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Davenport TE, Blitshteyn S, Clague-Baker N, Davies-Payne D, Treisman GJ, Tyson SF. Long COVID Is Not a Functional Neurologic Disorder. J Pers Med 2024; 14:799. [PMID: 39201991 PMCID: PMC11355889 DOI: 10.3390/jpm14080799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 09/03/2024] Open
Abstract
Long COVID is a common sequela of SARS-CoV-2 infection. Data from numerous scientific studies indicate that long COVID involves a complex interaction between pathophysiological processes. Long COVID may involve the development of new diagnosable health conditions and exacerbation of pre-existing health conditions. However, despite this rapidly accumulating body of evidence regarding the pathobiology of long COVID, psychogenic and functional interpretations of the illness presentation continue to be endorsed by some healthcare professionals, creating confusion and inappropriate diagnostic and therapeutic pathways for people living with long COVID. The purpose of this perspective is to present a clinical and scientific rationale for why long COVID should not be considered as a functional neurologic disorder. It will begin by discussing the parallel historical development of pathobiological and psychosomatic/sociogenic diagnostic constructs arising from a common root in neurasthenia, which has resulted in the collective understandings of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and functional neurologic disorder (FND), respectively. We will also review the case definition criteria for FND and the distinguishing clinical and neuroimaging findings in FND vs. long COVID. We conclude that considering long COVID as FND is inappropriate based on differentiating pathophysiologic mechanisms and distinguishing clinical findings.
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Affiliation(s)
- Todd E. Davenport
- Department of Physical Therapy, University of the Pacific, Stockton, CA 95211, USA
- Workwell Foundation, Santa Rosa, CA 95403, USA
| | - Svetlana Blitshteyn
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, NY 14203, USA
- Dysautonomia Clinic, Williamsville, NY 14221, USA
| | - Nicola Clague-Baker
- School of Allied Health Professions and Nursing, Institute of Population Health, University of Liverpool, Liverpool L69 7ZX, UK
| | - David Davies-Payne
- Department of Radiology, Starship Children’s Hospital, Auckland 1023, New Zealand
| | - Glenn J. Treisman
- Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA;
| | - Sarah F. Tyson
- School of Health Sciences, University of Manchester, Manchester M14 4PX, UK;
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2
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Zawadka-Kunikowska M, Cieślicka M, Klawe JJ, Tafil-Klawe M, Kaźmierczak W, Rzepiński Ł. Frequency and severity of autonomic dysfunction assessed by objective hemodynamic responses and patient-reported symptoms in individuals with myasthenia gravis. Front Neurosci 2024; 18:1415615. [PMID: 39099636 PMCID: PMC11295281 DOI: 10.3389/fnins.2024.1415615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/10/2024] [Indexed: 08/06/2024] Open
Abstract
Introduction Myasthenia gravis (MG), a rare autoimmune disorder, poses diagnostic and management challenges, with increasing incidence in Europe and significant impact on patient quality of life. Despite prevalent autonomic symptoms, comprehensive assessments integrating subjective and objective measures are lacking. We aimed to investigate the prevalence and severity of autonomic dysfunction in patients with MG and healthy controls (HCs). Materials and methods We used beat-to-beat hemodynamic responses during standardized autonomic function tests (AFTs) and the Composite Autonomic Symptom Score 31 (COMPASS-31) questionnaire. Study participants including, 53 patients with MG and 30 age- and sex matched HCs underwent standardized cardiovascular AFTs and completed the COMPASS-31 questionnaire. Patients were categorized into Non-CAN and CAN groups based on their Cardiovascular Autonomic Neuropathy (CAN) status, as evaluated using the Composite Autonomic Scoring Scale (CASS). During the AFTs, cardiovascular parameters including heart rate, systolic blood pressure (BP), diastolic BP, mean BP, stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR) were measured. Results Twenty patients with MG (38%) exhibited mild CAN (CASS ≥2) with a median total CASS score of 1.00 and CASS 0.00 in HCs. Adrenergic impairment was observed in 27 patients (52%), with 13 patients (24.5%) exhibiting longer pressure recovery time after Valsalva maneuver (VM). Cardiovagal impairment was evident in 71% of patients, with abnormal results observed in 39.6% for the deep breathing test and 56.6% for the VM. CAN MG showed worse scores than HCs for the total COMPASS-31 (p < 0.001), orthostatic (OI) (p < 0.001), secretomotor (p = 0.004), and pupillomotor domains (p = 0.004). Total COMPASS-31 and OI scores were correlated with worse disease outcomes (disease duration, severity), hemodynamic parameter changes (SV, CO, TPR) during phase II late of VM, and with changes (Δtilt-supine) in Δsystolic BP, Δdiastolic BP, Δmean BP, ΔTPR during head-up-tilt test, but not with CASS score. Conclusion Our findings demonstrate mild cardiovascular autonomic impairment in adrenergic and cardiovagal domains in patients with MG. Additionally, patient-reported autonomic symptoms correlated with hemodynamic changes during AFTs and worse disease outcomes and not with the grade of autonomic abnormalities. Incorporating beat-to-beat hemodynamics during AFTs may offer further insights for characterizing orthostatic intolerance symptoms in MG group.
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Affiliation(s)
- Monika Zawadka-Kunikowska
- Department of Human Physiology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Mirosława Cieślicka
- Department of Human Physiology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Jacek J. Klawe
- Department of Hygiene, Epidemiology, Ergonomy and Postgraduate Education, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Małgorzata Tafil-Klawe
- Faculty of Medical Sciences, Bydgoszcz University of Science and Technology, Bydgoszcz, Poland
| | - Wojciech Kaźmierczak
- Department of Human Physiology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland
- Institute of Physiology and Pathology of Hearing, Warsaw, Poland
| | - Łukasz Rzepiński
- Sanitas - Neurology Outpatient Clinic, Bydgoszcz, Poland
- Department of Neurology, 10th Military Research Hospital and Polyclinic, Bydgoszcz, Poland
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3
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Mylius V, Zenev E, Brook CS, Brugger F, Maetzler W, Gonzenbach R, Paraschiv-Ionescu A. Imbalance and Falls in Patients with Parkinson's Disease: Causes and Recent Developments in Training and Sensor-Based Assessment. Brain Sci 2024; 14:625. [PMID: 39061366 PMCID: PMC11274436 DOI: 10.3390/brainsci14070625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/16/2024] [Accepted: 05/28/2024] [Indexed: 07/28/2024] Open
Abstract
Imbalance and falls in patients with Parkinson's disease (PD) do not only reduce their quality of life but also their life expectancy. Aging-related symptoms as well as disease-specific motor and non-motor symptoms contribute to these conditions and should be treated when appropriate. In addition to an active lifestyle, advanced exercise training is useful and effective, especially for less medically responsive symptoms such as freezing of gait and postural instability at advanced stages. As treadmill training in non-immersive virtual reality, including dual tasks, significantly reduced the number of falls in PD patients, the mechanism(s) explaining this effect should be further investigated. Such research could help to select the most suitable patients and develop the most effective training protocols based on this novel technology. Real-life digital surrogate markers of mobility, such as those describing aspects of endurance, performance, and the complexity of specific movements, can further improve the quality of mobility assessment using wearables.
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Affiliation(s)
- Veit Mylius
- Department of Neurology, Center for Neurorehabilitation, 7317 Valens, Switzerland; (E.Z.); (C.S.B.); (R.G.)
- Department of Neurology, Philipps University, 35043 Marburg, Germany
| | - Elisabeth Zenev
- Department of Neurology, Center for Neurorehabilitation, 7317 Valens, Switzerland; (E.Z.); (C.S.B.); (R.G.)
| | - Caroline S. Brook
- Department of Neurology, Center for Neurorehabilitation, 7317 Valens, Switzerland; (E.Z.); (C.S.B.); (R.G.)
- Department of Neurology, University of Bern, Inselspital Bern, 3010 Bern, Switzerland
| | - Florian Brugger
- Department of Neurology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland;
| | - Walter Maetzler
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel University, 24105 Kiel, Germany;
| | - Roman Gonzenbach
- Department of Neurology, Center for Neurorehabilitation, 7317 Valens, Switzerland; (E.Z.); (C.S.B.); (R.G.)
| | - Anisoara Paraschiv-Ionescu
- Signal Processing Laboratory 5, Ecole Polytechnique Federale de Lausanne (EPFL), 1015 Lausanne, Switzerland;
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Fortrat JO. Purported Self-Organized Criticality of the Cardiovascular Function: Methodological Considerations for Zipf's Law Analysis. ENTROPY (BASEL, SWITZERLAND) 2024; 26:496. [PMID: 38920505 PMCID: PMC11203110 DOI: 10.3390/e26060496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/01/2024] [Accepted: 06/04/2024] [Indexed: 06/27/2024]
Abstract
Self-organized criticality is a universal theory for dynamical systems that has recently been applied to the cardiovascular system. Precise methodological approaches are essential for understanding the dynamics of cardiovascular self-organized criticality. This study examines how the duration and quality of data recording affect the analysis of cardiovascular self-organized criticality, with a focus on the beat-by-beat heart rate variability time series obtained from seven healthy subjects in a standing position. Drawing a Zipf diagram, we evaluated the distribution of cardiovascular events of bradycardia and tachycardia. We identified tipping points for the distribution of both bradycardia and tachycardia events. By varying the recording durations (1, 2, 5, 10, 20, 30, and 40 min) and sampling frequencies (500, 250, and 100 Hz), we investigated their influence on the observed distributions. While shorter recordings can effectively capture cardiovascular events, they may underestimate the variables describing their distribution. Additionally, the tipping point of the Zipf distribution differs between bradycardia and tachycardia events. Comparisons of the distribution of bradycardia and tachycardia events should be conducted using long data recordings. Utilizing devices with lower sampling frequencies may compromise data fidelity. These insights contribute to refining experimental protocols and advancing our understanding of the complex dynamics underlying cardiovascular regulation.
