Video-assisted thoracoscopic sympathectomy for Harlequin syndrome.

Harlequin syndrome is an exceedingly rare condition, characterized by unilateral facial flushing and hyperhidrosis. Postulated to be dysregulated sympathetic nervous system stimulation of the dermal vasculature and blood vessels of the face. There is no clear unifying pathological cause. Due to its heterogeneity and rarity, very little is known about the treatment of it. Hereafter, we describe our experience in successfully curing right-sided Harlequin syndrome through video-assisted thoracoscopic sympathectomy.

Approach to the Patient: Perioperative Management of the Patient with Pheochromocytoma or Sympathetic Paraganglioma.

Pheochromocytomas and sympathetic paraganglioma (PPGL) are rare chromaffin cell tumors originating in the adrenal medulla and sympathetic paraganglia, respectively, which share the capacity to synthesize and release catecholamines. The incidence of PPGL has increased in recent years. Surgical resection is the only curative treatment for PPGL. Management of patients with PPGL is complex and should be done by a specialized multidisciplinary team in centers with broad expertise. Surgical resection of a PPGL is a high-risk procedure for which optimal pretreatment with antihypertensive drugs is required in combination with state-of-the-art surgical procedures and anesthesiological techniques. In this article we discuss the underlying evidence and the pros and cons of presurgical medical preparation. Finally, the areas of uncertainty and controversies in this field are addressed.

Resection of hip heterotrophic ossification leads to resolution of autonomic nervous system dysfunction in a patient with spinal Charcot arthropathy: a case report.

INTRODUCTION: Patients with complete spinal cord injury (SCI) may develop concurrent sequalae that interact and share symptoms; thus, a careful approach to diagnosis and management of new symptoms is crucial. CASE PRESENTATION: A patient with prior T4 complete SCI presented with progressive autonomic nervous system (ANS) dysfunction. The initial differential diagnosis included syringomyelia and lumbar Charcot arthropathy. He had comorbid heterotopic ossification (HO) of the left hip. Surprisingly, his autonomic symptoms resolved following resection of the HO. In hindsight, loss of motion through the hip caused by HO may have led to hinging through a previously asymptomatic lumbar Charcot joint, causing dysautonomia. DISCUSSION: ANS dysfunction is a disabling sequela of complete SCI and has a broad differential diagnosis. Hip immobility may be an indirect and overlooked cause due to the mechanical relationship between the hip and the lumbar spine.

Tratamiento quirúrgico de la hiperhidrosis primaria y satisfacción postquirúrgica. Nuestra experiencia en 5 años / Surgical treatment of primary hyperhidrosis and post-surgical satisfaction. Our experience in 5 years

Introducción. La hiperhidrosis primaria palmar es una patología que comienza ya en la niñez y puede representar una importante reducción de la calidad de vida del adolescente. El tratamiento de elección actual es la simpaticolisis toracoscópica. El objetivo de nuestro estudio es evaluar los resultados de la cirugía en pacientes pediátricos. Material y métodos. Hemos estudiado retrospectivamente los pacientes diagnosticados de hiperhidrosis palmar y/o palmoaxilar que han sido tratados en nuestro centro durante los últimos 5 años. Resultados. En este periodo han sido tratados 28 pacientes (10 varones y 18 mujeres), con una edad media de 13,8 años (8-18 años). La simpaticolisis toracoscópica bilateral se practicó, con monopolar, entre los niveles T2-T4 con un tiempo quirúrgico medio de 63 minutos. La estancia media fue de 1,1 días. No se registraron neumotórax ni otras complicaciones intraoperatorias. Dos casos presentaron enfisema subcutáneo postoperatorio. No hubo otras complicaciones postoperatorias. Excepto un caso de recurrencia parcial, en el resto de pacientes la sudoración desapareció por completo y quedaron totalmente satisfechos con la cirugía (96,42%). Apareció sudoración compensatoria transitoria en el 57,14% de los casos, efecto colateral que no modificó su nivel de satisfacción. Conclusiones. La hiperhidrosis palmar puede ser un problema importante para la sociabilización y la calidad de vida del niño o adolescente que la padece. La simpaticolisis toracoscópica en el paciente pediátrico es un tratamiento efectivo, altamente resolutivo y de escasa morbilidad. A pesar de la sudoración compensatoria, los pacientes es-tán altamente satisfechos con los resultados del tratamiento quirúrgico

