patients on long-term glucocorticoid therapy, as chronically suppressed adrenal glands may not be capable of mounting adequate response to stress. A 52-year-old Caucasian male presented with fever, orthostatic hypotension, lymphadenopathy and hyponatraemia. Serum cortisol levels were within normal levels with a sub optimal response to stimulation by ACTH. Hyponatraemia and orthostasis responded poorly to fluid restriction, saline and salt repletion but corrected after increasing the steroid dose. The normal baseline cortisol levels represented a stimulated adrenal gland, however, the ACTH stimulation had inadequate response. This sub optimal stimulation and a good response to increased steroids suggest the presence of relative or occult adrenal insufficiency. Relative adrenal insufficiency must be considered in patients who have received prolonged glucocorticoid therapy and have symptoms such as hypotension and/or hyponatraemia.

Downbeating nystagmus and postural hypotension due to basilar invagination.

Downbeating nystagmus is an involuntary vertical rhythmic eye movement with the fast component in the downward direction. The sign indicates a craniocervical disorder. The most common cause is the Arnold-Chiari malformation, followed by cerebellar degeneration. Basilar invagination is a rare cause of downbeating nystagmus. However, with appropriate treatment its prognosis is good. Here, we report a case of basilar invagination which presented with downbeating nystagmus and postural hypotension. A 31 year-old Thai male patient had a 20 year history of postural hypotension. He had recurrent pneumonia and cough-induced syncope a year before admission. He complained of symptoms of an acute febrile illness and a productive cough. The physical examination showed high grade fever, postural hypotension and medium crepitation in the right upper lobe. The neurological examination showed downbeating nystagmus, atrophy and fasciculation of the right side of the tongue, atrophy of the right sternocleidomastoid muscle, mild weakness of the extremities and generalized hyperreflexia. The cervical spine X-ray revealed upward displacement of the vertebral bodies of C1 and C2, with a mild narrowing of the space between C1 and the occiput. The CT-myelogram and MRI showed upward displacement of C1 with overriding of the dens over the anterior lip of the foramen magnum; this also compressed the medulla. Syringomyelia was seen at the C1-C5 level. We report a patient who presented with postural hypotension, recurrent pneumonia and downbeating nystagmus due to basilar invagination. The symptoms were aggravated by cough which caused an increase in intracranial pressure. This resulted from medulla compression in the foramen magnum by the first cervical spine. The treatment of choice was surgical decompression.

Síncope y presíncope neurogénico recurrente: diagnóstico diferencial con epilepsia y disautonomía / Recurrent neurogenic syncope and presyncope: differential diagnosis with epilepsy and dysautonomia

Síncope es una disminución transitoria de conciencia y tono postural por una reducción global del flujo sanguíneo cerebral. Anormalidades en el control autonómico cardiovascular pueden comprometer el riego sanguíneo y producir síncope mediado por mecanismo neurogénico. Entre estos episodios el paciente tiene presión sanguínea y tolerancia ortostática normal. El síncope es un fenómeno médico muy frecuente y sus manifestaciones clínicas y evolutivas características. Un anamnesis cuidadosa aumenta el diagnóstico etiológico y permite efectuar diagnóstico diferencial con crisis epilépticas con las cuales se confunden en forma ocacional, al igual que con transtornos psiquiátricos los cuales pueden asociarse en forma secundaria (5,6,7)

Marcapasso atrial programável no tratamento da hipotensäo ortostática neurogênica no idoso / Programmed atrial pacemaker in the treatment of neurogenic orthostatic hypotension in the elderly

Marcapasso atrial programável foi implantado em paciente idoso (75 anos), portador de hipotensäo ortostática incapacitante, secundária á disfunçäo do sistema nervoso autónomo (Shy-Drager), näo responsiva à terapêutica clássica. Inicialmente, um marcapasso atrial programável temporário foi implantado, programado a uma freqüência de 96 bpm durante o dia, reduzindo para 60 bpm durante a noite. Observou-se com esta medida aumento do débito cardíaco. Os resultados favoráres encontrados nos encorajaram a implantar um marcapasso programável definitivo. O fabricante planejou um programador simples e seguro, operado pelo próprio paciente, que só altera a freqüência para a noite (60) e para o dia (96). Observou-se uma acentuada melhora na sintomatologia, sem quaisquer complicaçöes durante um seguimento de nove meses. Recomendamos que esta modalidade terapêutica seja considerada em idosos portadores de hipotensäo ortostática sintomática, secundária à disfunçäo autonômica, sem taquicardia compensatória adequada, quando näo houver resposta à terapêutica clássica