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Affiliation(s)
- Jacques-Olivier Fortrat
- Université d’Angers, CHU Angers, Inserm, CNRS, MITOVASC, Équipe CARME, SFR ICAT, 49000 Angers, France; ; Tel.: +33-2-41-35-36-89; Fax: +33-2-41-35-50-42
- Médecine Vasculaire, Centre Hospitalier Universitaire d’Angers, 4. rue Larrey, 49933 Angers Cedex 01, France
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Cheshire WP, Dudenkov DV, Munipalli B. Tilt Table Testing. JAMA 2024; 331:1494-1495. [PMID: 38602671 DOI: 10.1001/jama.2024.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
This Diagnostic Test Interpretation uses a patient case to illustrate tilt table testing, useful for evaluating patients with syncope of unknown cause or postural orthostatic tachycardia syndrome (POTS).
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Affiliation(s)
- William P Cheshire
- Division of Autonomic Neurology, Department of Neurology, Mayo Clinic, Jacksonville, Florida
| | - Daniel V Dudenkov
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - Bala Munipalli
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, Florida
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Liu M, Wang Z, Shang H. Multiple system atrophy: an update and emerging directions of biomarkers and clinical trials. J Neurol 2024; 271:2324-2344. [PMID: 38483626 PMCID: PMC11055738 DOI: 10.1007/s00415-024-12269-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 04/28/2024]
Abstract
Multiple system atrophy is a rare, debilitating, adult-onset neurodegenerative disorder that manifests clinically as a diverse combination of parkinsonism, cerebellar ataxia, and autonomic dysfunction. It is pathologically characterized by oligodendroglial cytoplasmic inclusions containing abnormally aggregated α-synuclein. According to the updated Movement Disorder Society diagnostic criteria for multiple system atrophy, the diagnosis of clinically established multiple system atrophy requires the manifestation of autonomic dysfunction in combination with poorly levo-dopa responsive parkinsonism and/or cerebellar syndrome. Although symptomatic management of multiple system atrophy can substantially improve quality of life, therapeutic benefits are often limited, ephemeral, and they fail to modify the disease progression and eradicate underlying causes. Consequently, effective breakthrough treatments that target the causes of disease are needed. Numerous preclinical and clinical studies are currently focusing on a set of hallmarks of neurodegenerative diseases to slow or halt the progression of multiple system atrophy: pathological protein aggregation, synaptic dysfunction, aberrant proteostasis, neuronal inflammation, and neuronal cell death. Meanwhile, specific biomarkers and measurements with higher specificity and sensitivity are being developed for the diagnosis of multiple system atrophy, particularly for early detection of the disease. More intriguingly, a growing number of new disease-modifying candidates, which can be used to design multi-targeted, personalized treatment in patients, are being investigated, notwithstanding the failure of most previous attempts.
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Affiliation(s)
- Min Liu
- Department of Neurology, Laboratory of Neurodegenerative Disorders, Rare Disease Center, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, 610041, Sichuan, China
| | - Zhiyao Wang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, Rare Disease Center, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, 610041, Sichuan, China
| | - Huifang Shang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, Rare Disease Center, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, 610041, Sichuan, China.
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Cantrell C, Reid C, Walker CS, Stallkamp Tidd SJ, Zhang R, Wilson R. Post-COVID postural orthostatic tachycardia syndrome (POTS): a new phenomenon. Front Neurol 2024; 15:1297964. [PMID: 38585346 PMCID: PMC10998446 DOI: 10.3389/fneur.2024.1297964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 03/12/2024] [Indexed: 04/09/2024] Open
Abstract
Background The impact of COVID-19 has been far-reaching, and the field of neurology is no exception. Due to the long-hauler effect, a variety of chronic health consequences have occurred for some post-COVID patients. A subset of these long-hauler patients experienced symptoms of autonomic dysfunction and tested positive for postural orthostatic tachycardia syndrome (POTS) via autonomic testing. Methods We conducted a chart review of a convenience sample from patients seen by neurologists at our tertiary care center for suspicion of post-COVID POTS. Patients included in our study had clearly defined POTS based on clinical criteria and positive tilt table test, were 81.25% female, and had an average age of approximately 36. Out of 16 patients, 12 had a confirmed positive COVID test result, with the remaining 4 having strong clinical suspicion for COVID infection. Our analysis examined the most bothersome 3 symptoms affecting each patient per the neurologist's note at their initial visit for post-COVID POTS, clinical presentation, comorbidities, neurological exam findings, autonomic testing results, and COMPASS-31 autonomic questionnaire and PROMIS fatigue survey results. Results Palpitations (68.75%) and fatigue (62.5%) were the most common of the impactful symptoms reported by patients in their initial Cleveland Clinic neurology visit. The most frequent comorbidities in our sample were chronic migraines (37.5%), irritable bowel syndrome (IBS) (18.75%), and Raynaud's (18.75%). Neurological exam findings and autonomic testing results other than tilt table yielded variable findings without clear trends. Survey results showed substantial autonomic symptom burden (COMPASS-31 autonomic questionnaire average score 44.45) and high levels of fatigue (PROMIS fatigue survey average score 64.64) in post-COVID POTS patients. Conclusion Our sample of post-COVID POTS patients are similar to the diagnosed POTS general population including in comorbidities and autonomic testing. Fatigue was identified by patients as a common and debilitating symptom. We hope that our study will be an early step toward further investigation of post-COVID POTS with focus on the trends identified in this chart review.
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Affiliation(s)
| | - Conor Reid
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, United States
| | - Claudia S. Walker
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, United States
| | | | - Ryan Zhang
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Robert Wilson
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, United States
- Department of Neuromuscular Medicine, Cleveland Clinic Foundation, Cleveland, OH, United States
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8
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van Zanten S, Sutton R, Hamrefors V, Fedorowski A, de Lange FJ. Tilt table testing, methodology and practical insights for the clinic. Clin Physiol Funct Imaging 2024; 44:119-130. [PMID: 37839043 DOI: 10.1111/cpf.12859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/18/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023]
Abstract
Tilt table testing (TTT) has been used for decades to study short-term blood pressure (BP) and heart rate regulation during orthostatic challenges. TTT provokes vasovagal reflex in many syncope patients as a background of widespread use. Despite the availability of evidence-based practice syncope guidelines, proper application and interpretation of TTT in the day-to-day care of syncope patients remain challenging. In this review, we offer practical information on what is needed to perform TTT, how results should be interpreted including the Vasovagal Syncope International Study classification, why syncope induction on TTT is necessary in patients with unexplained syncope and on indications for TTT in syncope patient care. The minimum requirements to perform TTT are a tilt table with an appropriate tilt-down time, a continuous beat-to-beat BP monitor with at least three electrocardiogram leads and trained staff. We emphasize that TTT remains a valuable asset that adds to history building but cannot replace it, and highlight the importance of recognition when TTT is abnormal even without syncope. Acknowledgement by the patient/eyewitness of the reproducibility of the induced attack is mandatory in concluding a diagnosis. TTT may be indicated when the initial syncope evaluation does not yield a certain, highly likely, or possible diagnosis, but raises clinical suspicion of (1) reflex syncope, (2) orthostatic hypotension (OH), (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT in the patient with a certain, highly likely or possible diagnosis of reflex syncope, may be to educate patients on prodromes. In patients with reflex syncope with OH TTT can be therapeutic to recognize hypotensive symptoms causing near-syncope to perform physical countermanoeuvres for syncope prevention (biofeedback). Detection of hypotensive susceptibility requiring therapy is of special value.
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Affiliation(s)
- Steven van Zanten
- Department of Cardiology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Richard Sutton
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Campus, London, UK
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Thijs RD, Raj SR. How low can you go: heart rate dynamics in between vasovagal syncope. Clin Auton Res 2024; 34:17-19. [PMID: 38141132 DOI: 10.1007/s10286-023-01005-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023]
Affiliation(s)
- Roland D Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands.
- Department of Neurology, Leiden University Medical Centre, PO box 9600, 2300 RC, Leiden, The Netherlands.
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Kell DB, Khan MA, Kane B, Lip GYH, Pretorius E. Possible Role of Fibrinaloid Microclots in Postural Orthostatic Tachycardia Syndrome (POTS): Focus on Long COVID. J Pers Med 2024; 14:170. [PMID: 38392604 PMCID: PMC10890060 DOI: 10.3390/jpm14020170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/16/2024] [Accepted: 01/27/2024] [Indexed: 02/24/2024] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a common accompaniment of a variety of chronic, inflammatory diseases, including long COVID, as are small, insoluble, 'fibrinaloid' microclots. We here develop the argument, with accompanying evidence, that fibrinaloid microclots, through their ability to block the flow of blood through microcapillaries and thus cause tissue hypoxia, are not simply correlated with but in fact, by preceding it, may be a chief intermediary cause of POTS, in which tachycardia is simply the body's exaggerated 'physiological' response to hypoxia. Similar reasoning accounts for the symptoms bundled under the term 'fatigue'. Amyloids are known to be membrane disruptors, and when their targets are nerve membranes, this can explain neurotoxicity and hence the autonomic nervous system dysfunction that contributes to POTS. Taken together as a system view, we indicate that fibrinaloid microclots can serve to link POTS and fatigue in long COVID in a manner that is at once both mechanistic and explanatory. This has clear implications for the treatment of such diseases.