Introduction. Primary palmar hyperhidrosis is a pathology that begins during childhood and can represent a significant reduction in the quality of life of adolescents. The current treatment of choice is thoracoscopic sympathicolysis.The aim of our study is to evaluate the results of surgery in paediatric patients. Material and methods. Retrospective study of patients with primary palmar or palmoaxillary hyperhidrosis who underwent thoracoscopic sympathicolysis in our hospital during the last 5 years. Results. We operated and included in the study 28 patients, 10 men and 18 women. Mean age was 13.8 (8-18) years. Bilateral thoracoscopic sympatholysis was performed with monopolar cautery, between T2-T4 ribs. Mean operative time was 63 minutes and mean hospitalisation time was 1.1 days. The incidence on intraoperative complications was zero. 2 patients presented postoperative subcutaneous emphysema. There were no other postoperative complications.1 patient presented partial recurrence. In all the rest, sweating completely disappeared and they were totally satisfied with the surgery (96.42%). Temporary compensatory sweating appeared in 57.14% of the cases, a collateral effect that did not change their level of satisfaction. Conclusions. Palmar hyperhidrosis can be a major problem for socialization and quality of life for the child or adolescent who suffers it. Thoracoscopic sympatholysis in the pediatric patient is an effective treatment, highly resolutive and with low morbidity. Despite compensatory sweating, patients are highly satisfied with the results of surgical treatment

Otitis Media: Long-Term Effect on Central Auditory Nervous System.

OBJECTIVES: To analyze the central auditory nervous system function through behavioral and electrophysiological tests in children with a history of otitis media and subsequent bilateral tubes placement surgery. METHODS: The participants were divided into two groups between eight and 14 years old: control group (CG) consisted of 40 children with no history of otitis media; experimental group (EG) consisted of 50 children with documented history of otitis media and undertook a surgery for bilateral tubes placement. All children completed audiological evaluation (audiometry, speech audiometry, and immittance audiometry), behavioral evaluation (tests: dichotic digits, synthetic sentence identification with ipsilateral competing message, gaps-in-noise, frequency pattern), and electrophysiological evaluation (Auditory Brainstem Response, ABR, Frequency Following Response, FFR (verbal), and Long Latency Auditory Evoked Potential, LLAEP). RESULTS: The EG group showed significantly poorer performance (p<0.001) than the CG for all auditory abilities studied. The results revealed significant latency delays and reduced amplitude (p<0.05) of waves III and V for ABR; significant latency delay was seen of potentials P2, N2, and P300 for LLAEP; significant latency delays and reduced amplitude (p<0.05) were observed for FFR in children with a history of otitis media. CONCLUSION: The results demonstrate negative effect of otitis media in the auditory abilities and electrophysiological measures in children with a history of otitis media.

Histological characteristics of eosinophilic myenteric ganglionitis: an under-recognised cause of chronic intestinal pseudo-obstruction.

Eosinophilic myenteric ganglionitis (EMG) is characterised by eosinophilic infiltration of the myenteric plexus. EMG has been rarely reported as a cause of chronic intestinal pseudo-obstruction (CIPO), and its histopathological features are not fully elucidated. We analysed seven patients with CIPO. Three of them were diagnosed with EMG and four patients were categorised as non-EMG. Clinicopathological features were similar in both groups. These features included subtle to mild lymphocytic infiltration at the myenteric ganglia/muscularis propria, loss of myenteric ganglions and interstitial cells of Cajal (ICC), and no significant findings in the mucosa. The exceptions were moderate to severe degree of eosinophilic infiltration at the myenteric ganglia/muscularis propria in EMG. Functional gastrointestinal obstruction may be associated with inflammatory cell infiltration at the myenteric ganglia/muscularis propria, leading to subsequent hypoganglionosis and deficiency of ICC in EMG. Pathologists and clinicians should be aware of this distinction during differential diagnosis of patients with CIPO.

Carotid Body Ablation: a New Target to Address Central Autonomic Dysfunction.