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Affiliation(s)
- Douglas B Kell
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- The Novo Nordisk Foundation Centre for Biosustainability, Building 220, Chemitorvet 200, Technical University of Denmark, 2800 Kongens Lyngby, Denmark
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch Private Bag X1, Matieland 7602, South Africa
| | - Muhammed Asad Khan
- Directorate of Respiratory Medicine, Manchester University Hospitals, Wythenshawe Hospital, Manchester M23 9LT, UK
| | - Binita Kane
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- Manchester University Foundation Trust and School of Biological Sciences, University of Manchester, Manchester M13 9PL, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
| | - Etheresia Pretorius
- Department of Biochemistry, Cell and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Crown St, Liverpool L69 7ZB, UK
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch Private Bag X1, Matieland 7602, South Africa
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Faisal A. Understanding fatigue and pruritus in primary biliary cholangitis. Clin Liver Dis (Hoboken) 2024; 23:e0216. [PMID: 38831766 PMCID: PMC11146472 DOI: 10.1097/cld.0000000000000216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/08/2024] [Indexed: 06/05/2024] Open
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12
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Groppelli A, Rafanelli M, Testa GD, Agusto S, Rivasi G, Carbone E, Soranna D, Zambon A, Castiglioni P, Ungar A, Brignole M, Parati G. Detection of impending reflex syncope by means of an integrated multisensor patch-type recorder. J Hum Hypertens 2023; 37:1098-1104. [PMID: 37208523 DOI: 10.1038/s41371-023-00840-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/20/2023] [Accepted: 05/04/2023] [Indexed: 05/21/2023]
Abstract
We assessed the capability of an integrated multisensory patch-type monitor (RootiRx®) in detecting episodes of reflex (pre)syncope induced by tilt table test (TTT). Firstly, we performed an intrapatient comparison of cuffless systolic blood pressure (SBP), R-R interval (RRI) and variability (power spectrum analysis) obtained by means of the RootiRx® with those obtained with conventional methods (CONV) with validated finger pressure devices at baseline in supine position and repeatedly during TTT in 32 patients affected by likely reflex syncope. Secondly, the LF/HF values obtained with RootiRx® during TTT were analyzed in 50 syncope patients. Compared with baseline supine recordings, during TTT a decrement of median SBP was observed with CONV (-53.5 mmHg) but not with RootiRx® ®(-1 mmHg). Conversely, RRI reduction (CONV: 102 ms; RootiRx®: 127 ms) and RRI Low Frequency/High Frequency powers ratio (LF/HF) increase (CONV: 1.6; RootiRx®: 2.5) were similar. The concordance was good for RRI (0.97 [95% CI 0.96-0.98]) and fair for LF/HF ratio (0.69 [95% CI 0.46-0.83]). During the first 5 min of TTT the LF/HF ratio was higher in patients who later developed syncope than in no-syncope patients. This ratio was significantly different among patients with syncope, presyncope or without symptoms at the time of syncope (p value = 0.02). In conclusion, cuffless RootiRx® was unable to detect rapid drops of SBP occurring during impending reflex syncope and thus cannot be used as a diagnostic tool for hypotensive syncope. On the other hand, RRI mean values and LF/HF power ratios obtained with RootiRx® were consistent with those simultaneously obtained using conventional methods.
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Affiliation(s)
- Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, San Luca Hospital, Milan, Italy
| | - Martina Rafanelli
- Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Giuseppe Dario Testa
- Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Samuele Agusto
- Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Giulia Rivasi
- Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Erika Carbone
- Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Davide Soranna
- Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Antonella Zambon
- Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Paolo Castiglioni
- IRCCS Fondazione Don C. Gnocchi ONLUS, Milan, Italy
- Department of Biotechnology and Life sciences (DBSV), University of Insubria, Varese, Italy
| | - Andrea Ungar
- Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, San Luca Hospital, Milan, Italy.
| | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, San Luca Hospital, Milan, Italy
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
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13
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Blitshteyn S. Dysautonomia, Hypermobility Spectrum Disorders and Mast Cell Activation Syndrome as Migraine Comorbidities. Curr Neurol Neurosci Rep 2023; 23:769-776. [PMID: 37847487 DOI: 10.1007/s11910-023-01307-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE OF REVIEW Dysautonomia refers to the dysfunction of the autonomic nervous system and encompasses a wide variety of autonomic symptoms and disorders. The most common autonomic disorders are postural orthostatic tachycardia syndrome (POTS), neurocardiogenic syncope (NCS), and orthostatic hypotension (OH), which may be encountered in clinical practice as part of a triad of dysautonomia, hypermobility spectrum disorders (HSD), and mast cell activation syndrome (MCAS). Migraine is one of the most common comorbidities of POTS, HSD, and MCAS; conversely, these conditions are also prevalent in patients with migraine, especially in those with multiple systemic symptoms, such as chronic dizziness, lightheadedness, orthostatic intolerance, joint pain, and allergic symptoms. Diagnostic criteria, pathophysiologic mechanisms, and therapeutic considerations in patients with migraine and comorbid dysautonomia, HSD, and MCAS are reviewed. RECENT FINDINGS Numerous studies indicate a significant overlap and shared pathophysiology in migraine, dysautonomia, HSD, and MCAS. In clinical setting, dysautonomia, HSD, and MCAS may present a diagnostic and therapeutic challenge in patients with migraine and require a high index of suspicion on the part of the neurologist. Diagnosis and treatment of these complex disorders in patients with migraine is essential to comprehensive patient-centric care, reduced symptom burden, and improved functional impairment secondary to both migraine and comorbidities.
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Affiliation(s)
- Svetlana Blitshteyn
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 955 Main Street, Buffalo, NY, 14203, USA.
- Dysautonomia Clinic, 300 International Drive, Suite 100, Williamsville, NY, 14221, USA.
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14
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Stewart JM, van Dijk JG, Balaji S, Sutton R. A framework to simplify paediatric syncope diagnosis. Eur J Pediatr 2023; 182:4771-4780. [PMID: 37470792 PMCID: PMC10640507 DOI: 10.1007/s00431-023-05114-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/06/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
This paper aims to improve the diagnosis of syncope and transient loss of consciousness (TLOC) in children. Diagnostic problems stem, first, from some causes spanning various disciplines, e.g. cardiology, neurology and psychiatry, while the most common cause, vasovagal syncope, is not embraced by any specialty. Second, clinical variability is huge with overlapping signs and symptoms. Third, the approach to TLOC/syncope of the European Society of Cardiology (ESC) is underused in childcare. We explain the ESC guidelines using an additional paediatric literature review. Classification of TLOC and syncope is hierarchic and based on history taking. Loss of consciousness (LOC) is defined using three features: abnormal motor control including falling, reduced responsiveness and amnesia. Adding a < 5 min duration and spontaneous recovery defines TLOC. TLOC simplifies diagnosis by excluding long LOC (e.g. some trauma, intoxications and hypoglycaemia) and focussing on syncope, tonic-clonic seizures and functional TLOC. Syncope, i.e. TLOC due to cerebral hypoperfusion, is divided into reflex syncope (mostly vasovagal), orthostatic hypotension (mostly initial orthostatic hypotension in adolescents) and cardiac syncope (arrhythmias and structural cardiac disorders). The initial investigation comprises history taking, physical examination and ECG; the value of orthostatic blood pressure measurement is unproven in children but probably low. When this fails to yield a diagnosis, cardiac risk factors are assessed; important clues are supine syncope, syncope during exercise, early death in relatives and ECG abnormalities. Conclusions: In adults, the application of the ESC guidelines reduced the number of absent diagnoses and costs; we hope this also holds for children. What is Known: • Syncope and its mimics are very common in childhood, as they are at other ages. • Syncope and its mimics provide considerable diagnostic challenges. What is New: • Application of the hierarchic framework of transient loss of consciousness (TLOC) simplifies diagnosis. • The framework stresses history-taking to diagnose common conditions while keeping an eye on cardiac danger signs.
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Affiliation(s)
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300RC, Leiden, The Netherlands.
| | | | - Richard Sutton
- Department of Cardiology, National Heart & Lung Institute, Hammersmith Hospital Campus, Imperial College, London, UK
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15
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Ghariq M, van den Hout WB, Dekkers OM, Bootsma M, de Groot B, Groothuis JGJ, Harms MPM, Hemels MEW, Kaal ECA, Koomen EM, de Lange FJ, Peeters SYG, van Rossum IA, Rutten JHW, van Zwet EW, van Dijk JG, Thijs RD. Diagnostic and societal impact of implementing the syncope guidelines of the European Society of Cardiology (SYNERGY study). BMC Med 2023; 21:365. [PMID: 37743496 PMCID: PMC10518933 DOI: 10.1186/s12916-023-03056-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Syncope management is fraught with unnecessary tests and frequent failure to establish a diagnosis. We evaluated the potential of implementing the 2018 European Society of Cardiology (ESC) Syncope Guidelines regarding diagnostic yield, accuracy and costs. METHODS A multicentre pre-post study in five Dutch hospitals comparing two groups of syncope patients visiting the emergency department: one before intervention (usual care; from March 2017 to February 2019) and one afterwards (from October 2017 to September 2019). The intervention consisted of the simultaneous implementation of the ESC Syncope Guidelines with quick referral routes to a syncope unit when indicated. The primary objective was to compare diagnostic accuracy using logistic regression analysis accounting for the study site. Secondary outcome measures included diagnostic yield, syncope-related healthcare and societal costs. One-year follow-up data were used to define a gold standard reference diagnosis by applying ESC criteria or, if not possible, evaluation by an expert committee. We determined the accuracy by comparing the treating physician's diagnosis with the reference diagnosis. RESULTS We included 521 patients (usual care, n = 275; syncope guidelines intervention, n = 246). The syncope guidelines intervention resulted in a higher diagnostic accuracy in the syncope guidelines group than in the usual care group (86% vs.69%; risk ratio 1.15; 95% CI 1.07 to 1.23) and a higher diagnostic yield (89% vs. 76%, 95% CI of the difference 6 to 19%). Syncope-related healthcare costs did not differ between the groups, yet the syncope guideline implementation resulted in lower total syncope-related societal costs compared to usual care (saving €908 per patient; 95% CI €34 to €1782). CONCLUSIONS ESC Syncope Guidelines implementation in the emergency department with quick referral routes to a syncope unit improved diagnostic yield and accuracy and lowered societal costs. TRIAL REGISTRATION Netherlands Trial Register, NTR6268.
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Affiliation(s)
- M Ghariq
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands.
| | - W B van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - O M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M Bootsma
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - B de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - J G J Groothuis
- Department of Cardiology, Diakonessenhuis, Utrecht, The Netherlands
| | - M P M Harms
- Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - M E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E C A Kaal
- Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | - E M Koomen
- Department of Cardiology, Gelre Hospital, Apeldoorn, The Netherlands
| | - F J de Lange
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - S Y G Peeters
- Department of Emergency Medicine, Flevo Hospital, Almere, The Netherlands
| | - I A van Rossum
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - J H W Rutten
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - J G van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - R D Thijs
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Stichting Epilepsie Instellingen Nederland, Heemstede, The Netherlands
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16
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Zawadka-Kunikowska M, Rzepiński Ł, Cieślicka M, Klawe JJ, Tafil-Klawe M. Association between Daytime Sleepiness, Fatigue and Autonomic Responses during Head-Up Tilt Test in Multiple Sclerosis Patients. Brain Sci 2023; 13:1342. [PMID: 37759943 PMCID: PMC10526123 DOI: 10.3390/brainsci13091342] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/10/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
We aimed to assess dynamic changes in hemodynamic and autonomic function in response to the head-up tilt test (HUTT) in patients with multiple sclerosis (MS) compared to healthy controls (HCs) and evaluate its relationship with the patients' reported daytime sleepiness and fatigue symptoms. A total of 58 MS patients and 30 HCs were included in the analysis. Fatigue and sleepiness were evaluated using the Chalder Fatigue Scale (CFQ) and the Epworth Sleepiness Scale (ESS), respectively. Hemodynamic response, baroreflex sensitivity, heart rate variability, and systolic and diastolic blood pressure (BP) variability (SBPV, DBPV) parameters were calculated at rest, and in response to the HUTT. The MS patients displayed attenuated BP responses coupled with a more pronounced decrease in cardiac index as well as a reduced increase in the low frequency (LFnu) of DBPV (p = 0.021) and the sympathovagal ratio (p = 0.031) in the latter-phase orthostatic challenge compared to HCs. In MS patients, the ESS score showed no correlation with CFQ or clinical disease outcomes, but exhibited a moderate correlation with LFnu of BPVrest. Fatigue and disease variants predicted blood pressure response to HUTT. These findings underscore the importance of subjective daytime sleepiness and fatigue symptoms and their role in blood pressure regulation in MS patients.
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Affiliation(s)
- Monika Zawadka-Kunikowska
- Department of Human Physiology, Nicolaus Copernicus University, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Karłowicza 24, 85-092 Bydgoszcz, Poland; (M.C.); (M.T.-K.)
| | - Łukasz Rzepiński
- Sanitas–Neurology Outpatient Clinic, Dworcowa 110, 85-010 Bydgoszcz, Poland;
- Department of Neurology, 10th Military Research Hospital and Polyclinic, 85-681 Bydgoszcz, Poland
| | - Mirosława Cieślicka
- Department of Human Physiology, Nicolaus Copernicus University, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Karłowicza 24, 85-092 Bydgoszcz, Poland; (M.C.); (M.T.-K.)
| | - Jacek J. Klawe
- Department of Hygiene, Epidemiology, Ergonomy and Postgraduate Education, Nicolaus Copernicus University, Ludwik Rydygier Collegium Medicum in Bydgoszcz, M. Sklodowskiej-Curie 9, 85-094 Bydgoszcz, Poland;
| | - Małgorzata Tafil-Klawe
- Department of Human Physiology, Nicolaus Copernicus University, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Karłowicza 24, 85-092 Bydgoszcz, Poland; (M.C.); (M.T.-K.)
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17
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Junaković A, Skočić Hanžek M, Adamec I, Krbot Skorić M, Habek M. A complex interplay between autonomic symptoms and symptoms of depression, anxiety, and stress. Neurol Sci 2023; 44:3169-3179. [PMID: 37016063 DOI: 10.1007/s10072-023-06787-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 03/27/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND We evaluated the influence of symptoms of depression, anxiety, and stress on the results of COMPASS-31 in a large population of people referred to the head-up tilt test (HUTT) and healthy controls (HC). METHODS Nine hundred fifty-nine consecutive patients referred to HUTT and 518 HC were enrolled. All participants completed Composite Autonomic Symptom Score-31 (COMPASS-31). Stress symptoms were evaluated by Depression, Anxiety, and Stress-21 (DASS-21) questionnaire. We corrected the result of the COMPASS-31 with the independent predictors in order to improve the specificity of the test. RESULTS In both patients and HC, COMPASS-31 was higher in participants with depression, anxiety, and stress symptoms (all p < 0.001). In a multivariable linear regression analysis, HC was negative, while female sex and symptoms of depression, anxiety, and stress were independent positive predictors of COMPASS-31. In HC, COMPASS-31 had a median of 7.913, and this value differentiated between HC and patients with a high sensitivity of 87% and low specificity of 50%. In order to adjust the value of COMPASS-31 with the parameters that were significant in the multivariable linear regression model, we calculated the new corrected COMAPSS-31 (cCOMPASS-31), which had comparable sensitivity of 77%, but an increased specificity of 73%. CONCLUSION This study has shown that symptoms of depression, anxiety, and/or stress worsen the perceived severity of autonomic symptoms in people with symptoms of orthostatic intolerance and healthy population. cCOMPASS-31 is a valuable tool that can help clinicians in discerning the true autonomic background of patients' complaints.
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Affiliation(s)
- Anamari Junaković
- Referral Center for Autonomic Nervous System Disorders, Department of Neurology, University Hospital Center Zagreb, Kišpatićeva 12, HR-10000, Zagreb, Croatia
| | - Milena Skočić Hanžek
- Department of Psychiatry and Psychological Medicine, University Hospital Center Zagreb, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Adamec
- Referral Center for Autonomic Nervous System Disorders, Department of Neurology, University Hospital Center Zagreb, Kišpatićeva 12, HR-10000, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Magdalena Krbot Skorić
- Referral Center for Autonomic Nervous System Disorders, Department of Neurology, University Hospital Center Zagreb, Kišpatićeva 12, HR-10000, Zagreb, Croatia
- Faculty of Electrical Engineering, University of Zagreb, Zagreb, Croatia
| | - Mario Habek
- Referral Center for Autonomic Nervous System Disorders, Department of Neurology, University Hospital Center Zagreb, Kišpatićeva 12, HR-10000, Zagreb, Croatia.
- School of Medicine, University of Zagreb, Zagreb, Croatia.
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18
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Chang L, Peng L, Liu J, Wang M, Li M, Kong Q, Zhao H, Zhao C. Predictive analysis of catecholamines and electrolytes for recurrence of orthostatic intolerance in children. Front Pediatr 2023; 11:1220990. [PMID: 37705599 PMCID: PMC10495584 DOI: 10.3389/fped.2023.1220990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/08/2023] [Indexed: 09/15/2023] Open
Abstract
Background Orthostatic intolerance (OI) is usually mediated by the autonomic nerve and most often happens in the upright position. However, it can also occur in other positions and can be relieved by lying down while likely to have another attack after relief. In the current study, we aim to evaluate the predictive effect of catecholamines and electrolytes on the recurrence of OI in children. Materials and methods Children who were diagnosed with vasovagal syncope (VVS), postural tachycardia syndrome (POTS), and VVS combined with POTS were enrolled in this retrospective study and were followed up after 1-year physical treatment. Catecholamines in urine collected within 24 h, renin, angiotensin II, aldosterone in plasma, and electrolytes in both blood and urine collected in the morning were tested. A multivariate analysis and a receiver operating characteristic curve were used to validate the prediction effect. Results In the VVS cohort, the 24 h urine adrenaline (AD) and norepinephrine (NE) levels of the non-recurrence group were lower than the 24 h urine AD and NE levels of the recurrence group, with a significant difference of P < 0.05. A different content can also be witnessed in the POTS cohort that the urine of the non-recurrence group contained lower sodium and chlorine. As for the VVS + POTS cohort, the non-recurrence group has lower AD and NE levels and higher potassium and phosphorus levels in urine, the difference of which proved prominent as well. Conclusion The study provides further evidence that AD, NE, and electrolytes in urine are promising factors that are closely related to the recurrence of OI in children. The integrated evaluation system merging AD and NE may have better predictive ability.
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Affiliation(s)
| | | | | | | | | | | | | | - Cuifen Zhao
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
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19
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Rabady S, Hoffmann K, Aigner M, Altenberger J, Brose M, Costa U, Denk-Linnert DM, Gruber S, Götzinger F, Helbok R, Hüfner K, Koczulla R, Kurz K, Lamprecht B, Leis S, Löffler J, Müller CA, Rittmannsberger H, Rommer PS, Sator P, Strenger V, Struhal W, Untersmayr E, Vonbank K, Wancata J, Weber T, Wendler M, Zwick RH. [S1 guidelines for the management of postviral conditions using the example of post-COVID-19]. Wien Klin Wochenschr 2023; 135:525-598. [PMID: 37555900 PMCID: PMC10504206 DOI: 10.1007/s00508-023-02242-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 08/10/2023]
Abstract
These S1 guidelines are an updated and expanded version of the S1 guidelines on long COVID differential diagnostic and management strategies. They summarize the state of knowledge on postviral conditions like long/post COVID at the time of writing. Due to the dynamic nature of knowledge development, they are intended to be "living guidelines". The focus is on practical applicability at the level of primary care, which is understood to be the appropriate place for initial access and for primary care and treatment. The guidelines provide recommendations on the course of treatment, differential diagnostics of the most common symptoms that can result from infections like with SARS-CoV-2, treatment options, patient management and care, reintegration and rehabilitation. The guidelines have been developed through an interdisciplinary and interprofessional process and provide recommendations on interfaces and possibilities for collaboration.