PURPOSE OF REVIEW: An abnormal heightened carotid body (CB) chemoreflex, which produces autonomic dysfunction and sympathetic overactivation, is the common hallmark of obstructive sleep apnea (OSA), resistant hypertension, systolic heart failure (HF), and cardiometabolic diseases. Accordingly, it has been proposed that the elimination of the CB chemosensory input to the brainstem may reduce the autonomic and cardiorespiratory alterations in sympathetic-associated diseases in humans. RECENT FINDINGS: A growing body of evidence obtained in preclinical animal models support that an enhanced CB discharge produces sympathetic hyperactivity, baroreflex sensitivity and heart rate variability impairment, breathing instability, hypertension, and insulin resistance. The elimination CB chemosensory input reduces the sympathetic hyperactivity, the elevated arterial blood pressure in OSA and hypertensive models, abolishes breathing instability and improves animal survival in HF models, and restores insulin tolerance in metabolic models. These results highlight the role played by the enhanced CB drive in the progression of sympathetic-related diseases and support the proposal that the surgical ablation of the CB is useful to restore the autonomic balance and normal cardiorespiratory function in humans. Accordingly, the CB ablation has been used in pilot human studies as a therapeutic treatment for resistant hypertension and HF-induced sympathetic hyperactivity. In this review, I will discuss the supporting evidence for a crucial contribution of the CB in the central autonomic dysfunction and the pros and cons of the CB ablation as a therapy to revert autonomic overactivation. The CB ablation could be a useful method to reverse the enhanced chemoreflex in HF and severe hypertension, but caution is required before extensive use of bilateral CB ablation, which abolished ventilatory responses to hypoxia and may impair baroreceptor function.

Alternative approach to autonomic instability of very severe tetanus: stellate ganglion block / Abordagem alternativa para instabilidade autonômica no tétano muito grave: bloqueio do gânglio estrelado

Abstract Tetanus is an acute and deadly disease caused by Clostridium tetani. A 60-year-old male came to hospital after he injured his thumb with a knife. Ten days later, he returned to hospital with abdominal spasms. He was vaccinated against tetanus and referred to intensive care unit. As he had sudden difficulty in respiration, he was entubated. Midazolam, magnesium and esmolol infusion were started. Next day, muscle spasms progressed all over his body. Midazolam infusion was replaced with propofol and vecuronium. At the third day, morphine infusion was added. At the 16th day, dexmedetomidine infusion was started. At the 20th day, ultrasound guided stellate ganglion block was performed to denervate sympathetic activity. The block was performed three times in a 10 days period. At the 30th, the patient recovered from very severe tetanus. The mainstay of tetanus treatment is adequate sedation. Neuroaxial blocks were proved to be effective for the control of sympathetic overactivity in recent years. Circulatory collapse remains to be the major cause of death. The mechanism is unclear but altered myocardial function is thought to be related to changeable catecholamine levels. The effect of stellate ganglion block on sympathetic and parasympathetic control of heart has been studied since the beginning of 1980s. Recently Scanlon et al. reported they treated a patient with medically refractory ventricular arrhythmias by ultrasound guided bilateral stellate ganglion block. In conclusion, stellate ganglion block can be an alternative method when the autonomic storm cannot be controlled with medical agents.

Resumo O tétano é uma doença aguda e fatal causada por Clostridium tetani. Um homem de 60 anos deu entrada em nosso hospital depois de ferir o polegar com uma faca. Após dez dias, deu entrada no hospital com espasmos abdominais; foi vacinado contra tétano e enviado para a unidade de terapia intensiva. Como apresentava dificuldade súbita na respiração, foi intubado. Foi iniciada uma infusão de midazolam, magnésio e esmolol. No dia seguinte, os espasmos musculares progrediram para o corpo todo. A infusão de midazolam foi substituída por propofol e vecurônio. No terceiro dia, foi adicionada morfina à infusão. No 16º dia, foi iniciada uma infusão de dexmedetomidina. No 20º dia, o bloqueio do gânglio estrelado guiado por ultrassom foi realizado para dessensibilizar a atividade simpática. O bloqueio foi feito três vezes em dez dias. No 30º dia, o paciente recuperou-se de um tétano muito grave. A base do tratamento de tétano é a sedação adequada. Nos últimos anos, os bloqueios neuraxiais provaram ser eficazes para o controle da hiperatividade simpática. O colapso circulatório continua a ser a principal causa de morte. O mecanismo não está claro, mas se acredita que a função alterada do miocárdio esteja relacionada com os níveis de catecolaminas mutáveis. O efeito do bloqueio do gânglio estrelado sobre o controle simpático e parassimpático do coração tem sido estudado desde o início da década de 1980. Recentemente, Scanlon et al. relataram o tratamento de um paciente com arritmia ventricular refratária a medicamentos com bloqueio bilateral do gânglio estrelado guiado por ultrassom. Em conclusão, o bloqueio do gânglio estrelado pode ser um método opcional quando a tempestade autonômica não pode ser controlada com agentes medicamentosos.