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Affiliation(s)
- Susanne Rabady
- Department Allgemeine Gesundheitsstudien, Kompetenzzentrum für Allgemein- und Familienmedizin, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dr. Karl-Dorrek-Str. 30, 3500, Krems, Österreich.
| | - Kathryn Hoffmann
- Leiterin der Abteilung Primary Care Medicine, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Martin Aigner
- Abteilung für Psychiatrie und psychotherapeutische Medizin, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dr. Karl-Dorrek-Str. 30, 3500, Krems, Österreich
| | - Johann Altenberger
- Pensionsversicherungsanstalt, Rehabilitationszentrum Großgmain, Salzburger Str. 520, 5084, Großgmain, Österreich
| | - Markus Brose
- Department Allgemeine Gesundheitsstudien, Kompetenzzentrum für Allgemein- und Familienmedizin, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dr. Karl-Dorrek-Str. 30, 3500, Krems, Österreich
| | - Ursula Costa
- Ergotherapie und Handlungswissenschaft, fhg - Zentrum für Gesundheitsberufe Tirol GmbH/fh, Innrain 98, 6020, Innsbruck, Österreich
| | - Doris-Maria Denk-Linnert
- Klinische Abteilung für Allgemeine Hals‑, Nasen- und Ohrenkrankheiten, Klin. Abteilung Phoniatrie-Logopädie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Samuel Gruber
- Department Allgemeine Gesundheitsstudien, Kompetenzzentrum für Allgemein- und Familienmedizin, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dr. Karl-Dorrek-Str. 30, 3500, Krems, Österreich
| | - Florian Götzinger
- Abteilung für Kinderheilkunde, Klinik Ottakring, Montleartstr. 37, 1160, Wien, Österreich
| | - Raimund Helbok
- Universitätsklinik für Neurologie, Johannes Kepler Universität Linz, Standort Neuromed Campus & Med Campus Kepler Universitätsklinikum GmbH, 4020, Linz, Österreich
| | - Katharina Hüfner
- Dep. für Psychiatrie, Psychotherapie, Psychosomatik und Medizinische Psychologie, Universitätsklinik für Psychiatrie II, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich
| | - Rembert Koczulla
- Fachbereich Medizin, Klinik für Pneumologie Marburg, Baldingerstr., 35035, Marburg, Deutschland
| | - Katharina Kurz
- Innere Medizin II, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich
| | - Bernd Lamprecht
- Universitätsklinik für Innere Medizin mit Schwerpunkt Pneumologie, Kepler Universitätsklinikum, 4020, Linz, Österreich
| | - Stefan Leis
- Universitätsklinik für Neurologie der PMU, MME Universitätsklinikum Salzburg Christian-Doppler-Klinik, Ignaz-Harrer-Str. 79, 5020, Salzburg, Österreich
| | - Judith Löffler
- Innere Medizin II, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich
| | - Christian A Müller
- Klinische Abteilung für Allgemeine Hals‑, Nasen- und Ohrenkrankheiten, Klin. Abteilung für Allgemeine HNO, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | | | - Paulus S Rommer
- Universitätsklinik für Neurologie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Paul Sator
- Dermatologische Abteilung, Klinik Hietzing, Wolkersbergenstr. 1, 1130, Wien, Österreich
| | - Volker Strenger
- Klinische Abteilung für Allgemeinpädiatrie, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, 8036, Graz, Österreich
| | - Walter Struhal
- Klinische Abteilung für Neurologie, Universitätsklinikum Tulln, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Alter Ziegelweg 10, 3430, Tulln an der Donau, Österreich
| | - Eva Untersmayr
- Institut für Pathophysiologie und Allergieforschung Zentrum für Pathophysiologie, Infektiologie und Immunologie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Karin Vonbank
- Klinische Abteilung für Pulmologie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Johannes Wancata
- Klinische Abteilung für Sozialpsychiatrie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Thomas Weber
- Kardiologische Abteilung Klinikum Wels-Grieskirchen, Grieskirchnerstr. 42, 4600, Wels, Österreich
| | | | - Ralf-Harun Zwick
- Ludwig Boltzmann Institute for Rehabilitation Research, Kurbadstr. 14, 1100, Wien, Österreich
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Affiliation(s)
- Artur Fedorowski
- Departments of Cardiology and Medicine, Karolinska University Hospital, and Karolinska Institute, Eugeniavägen 3, Solna, 17176 Stockholm, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Robert Sheldon
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, National Heart & Lung Institute, Hammersmith Hospital Campus, London, UK
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21
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Crnošija L, Adamec I, Krbot Skorić M, Habek M. How to explore and explain autonomic changes in multiple sclerosis. Neurophysiol Clin 2023; 53:102854. [PMID: 36966707 DOI: 10.1016/j.neucli.2023.102854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 03/29/2023] Open
Abstract
Autonomic dysfunction (AD) in people with MS (pwMS) is a frequent finding. This narrative review will present an overview of central neural mechanisms involved in the control of cardiovascular and thermoregulatory systems, and methods of autonomic nervous system testing will be discussed thereafter. Since the need for standardization of autonomic nervous system (ANS) testing, we will focus on the standard battery of tests (blood pressure and heart rate response to Valsalva maneuver and head-up tilt, and heart rate response to deep breathing test plus one of the tests for sudomotor function), which can detect ANS pathology in the majority of pwMS. The review will briefly discuss the other types of AD in pwMS and the use of appropriate tests. While performing ANS testing in pwMS one has to consider the multiple sclerosis phenotypes, disease duration, and its activity, the degree of clinical disability of patients included in the study, and the disease-modifying therapies taken, as these factors may have a great influence on the results of ANS testing. In other words, detailed patient characteristics presentation and patient stratification are beneficial when reporting results of ANS testing in pwMS.
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22
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Russo V, Parente E, Groppelli A, Rivasi G, Tomaino M, Gargaro A, Giacopelli D, Ungar A, Parati G, Fedorowski A, Sutton R, van Dijk JG, Brignole M. Prevalence of asystole during tilt test-induced vasovagal syncope may depend on test methodology. Europace 2023; 25:263-269. [PMID: 36796797 PMCID: PMC10103574 DOI: 10.1093/europace/euac154] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
This review addresses tilt-testing methodology by searching the literature which reports timing of asystole and loss of consciousness (LOC). Despite the Italian protocol being the most widely adopted, its stipulations are not always followed to the letter of the European Society of Cardiology guidelines. The discrepancies permit reassessment of the incidence of asystole when tilt-down is early, impending syncope, compared with late, established LOC. Asystole is uncommon with early tilt down and diminishes with increasing age. However, if LOC is established as test-end, asystole is more common, and it is age-independent. Thus, the implications are that asystole is commonly under-diagnosed by early tilt-down. The prevalence of asystolic responses observed using the Italian protocol with a rigorous tilt down time is numerically close to that observed during spontaneous attacks by electrocardiogram loop recorder. Recently, tilt-testing has been questioned as to its validity but, in selection of pacemaker therapy in older highly symptomatic vasovagal syncope patients, the occurrence of asystole has been shown to be an effective guide for treatment. The use of head-up tilt test as an indication for cardiac pacing therapy requires pursuing the test until complete LOC. This review offers explanations for the findings and their applicability to practice. A novel interpretation is offered to explain why pacing induced earlier may combat vasodepression by raising the heart rate when sufficient blood remains in the heart.
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Affiliation(s)
- Vincenzo Russo
- Chair of Cardiology, University of the Study of Campania 'Luigi Vanvitelli', Ospedale Monaldi, Via Leonardo Bianchi, 80131 Napoli, Italy
| | - Erika Parente
- Chair of Cardiology, University of the Study of Campania 'Luigi Vanvitelli', Ospedale Monaldi, Via Leonardo Bianchi, 80131 Napoli, Italy
| | - Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Marco Tomaino
- Ospedale Generale Regionale, Via Lorenz Böhler, 5, 39100 Bolzano, Italy
| | - Alessio Gargaro
- Research Clinical Unit, BIOTRONIK Italia S.p.A., Via Alessandro Volta 16, 20093 Cologno, Monzese, Italy
| | - Daniele Giacopelli
- Research Clinical Unit, BIOTRONIK Italia S.p.A., Via Alessandro Volta 16, 20093 Cologno, Monzese, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska Institute, Nobels väg 6, 171 77 Solna, Stockholm, Sweden.,Department of Medicine, Karolinska Institute, Nobels väg 6, 171 77 Solna, Stockholm, Sweden
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300RC Leiden, The Netherlands
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
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23
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How to unblur the vasovagal evidence? Clin Auton Res 2023; 33:5-7. [PMID: 36538152 DOI: 10.1007/s10286-022-00915-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
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24
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Reis Carneiro D, Rocha I, Habek M, Helbok R, Sellner J, Struhal W, Wenning G, Fanciulli A. Clinical presentation and management strategies of cardiovascular autonomic dysfunction following a COVID-19 infection - A systematic review. Eur J Neurol 2023; 30:1528-1539. [PMID: 36694382 DOI: 10.1111/ene.15714] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/17/2022] [Accepted: 12/20/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Cardiovascular autonomic dysfunction may reportedly occur after a coronavirus-disease-2019 (COVID-19) infection, but the available evidence is scattered. Here we sought to understand the acute and mid-term effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on cardiovascular autonomic function. METHODS We performed a systematic PubMed, Embase, Web of Science, medRxiv, and bioRxiv search for cases of cardiovascular autonomic dysfunction during an acute SARS-CoV-2 infection or post-COVID-19 condition. The clinical-demographic characteristics of individuals in the acute versus post-COVID-19 phase were compared. RESULTS We screened 6470 titles and abstracts. Fifty-four full-length articles were included in the data synthesis. One-hundred and thirty-four cases were identified: 81 during the acute SARS-CoV-2 infection (24 thereof diagnosed by history) and 53 in the post-COVID-19 phase. Post-COVID-19 cases were younger than those with cardiovascular autonomic disturbances in the acute SARS-CoV-2 phase (42 vs. 51 years old, p = 0.002) and were more frequently women (68% vs. 49%, p = 0.034). Reflex syncope was the most common cardiovascular autonomic disorder in the acute phase (p = 0.008) and postural orthostatic tachycardia syndrome (POTS) the most frequent diagnosis in individuals with post-COVID-19 orthostatic complaints (p < 0.001). Full recovery was more frequent in individuals with acute versus post-COVID-19 onset of cardiovascular autonomic disturbances (43% vs. 15%, p = 0.002). CONCLUSIONS There is evidence from the scientific literature about different types of cardiovascular autonomic dysfunction developing during and after COVID-19. More data about the prevalence of autonomic disorders associated with a SARS-CoV-2 infection are needed to quantify its impact on human health.
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Affiliation(s)
- Diogo Reis Carneiro
- Department of Neurology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Isabel Rocha
- Cardiovascular Autonomic Function Lab, Institute of Physiology, CCUL, Faculty of Medicine of University of Lisbon, Lisbon, Portugal
| | - Mario Habek
- Department of Neurology, University Hospital Centre Zagreb, Zagreb, Croatia.,Department of Neurology, University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Johann Sellner
- Landesklinikum Mistlbach-Gänserndorf, Mistelbach, Austria.,Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Walter Struhal
- Karl Landsteiner University of Health Sciences, Department of Neurology, University Hospital Tulln, Tulln, Austria
| | - Gregor Wenning
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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25
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Orthostatic Intolerance and Chiari I Malformation. Neurosurg Clin N Am 2023; 34:43-54. [DOI: 10.1016/j.nec.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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26
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Habek M, Leys F, Krbot Skorić M, Reis Carneiro D, Calandra‐Buonaura G, Camaradou J, Chiaro G, Cortelli P, Falup‐Pecurariu C, Granata R, Guaraldi P, Helbok R, Hilz MJ, Iodice V, Jordan J, Kaal ECA, Kamondi A, Pavy Le Traon A, Rocha I, Sellner J, Senard JM, Terkelsen A, Wenning GK, Berger T, Thijs RD, Struhal W, Fanciulli A. Clinical autonomic nervous system laboratories in Europe: A joint survey of the European Academy of Neurology and the European Federation of Autonomic Societies: A joint survey of the European Academy of Neurology and the European Federation of Autonomic Societies. Eur J Neurol 2022; 29:3633-3646. [PMID: 36056590 PMCID: PMC9826284 DOI: 10.1111/ene.15538] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 08/21/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Disorders of the autonomic nervous system (ANS) are common conditions, but it is unclear whether access to ANS healthcare provision is homogeneous across European countries. The aim of this study was to identify neurology-driven or interdisciplinary clinical ANS laboratories in Europe, describe their characteristics and explore regional differences. METHODS We contacted the European national ANS and neurological societies, as well as members of our professional network, to identify clinical ANS laboratories in each country and invite them to answer a web-based survey. RESULTS We identified 84 laboratories in 22 countries and 46 (55%) answered the survey. All laboratories perform cardiovascular autonomic function tests, and 83% also perform sweat tests. Testing for catecholamines and autoantibodies are performed in 63% and 56% of laboratories, and epidermal nerve fiber density analysis in 63%. Each laboratory is staffed by a median of two consultants, one resident, one technician and one nurse. The median (interquartile range [IQR]) number of head-up tilt tests/laboratory/year is 105 (49-251). Reflex syncope and neurogenic orthostatic hypotension are the most frequently diagnosed cardiovascular ANS disorders. Thirty-five centers (76%) have an ANS outpatient clinic, with a median (IQR) of 200 (100-360) outpatient visits/year; 42 centers (91%) also offer inpatient care (median 20 [IQR 4-110] inpatient stays/year). Forty-one laboratories (89%) are involved in research activities. We observed a significant difference in the geographical distribution of ANS services among European regions: 11 out of 12 countries from North/West Europe have at least one ANS laboratory versus 11 out of 21 from South/East/Greater Europe (p = 0.021). CONCLUSIONS This survey highlights disparities in the availability of healthcare services for people with ANS disorders across European countries, stressing the need for improved access to specialized care in South, East and Greater Europe.
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Affiliation(s)
- Mario Habek
- Department of NeurologyUniversity Hospital Centre ZagrebZagrebCroatia,Department of NeurologyUniversity of Zagreb, School of MedicineZagrebCroatia
| | - Fabian Leys
- Department of NeurologyMedical University of InnsbruckInnsbruckAustria
| | - Magdalena Krbot Skorić
- Department of NeurologyUniversity Hospital Centre ZagrebZagrebCroatia,Faculty of Electrical Engineering and ComputingUniversity of ZagrebZagrebCroatia
| | - Diogo Reis Carneiro
- Neurology DepartmentCentro Hospitalar e Universitário de CoimbraCoimbraPortugal,Faculty of MedicineUniversity of CoimbraCoimbraPortugal
| | - Giovanna Calandra‐Buonaura
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly,Department of Biomedical and Neuromotor SciencesUniversity of BolognaBolognaItaly
| | - Jennifer Camaradou
- Patient Partner of the EAN Scientific Panel for Autonomic Nervous System DisordersLondonUK,UCL Social Research InstituteUniversity College LondonLondonUK
| | - Giacomo Chiaro
- Autonomic UnitNational Hospital for Neurology and Neurosurgery, Queen SquareLondonUK,UCL Queen Square Institute of Neurology, Faculty of Brain SciencesUniversity College LondonLondonUK
| | - Pietro Cortelli
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly,Department of Biomedical and Neuromotor SciencesUniversity of BolognaBolognaItaly
| | | | - Roberta Granata
- Department of NeurologyMedical University of InnsbruckInnsbruckAustria
| | - Pietro Guaraldi
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly,Department of Biomedical and Neuromotor SciencesUniversity of BolognaBolognaItaly
| | - Raimund Helbok
- Department of NeurologyMedical University of InnsbruckInnsbruckAustria
| | - Max J. Hilz
- Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA,Department of NeurologyUniversity Erlangen‐NurembergErlangen‐NurembergGermany
| | - Valeria Iodice
- Autonomic UnitNational Hospital for Neurology and Neurosurgery, Queen SquareLondonUK,UCL Queen Square Institute of Neurology, Faculty of Brain SciencesUniversity College LondonLondonUK
| | - Jens Jordan
- Institute of Aerospace MedicineGerman Aerospace Center (DLR) and Medical FacultyUniversity of CologneCologneGermany
| | - Evert C. A. Kaal
- Department of Neurology, Maasstad ZiekenhuisRotterdamThe Netherlands
| | - Anita Kamondi
- Department of NeurologyNational Institute of Mental Health, Neurology and NeurosurgeryBudapestHungary
| | - Anne Pavy Le Traon
- Department of NeurologyCentre Hospitalier Universitaire de Toulouse and INSERM U 1297ToulouseFrance
| | - Isabel Rocha
- Institute of Physiology, Faculty of MedicineUniversity of LisbonLisbonPortugal
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach‐GänserndorfMistelbachAustria,Department of Neurology, Klinikum rechts der IsarTechnische Universität MünchenMunichGermany
| | - Jean Michel Senard
- Department of Cardiolog, Toulouse University HospitalInstitute des Maladies Métaboliques et Cardiovasculaires, INSERM U 1297ToulouseFrance
| | - Astrid Terkelsen
- Department of NeurologyAarhus University Hospital and Danish Pain Research CenterAarhus UniversityAarhusDenmark
| | - Gregor K. Wenning
- Department of NeurologyMedical University of InnsbruckInnsbruckAustria
| | - Thomas Berger
- Department of NeurologyMedical University of ViennaViennaAustria
| | - Roland D. Thijs
- Department of NeurologyLeiden University Medical CentreLeidenThe Netherlands,Stichting Epilepsie Instellingen Nederland (SEIN)HeemstedeThe Netherlands
| | - Walter Struhal
- Department of Neurology, University Hospital TullnKarl Landsteiner University of Health SciencesTullnAustria
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27
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de Lange FJ, Hofland WPME, Ferrara A, Gargaro A, Brignole M, van Dijk JG. A novel and practical method to add video monitoring to tilt table testing. Europace 2022; 25:762-766. [PMID: 36351661 PMCID: PMC9935048 DOI: 10.1093/europace/euac193] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/05/2022] [Indexed: 11/11/2022] Open
Abstract
AIMS We describe a novel, practical, and inexpensive method to add video recording during tilt table testing (TTT): Open-Access-Video-TTT. METHODS AND RESULTS The Open-Access-Video-TTT set-up uses a personal computer (PC) to capture screen video data from a non-invasive-beat-to-beat (NIBTB) haemodynamic blood pressure (BP) device, combined with video recording of a patient, using Open Broadcaster Software (OBS®). The new Open-Access-Video-TTT set up was tested with both the Finometer (model Finapres Nova®, Medical Systems, the Netherlands) and the Task Force® Touch Cardio monitor (CNSystems, Austria). For this, the Finapres Nova® was enabled in 'remote' mode and Real Video Network Computing (RealVNC®) was installed on the PC/laptop. The Task Force® has a DisplayPort (DP) port, for which a DP/ high-definition multimedia interface (HDMI) cable and a video capture card is used to merge the signals to the PC/laptop. With this method the combined images are stored as a new video signal. TTT can be performed with any routine protocol. CONCLUSIONS Open Access-Video-TTT worked well for both the Finapres NOVA® and the Task Force Monitor ®. This novel method can be used easily by all physicians who wish to add video recording during TTT who do not have access to an electroencephalogram machine.
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Affiliation(s)
| | - Willem Petrus Merijn Emmanuël Hofland
- Amsterdam UMC, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, University of Amsterdam, Heart Centre, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | | | | | | | - Jan Gerrit van Dijk
- Department of Neurology, Leiden University Medical Centre, Albinusdreef 2, Zuid Holland, 2333 ZA Leiden, The Netherlands
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28
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Ormiston CK, Świątkiewicz I, Taub PR. Postural orthostatic tachycardia syndrome as a sequela of COVID-19. Heart Rhythm 2022; 19:1880-1889. [PMID: 35853576 PMCID: PMC9287587 DOI: 10.1016/j.hrthm.2022.07.014] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 12/19/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a complex multisystem disorder characterized by orthostatic intolerance and tachycardia and may be triggered by viral infection. Recent reports indicate that 2%-14% of coronavirus disease 2019 (COVID-19) survivors develop POTS and 9%-61% experience POTS-like symptoms, such as tachycardia, orthostatic intolerance, fatigue, and cognitive impairment within 6-8 months of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Pathophysiological mechanisms of post-COVID-19 POTS are not well understood. Current hypotheses include autoimmunity related to SARS-CoV-2 infection, autonomic dysfunction, direct toxic injury by SARS-CoV-2 to the autonomic nervous system, and invasion of the central nervous system by SARS-CoV-2. Practitioners should actively assess POTS in patients with post-acute COVID-19 syndrome symptoms. Given that the symptoms of post-COVID-19 POTS are predominantly chronic orthostatic tachycardia, lifestyle modifications in combination with the use of heart rate-lowering medications along with other pharmacotherapies should be considered. For example, ivabradine or β-blockers in combination with compression stockings and increasing salt and fluid intake has shown potential. Treatment teams should be multidisciplinary, including physicians of various specialties, nurses, psychologists, and physiotherapists. Additionally, more resources to adequately care for this patient population are urgently needed given the increased demand for autonomic specialists and clinics since the start of the COVID-19 pandemic. Considering our limited understanding of post-COVID-19 POTS, further research on topics such as its natural history, pathophysiological mechanisms, and ideal treatment is warranted. This review evaluates the current literature available on the associations between COVID-19 and POTS, possible mechanisms, patient assessment, treatments, and future directions to improving our understanding of post-COVID-19 POTS.