Modulation of renal sympathetic innervation: recent insights beyond blood pressure control.

Renal afferent and efferent sympathetic nerves are involved in the regulation of blood pressure and have a pathophysiological role in hypertension. Additionally, several conditions that frequently coexist with hypertension, such as heart failure, obstructive sleep apnea, atrial fibrillation, renal dysfunction, and metabolic syndrome, demonstrate enhanced sympathetic activity. Renal denervation (RDN) is an approach to reduce renal and whole body sympathetic activation. Experimental models indicate that RDN has the potential to lower blood pressure and prevent cardio-renal remodeling in chronic diseases associated with enhanced sympathetic activation. Studies have shown that RDN can reduce blood pressure in drug-naïve hypertensive patients and in hypertensive patients under drug treatment. Beyond its effects on blood pressure, sympathetic modulation by RDN has been shown to have profound effects on cardiac electrophysiology and cardiac arrhythmogenesis. RDN can display anti-arrhythmic effects in a variety of animal models for atrial fibrillation and ventricular arrhythmias. The first non-randomized studies demonstrate that RDN may promote the maintenance of sinus rhythm following catheter ablation in patients with atrial fibrillation. Registry data point towards a beneficial effect of RDN to prevent ventricular arrhythmias in patients with heart failure and electrical storm. Further large randomized placebo-controlled trials are needed to confirm the antihypertensive and anti-arrhythmic effects of RDN. Here, we will review the current literature on anti-arrhythmic effects of RDN with the focus on atrial fibrillation and ventricular arrhythmias. We will discuss new insights from preclinical and clinical mechanistic studies and possible clinical implications of RDN.

[Alternative approach to autonomic instability of very severe tetanus: stellate ganglion block]. / Abordagem alternativa para instabilidade autonômica no tétano muito grave: bloqueio do gânglio estrelado.

Tetanus is an acute and deadly disease caused by Clostridium tetani. A 60-year-old male came to hospital after he injured his thumb with a knife. Ten days later, he returned to hospital with abdominal spasms. He was vaccinated against tetanus and referred to intensive care unit. As he had sudden difficulty in respiration, he was entubated. Midazolam, magnesium and esmolol infusion were started. Next day, muscle spasms progressed all over his body. Midazolam infusion was replaced with propofol and vecuronium. At the third day, morphine infusion was added. At the 16th day, dexmedetomidine infusion was started. At the 20th day, ultrasound guided stellate ganglion block was performed to denervate sympathetic activity. The block was performed three times in a 10 days period. At the 30th the patient recovered from very severe tetanus. The mainstay of tetanus treatment is adequate sedation. Neuroaxial blocks were proved to be effective for the control of sympathetic overactivity in recent years. Circulatory collapse remains to be the major cause of death. The mechanism is unclear but altered myocardial function is thought to be related to changeable catecholamine levels. The effect of stellate ganglion block on sympathetic and parasympathetic control of heart has been studied since the beginning of 1980s. Recently Scanlon et al. reported they treated a patient with medically refractory ventricular arrhythmias by ultrasound guided bilateral stellate ganglion block. In conclusion, stellate ganglion block can be an alternative method when the autonomic storm cannot be controlled with medical agents.

Reparación de lesiones en nervios mediante el implante de prótesis obtenidas de segmentos acelulares de nervio isogénico / Repair of nerve injury by implanting prostheses obtained from isogenic acellular nerve segments