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Affiliation(s)
- Cameron K Ormiston
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, California; Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland
| | - Iwona Świątkiewicz
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, California; Department of Cardiology and Internal Medicine, Nicolaus Copernicus University Torun, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
| | - Pam R Taub
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, California.
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29
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Hovaguimian A. Dysautonomia. Neurol Clin 2022; 41:193-213. [DOI: 10.1016/j.ncl.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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30
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Personalised physiological medicine: Orthostatic hypotension. Med Hypotheses 2022. [DOI: 10.1016/j.mehy.2022.110928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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31
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Rasmussen TK, Finnerup NB, Singer W, Jensen TS, Hansen J, Terkelsen AJ. Preferential impairment of parasympathetic autonomic function in type 2 diabetes. Auton Neurosci 2022; 243:103026. [PMID: 36137485 DOI: 10.1016/j.autneu.2022.103026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 07/07/2022] [Accepted: 09/07/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Cardiovascular autonomic neuropathy is a known complication in type 2 diabetes (T2D). However, the extent of sympathetic dysfunction and its relation to blood pressure (BP) dysregulation is insufficiently studied. We therefore assessed the cardiovascular sympathetic function using a standardized autonomic test-battery. RESEARCH DESIGN AND METHODS Forty T2D patients (mean age and duration of diabetes ±SD, 65.5 ± 7.3 and 9.5 ± 4.2 years) and 40 age- and gender-matched controls were examined through autonomic testing, assessing cardiovascular responses to deep breathing, Valsalva maneuver and tilt-table testing. Additionally, 24-hour oscillometric BP and self-reported autonomic symptoms on COMPASS-31 questionnaire was recorded. RESULTS Patients with T2D had reduced parasympathetic activity with reduced deep breathing inspiratory:expiratory-ratio (median [IQR] T2D 1.11 [1.08-1.18] vs. controls 1.18 [1.11-1.25] (p = 0.01)), and reduced heart rate variability (p < 0.05). We found no differences in cardiovascular sympathetic function measured through BP responses during the Valsalva maneuver (p > 0.05). 24-hour-BP detected reduced night-time systolic BP drop in T2D (9.8 % ± 8.8 vs. controls 15.8 % ± 7.7 (p < 0.01)) with more patients having reverse dipping. Patients with T2D reported more symptoms of orthostatic intolerance on the COMPASS-31 (p = 0.04). CONCLUSIONS Patients with T2D showed reduced parasympathetic activity but preserved short-term cardiovascular sympathetic function, compared to controls, indicating autonomic dysfunction with predominantly parasympathetic impairment. Despite this, T2D patients reported more symptoms of orthostatic intolerance in COMPASS-31 and had reduced nocturnal BP dipping, indicating that these are not a consequence of cardiovascular sympathetic dysfunction.
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Affiliation(s)
- Thorsten K Rasmussen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
| | | | - Troels S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - John Hansen
- Department of Health Science and Technology, Aalborg University, Denmark
| | - Astrid J Terkelsen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
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32
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Eldokla AM, Ali ST. Autonomic function testing in long-COVID syndrome patients with orthostatic intolerance. Auton Neurosci 2022; 241:102997. [DOI: 10.1016/j.autneu.2022.102997] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/08/2022] [Accepted: 05/30/2022] [Indexed: 12/26/2022]
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33
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Liao Y, Du J, Benditt DG, Jin H. Vasovagal syncope or psychogenic pseudosyncope: a major issue in the differential diagnosis of apparent transient loss of consciousness in children. Sci Bull (Beijing) 2022; 67:1618-1620. [PMID: 36546036 DOI: 10.1016/j.scib.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - David G Benditt
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis 55455, USA
| | - Hongfang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China.
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34
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Groppelli A, Rafanelli M, Testa GD, Agusto S, Rivasi G, Ungar A, Carbone E, Soranna D, Zambon A, Brignole M, Parati G. Feasibility of Blood Pressure Measurement With a Wearable (Watch-Type) Monitor During Impending Syncopal Episodes. J Am Heart Assoc 2022; 11:e026420. [PMID: 35929469 PMCID: PMC9496316 DOI: 10.1161/jaha.122.026420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background We assessed the reliability and feasibility of blood pressure (BP) measurements by means of a new wearable watch‐type BP monitor (HeartGuide) in detecting episodes of hypotensive (pre)syncope induced by tilt table test. Methods and Results An intrapatient comparison between systolic BP (SBP) measured by means of the HeartGuide device and noninvasive finger beat‐to‐beat BP monitoring was undertaken both at baseline in supine position and repeatedly during tilt table test in patients evaluated for reflex syncope. Intrapatient fall of systolic BP from baseline was measured. Eighty‐one patients (mean age, 61±19 years; 46 women) were included. Overall, HeartGuide was able to yield BP values at the time of BP nadir in 58 (72%) patients (average HeartGuide SBP 102±18 mm Hg, versus finger SBP 101±19 mm Hg). Compared with baseline, the maximum SBP decrease was on average −28.5±27.8 and −30.3±33.9 mm Hg respectively (Lin's concordance correlation coefficient=0.78, r=0.79, P=0.001). In the subgroup of 38 patients with tilt table test induced (pre)syncope, the average HeartGuide SBP during symptoms was 97±16 mm Hg, and the finger SBP was 94±18 mm Hg. Compared with baseline, the maximum SBP decrease was on average −35.2±29.3 and −43.3±31.8 mm Hg, respectively (Lin's concordance correlation coefficient=0.83, r=0.87, P=0.001). Conclusions Our data indicate that the HeartGuide BP monitor can detect low BP during presyncope and that its measure of SBP change is consistent with that simultaneously obtained through continuous BP monitoring, despite some intrapatient variability. Thus, this device might be useful in determining the hypotensive nature of spontaneous (pre)syncopal symptoms, a possibility that should be verified by field studies.
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Affiliation(s)
- Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Cardiology Unit and Department of Cardiology San Luca Hospital Milan Italy
| | - Martina Rafanelli
- Syncope Unit, Division of Geriatric and Intensive Care Medicine University of Florence and Azienda Ospedaliero Universitaria Careggi Florence Italy
| | - Giuseppe Dario Testa
- Syncope Unit, Division of Geriatric and Intensive Care Medicine University of Florence and Azienda Ospedaliero Universitaria Careggi Florence Italy
| | - Samuele Agusto
- Syncope Unit, Division of Geriatric and Intensive Care Medicine University of Florence and Azienda Ospedaliero Universitaria Careggi Florence Italy
| | - Giulia Rivasi
- Syncope Unit, Division of Geriatric and Intensive Care Medicine University of Florence and Azienda Ospedaliero Universitaria Careggi Florence Italy
| | - Andrea Ungar
- Syncope Unit, Division of Geriatric and Intensive Care Medicine University of Florence and Azienda Ospedaliero Universitaria Careggi Florence Italy
| | - Erika Carbone
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Cardiology Unit and Department of Cardiology San Luca Hospital Milan Italy
| | - Davide Soranna
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Cardiology Unit and Department of Cardiology San Luca Hospital Milan Italy
| | - Antonella Zambon
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Cardiology Unit and Department of Cardiology San Luca Hospital Milan Italy.,Department of Statistics University of Milano-Bicocca Milan Italy
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Cardiology Unit and Department of Cardiology San Luca Hospital Milan Italy
| | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Cardiology Unit and Department of Cardiology San Luca Hospital Milan Italy.,Department of Medicine and Surgery University of Milano Bicocca Milan Italy
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35
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Wieling W, Kaufmann H, Claydon VE, van Wijnen VK, Harms MPM, Juraschek SP, Thijs RD. Diagnosis and treatment of orthostatic hypotension. Lancet Neurol 2022; 21:735-746. [PMID: 35841911 PMCID: PMC10024337 DOI: 10.1016/s1474-4422(22)00169-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 01/24/2023]
Abstract
Orthostatic hypotension is an unusually large decrease in blood pressure on standing that increases the risk of adverse outcomes even when asymptomatic. Improvements in haemodynamic profiling with continuous blood pressure measurements have uncovered four major subtypes: initial orthostatic hypotension, delayed blood pressure recovery, classic orthostatic hypotension, and delayed orthostatic hypotension. Clinical presentations are varied and range from cognitive slowing with hypotensive unawareness or unexplained falls to classic presyncope and syncope. Establishing whether symptoms are due to orthostatic hypotension requires careful history taking, a thorough physical examination, and supine and upright blood pressure measurements. Management and prognosis vary according to the underlying cause, with the main distinction being whether orthostatic hypotension is neurogenic or non-neurogenic. Neurogenic orthostatic hypotension might be the earliest clinical manifestation of Parkinson's disease or related synucleinopathies, and often coincides with supine hypertension. The emerging variety of clinical presentations advocates a stepwise, individualised, and primarily non-pharmacological approach to the management of orthostatic hypotension. Such an approach could include the cessation of blood pressure lowering drugs, adoption of lifestyle measures (eg, counterpressure manoeuvres), and treatment with pharmacological agents in selected cases.
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Affiliation(s)
- Wouter Wieling
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Victoria E Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Veera K van Wijnen
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Mark P M Harms
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands; UCL Queen Square Institute of Neurology, University College London, London, UK; Stichting Epilepsie Instellingen Nederland, Heemstede, Netherlands.