Introducción. Cuando se produce una sección nerviosa con separación significativa de los cabos es necesario utilizar una prótesis, a modo de puente, para suturarlos. La mejor prótesis es un segmento de nervio autógeno, pero presenta importantes inconvenientes. Nuestro objetivo es comparar la eficacia de la sutura simple con la tubulización para el implante de una prótesis de nervio isogénico descelularizado. Material y método. Se utilizan 4 grupos de ratas Wistar. Grupo 0: animales donantes de nervio ciático. Grupo 1: recibió el implante con sutura término-terminal. Grupo 2: recibió el implante dentro de un tubo de ??-caprolactona. Grupo 3: lo recibió en un tubo de poliláctico-co-glicólico. Se evaluó la función motora (índice ciático) y la extensión de la regeneración (estudio histológico) a las 3 semanas del implante. Resultados. La regeneración ha sido irregular en los 3 grupos experimentales. En todos hay implantes en los que las fibras nerviosas regeneran la longitud máxima estudiada (15mm) y otros en los que la regeneración es muy escasa. La longitud media de regeneración es mayor en el grupo de sutura directa (G1), aunque la velocidad es similar en los 3. El grupo 1 muestra el mayor porcentaje de regeneración, aunque la variabilidad de los resultados impide que esta diferencia alcance significación estadística. No hemos hallado diferencias significativas entre los dos grupos con tubos de diferentes polímeros. Conclusión. Para implantar prótesis de nervios isogénicos descelularizados es más eficaz, en nuestras condiciones experimentales, la sutura término-terminal que los tubos de polímeros biocompatibles (AU)

Introduction. When a nerve section with a significant gap occurs, it is necessary to use a prosthesis to suture it. To date an autologous nerve segment graft appears to be the best treatment; but it has several important disadvantages. Our goal is to study the effectiveness of an isogenic acellular nerve prosthesis comparing a simple suture with tubulisation. Material and method. Four groups of Wistar rats were used. The animals in Group 0 served as donors of nerve segments to graft. Group 1 received the implant with an end-to-end suture. In group 2, the implant was sutured inside an ??-caprolactone tube. Group 3 received it in a polylactic-co-glycolic acid tube. We evaluated the motor function (sciatic index and step test in motion), and the regeneration length by histological study of regeneration, after a maximum of 3 weeks. Results. Regeneration was uneven in the three groups. In all groups, there were implants with regenerated nerve fibres at the maximum studied length (15mm) and others where regeneration was scarce. The mean regeneration length was greater in the direct end-to-end suture group (G1), although the regeneration speed was similar in the three groups. Group 1 showed the highest percentage of regeneration, but the variability of results prevents this difference reaching statistical significance. We found no significant differences between the two groups with polymer tubes. Conclusion. For the implantation of isogenic acellular nerve prosthesis, under our experimental conditions, the direct end-to-end suture was more effective than when it isprotected with biopolymer tubes (AU)

Extracranial schwannoma in the carotid space: A retrospective review of 91 cases.

BACKGROUND: Schwannomas of the vagus nerve and cervical sympathetic nerve are rare; hence, only limited information exists regarding their diagnosis and clinical management. METHODS: We conducted a retrospective review of the clinical features, imaging studies, and treatment results of patients with schwannoma of the vagus nerve and schwannoma of the sympathetic nerve. RESULTS: Of 91 patients, 91% (n = 83) were preoperatively diagnosed with schwannoma tumors. Using the hyoid bone as an anatomic landmark, the location of the schwannoma of the vagus nerve in the carotid space was significantly different to the location of schwannoma of the sympathetic nerve (p = .003). Although 52 of the 76 patients followed up (68%) had postoperative nerve weaknesses, 13 patients (50%) and 14 patients (53.8%), respectively, fully recovered from schwannoma of the vagus nerve and schwannoma of the sympathetic nerve. CONCLUSION: In the carotid space, schwannomas of the vagus nerve are usually located below the hyoid bone, whereas schwannomas of the sympathetic nerve more commonly arise from the suprahyoid compartment. Accurate preoperative diagnosis and the intracapsular enucleation surgical approach decreased the incidence of postoperative morbidity. © 2016 Wiley Periodicals, Head Neck 39: 42-47, 2017.

Sympathetic Chain Schwannoma Resembling Carotid Body Tumour.

Schwannomas are rare, benign nerve sheath tumours of parapharyngeal space. Differential diagnosis should include salivary gland tumours, paragangliomas, neurofibromas, and metastatic lymph nodes. The tumours may arise from vagus nerve and cervical sympathetic chain (CSC). Diagnosis is usually made by imaging techniques: contrast CT, magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA). Fine needle aspiration cytology (FNAC) is useful diagnostic procedure but poor results are seen in neurogenic tumours. Rarely, a vascular CSC schwannoma at the level of carotid arteries bifurcation may mimic carotid body tumour (CBT) on imaging techniques, especially if they are vascular, causing splaying of internal and external carotid arteries. Clinically patient was asymptomatic except for a pulsatile swelling in neck for 5 years. The presented case resembled CBTclinically, on ultrasound and on imaging techniques causing splaying of carotid arteries. FNAC was inconclusive and was always hemorrhagic. During operation, it was found to be CSC schwannoma just posterior to carotid body. CSC was sacrificed and patient developed Horner syndrome postoperatively.

[Features of vegetative dysfunction development in patients with cholelithiasis before and after cholecystectomy].

UNLABELLED: The aim of the present study was a comprehensive study of the features autonomic nervous system in cholelithiasis before and after cholecystectomy. MATERIALS AND METHODS: 88 patients aged 40 to 60 years. 55 patients with cholelithiasis before and after laparoscopic cholecystectomy (CE). Control group consisted of 33 patients of similar age and gender. To investigate the function of the autonomic nervous system were evaluated themes complaint history, physical examination data, and used less Tod mathematical analysis of cardiac rhythm by Baevsky RM using the author's computer-related programs "Korveg" with the definition of heart rate variability and table--Solovevoj Wayne. RESULTS AND CONCLUSIONS: The study of autonomic provision in rest and during exercise were increased sympathetic activity, exceeding those in the control group. Studies indicate a tendency to sympathicotonia patients with gall stones before and after cholecystectomy, which is enhanced adaptive compensatory mechanisms to maintain homeostasis in the body. Identify logical connections between clinical and autonomic indicators will predict flow pattern cholelithiasis before and after cholecystectomy, as well as pick individual therapy for each patient taking into account the autonomic features that can be widely used in practical medicine--not.

Gastrointestinal autonomic nerve tumour of jejunum presenting as a perforated mass.

Gastrointestinal autonomic nerve tumour (GANT) is a rare mesenchymal neoplasm of the gastrointestinal tract arising from the neural plexus of the intestinal wall. Herein, we present a 70-year-old male patient presenting with a clinical picture of acute abdomen. Examination of the specimen obtained from the small bowel by means of complete resection revealed a relatively soft submucosal mass measuring 4.5 x 3 cm in size with spindle morphology and high mitotic activity (> 10 mitoses per 50 high-power fields). The tumour cells were strong positive for c-kit (CD117), S-100 protein and glial fibrillary acidic protein (GFAP), but did not harbour mutations in the c-kit and PDGFR genes. The diagnosis was based on light microscopy and immunohistochemical verification. We started tyrosine kinase inhibitor 400 mg/day. The patient is currently alive without metastasis at 28 months postoperatively. He is under close follow-up and survival data of the patient will be presented in the later studies.

Autonomic nervous system activity in diabetic and healthy obese female subjects and the effect of distinct weight loss strategies.

OBJECTIVE: Obesity and type 2 diabetes mellitus (T2DM) are reported to be associated with relative overactivity of the sympathetic nervous system (SNS), which is reversible by weight loss. However, direct effects of weight loss by calorie restriction vs Roux-en-Y gastric bypass (RYGB) on SNS overactivity were not studied in parallel. This study compared the effects of RYGB vs restrictive weight loss in obese patients with normal glucose tolerance (NGT) and with T2DM on SNS function as measured by heart rate variability (HRV). DESIGN AND METHODS: Lean (n=12), obese NGT (n=27) and T2DM (n=27) subjects were included in this study. Weight reduction in NGT subjects was achieved by gastric banding (GB) or RYGB and in T2DM subjects by RYGB or high-protein very-low-calorie diet (VLCD). HRV analysis was performed and blood samples were taken at baseline, 3 weeks and 3 months after intervention. RESULTS: At baseline, T2DM subjects showed SNS overactivity and NGT subjects showed similar, but non-significant, findings when compared with lean controls. Weight loss after 3 weeks was comparable in all treatment groups, whereas after 3 months, weight loss was most in VLCD and RYGB subjects. RYGB and VLCD treatment reduced SNS activity within 3 weeks in T2DM patients. After 3 months, restoration to normal autonomic nervous system activity was evident for all groups, except for the NGT-GB group. CONCLUSION: We can conclude that SNS overactivity is more pronounced in obese T2DM subjects when compared with NGT subjects. Reduction of SNS overactivity coincides with weight loss with the time-course of reduction dependent on the type of intervention. Surgery or caloric restriction may transiently induce SNS overactivity but do not prevent a direct restoration of sympathovagal balance.