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36
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Comparison of pain-provoked versus standard 40-min tilt table test for the conformation of vasovagal syncope. Neurol Sci 2022; 43:4847-4851. [DOI: 10.1007/s10072-022-06079-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/15/2022] [Indexed: 10/18/2022]
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37
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Heinrich T, Sehner S, Wageringel I, Ehmke H, Schwoerer AP. The baroreceptor reflex brought to life outside the classroom - an e-learning based asynchronous laboratory class using a non-supervised modified Active Standing Test. BMC MEDICAL EDUCATION 2022; 22:515. [PMID: 35778720 PMCID: PMC9250187 DOI: 10.1186/s12909-022-03573-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 06/21/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND E-learning based laboratory classes can replace or enhance in-classroom laboratories. They typically offer temporal flexibility, self-determined learning speed, repeatability and do not require supervision or face-to-face contact. The aim of this feasibility study was to investigate whether the established in-classroom laboratory class on the baroreceptor reflex (BRR) can be transformed into a new e-learning based asynchronous laboratory class for untrained, non-supervised students without medical equipment. The BRR is a fundamental cardiovascular process which is regularly visualized in physiology during in-classroom laboratories by a student-performed Active Standing Test (AST). During this voluntary provocation of orthostatic stress, the BRR reliably causes a solid rise in heart rate (HR) and a stabilization or even increase in blood pressure (BP). METHODS The conventional AST was modified by omission of BP measurements which would require medical devices and was embedded into a framework of interactive digital material allowing independent student performance. With specific adaptions, this instrument was implemented to 1st and 2nd year curricula of human medicine, dental medicine, midwifery and pharmacy. An audience response system was used to collect the students' data on HR, epidemiology, technical problems, satisfaction and orthostatic symptoms. As primary outcome, we investigated the students' correct performance of the modified AST regarding textbook conformity of the HR data. Secondary outcomes included technical feasibility, the students' satisfaction and consistency of HR data within predefined subgroups (e.g., gender, curricula). Descriptive statistics are reported. RESULTS The class was completed by 217 students (mean age: 23 ± 8 [SD], 81% female, 19% male). Mean reported rise of HR during standing was ~ 20 bpm (~ 30%) which is highly concordant to textbooks. Reported feasibility (~ 80% negated any technical issues) and students' satisfaction (4.4 on 5-point Likert-scale) were high. The HR data were consistent within the subgroups. CONCLUSION This study demonstrates that the highly relevant BRR can be successfully addressed in an e-learning based asynchronous laboratory class implementing a non-supervised AST restricted to HR measurements embedded in digital material. The robust HR response and the adjustable complexity allow an application to different healthcare-related curricula. This class, therefore, provides a broad audience access to a fundamental concept of cardiovascular physiology.
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Affiliation(s)
- Tobias Heinrich
- Department of Cellular and Integrative Physiology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Susanne Sehner
- Department of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Isabel Wageringel
- Department of Cellular and Integrative Physiology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Heimo Ehmke
- Department of Cellular and Integrative Physiology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Alexander Peter Schwoerer
- Department of Cellular and Integrative Physiology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
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38
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Lisboa da Silva RMF, Oliveira PML, Tonelli HAF, Alves Meira ZM, Mota CDCC. Neurally Mediated Syncope in Children and Adolescents: An Updated Narrative Review. Open Cardiovasc Med J 2022. [DOI: 10.2174/18741924-v16-e2205110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Syncope presents a proportion of up to 25% among children and adolescents and accounts for 0.9% of emergency room visits. Its most frequent aetiology is neurally mediated syncope, which includes vasovagal syncope and orthostatic hypotension. Up to 70% of the paediatric population with reflex syncope is female. There are usually precipitating factors and prodromes. This mini-review will discuss the particularities of the clinical presentation, diagnosis, modified Calgary score, indications and accuracy of the head-up tilt test, classification, and pathophysiology in four sequential phases. Prognostic data and the non-pharmacological and pharmacological approaches will also be reviewed and differences regarding reflex syncope in adults will be discussed.
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39
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Morrow AK, Malone LA, Kokorelis C, Petracek LS, Eastin EF, Lobner KL, Neuendorff L, Rowe PC. Long-Term COVID 19 Sequelae in Adolescents: the Overlap with Orthostatic Intolerance and ME/CFS. CURRENT PEDIATRICS REPORTS 2022; 10:31-44. [PMID: 35287333 PMCID: PMC8906524 DOI: 10.1007/s40124-022-00261-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 12/13/2022]
Abstract
Purpose of Review To discuss emerging understandings of adolescent long COVID or post-COVID-19 conditions, including proposed clinical definitions, common symptoms, epidemiology, overlaps with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and orthostatic intolerance, and preliminary guidance on management. Recent Findings The recent World Health Organization clinical case definition of post-COVID-19 condition requires a history of probable or confirmed SARS-CoV-2 infection, with symptoms starting within 3 months of the onset of COVID-19. Symptoms must last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms of the post-COVID-19 condition include, but are not limited to, fatigue, shortness of breath, and cognitive dysfunction. These symptoms generally have an impact on everyday functioning. The incidence of prolonged symptoms following SARS-CoV-2 infection has proven challenging to define, but it is now clear that those with relatively mild initial infections, without severe initial respiratory disease or end-organ injury, can still develop chronic impairments, with symptoms that overlap with conditions like ME/CFS (profound fatigue, unrefreshing sleep, post-exertional malaise, cognitive dysfunction, and orthostatic intolerance). Summary We do not yet have a clear understanding of the mechanisms by which individuals develop post-COVID-19 conditions. There may be several distinct types of long COVID that require different treatments. At this point, there is no single pharmacologic agent to effectively treat all symptoms. Because some presentations of post-COVID-19 conditions mimic disorders such as ME/CFS, treatment guidelines for this and related conditions can be helpful for managing post-COVID-19 symptoms. Supplementary Information The online version contains supplementary material available at 10.1007/s40124-022-00261-4.
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Affiliation(s)
- Amanda K Morrow
- Kennedy Krieger Institute, Baltimore, MD USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Laura A Malone
- Kennedy Krieger Institute, Baltimore, MD USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Christina Kokorelis
- Kennedy Krieger Institute, Baltimore, MD USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Lindsay S Petracek
- Department of Pediatrics, Division of Adolescent/Young Adult Medicine, Johns Hopkins University School of Medicine, 200 N Wolfe St, Room 2077, Baltimore, MD USA
| | - Ella F Eastin
- Department of Pediatrics, Division of Adolescent/Young Adult Medicine, Johns Hopkins University School of Medicine, 200 N Wolfe St, Room 2077, Baltimore, MD USA
| | | | - Luise Neuendorff
- Division of Cardiology, Department of Internal Medicine, University of Toronto, Toronto, Canada
| | - Peter C Rowe
- Department of Pediatrics, Division of Adolescent/Young Adult Medicine, Johns Hopkins University School of Medicine, 200 N Wolfe St, Room 2077, Baltimore, MD USA
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40
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Peebles KC, Tan I, Butlin M, Collins F, Tofts L, Avolio AP, Pacey V. The prevalence and impact of orthostatic intolerance in young women across the hypermobility spectrum. Am J Med Genet A 2022; 188:1761-1776. [PMID: 35224842 PMCID: PMC9305471 DOI: 10.1002/ajmg.a.62705] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 01/16/2022] [Accepted: 02/08/2022] [Indexed: 11/10/2022]
Abstract
Orthostatic intolerance (OI) is frequently reported in young women with generalized hypermobility spectrum disorder (G-HSD) and hypermobile EDS (hEDS). However, it remains currently unclear whether OI is a comorbidity or fundamental part of the pathophysiology of G-HSD or hEDS. This study investigated the prevalence and impact of OI in young women across the hypermobility spectrum. Forty-five women (14-30 years, 15 controls, 15 G-HSD, and 15 hEDS) undertook a head-up tilt (HUT) and active stand test. Postural Orthostatic Tachycardia Syndrome (POTS) and Orthostatic Hypotension (OH) were assessed using age-related criteria. Autonomic dysfunction and quality-of-life questionnaires were also completed. The prevalence of POTS was higher in women with G-HSD than hEDS and control groups during HUT (43% vs. 7% and 7%, respectively, p < 0.05), but similar between groups during the active stand (47%, 27%, and 13% for G-HSD, hEDS, and control, respectively). No participants had OH. hEDS and G-HSD participants reported more severe orthostatic symptoms and poorer quality of life than controls. Although POTS was observed in hypermobile participants, there is no conclusive evidence that its prevalence differed between groups due to differences between the HUT and active stand assessments. Nevertheless, OI and broader autonomic dysfunction impacted on their quality of life.
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Affiliation(s)
- Karen C Peebles
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Isabella Tan
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Mark Butlin
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Felicity Collins
- Department of Medical Genomics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Louise Tofts
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.,Narrabeen Sports and Exercise Medicine Centre, Sydney, Australia
| | - Alberto P Avolio
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Verity Pacey
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
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41
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Struhal W, Hain B. A new light on an old condition. Eur Heart J Case Rep 2021; 5:ytab499. [PMID: 34993411 PMCID: PMC8716748 DOI: 10.1093/ehjcr/ytab499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 09/21/2021] [Accepted: 11/30/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Walter Struhal
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500 Krems, Austria
- Department of Neurology, University Hospital Tulln, Alter Ziegelweg 10, 3430 Tulln, Austria
| | - Barbara Hain
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500 Krems, Austria
- Department of Neurology, University Hospital Tulln, Alter Ziegelweg 10, 3430 Tulln, Austria
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42
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Post-Acute Sequelae of COVID-19 and Cardiovascular Autonomic Dysfunction: What Do We Know? J Cardiovasc Dev Dis 2021; 8:jcdd8110156. [PMID: 34821709 PMCID: PMC8621226 DOI: 10.3390/jcdd8110156] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023] Open
Abstract
Post-acute sequelae of SARS-CoV-2 (PASC), or long COVID syndrome, is emerging as a major health issue in patients with previous SARS-CoV-2 infection. Symptoms commonly experienced by patients include fatigue, palpitations, chest pain, dyspnea, reduced exercise tolerance, and “brain fog”. Additionally, symptoms of orthostatic intolerance and syncope suggest the involvement of the autonomic nervous system. Signs of cardiovascular autonomic dysfunction appear to be common in PASC and are similar to those observed in postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. In this review, we report on the epidemiology of PASC, discuss current evidence and possible mechanisms underpinning the dysregulation of the autonomic nervous system, and suggest nonpharmacological and pharmacological interventions to treat and relieve symptoms of PASC-associated dysautonomia.
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43
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van Dijk JG, Thijs RD. Rethinking neurological attitudes towards vasovagal syncope: The European Federation of Autonomic Societies (EFAS) recommendations regarding tilt table testing. Eur J Neurol 2021; 28:e69-e70. [PMID: 34117676 DOI: 10.1111/ene.14963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 11/30/2022]
Affiliation(s)
- J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.,Stichting Epilepsie Instellingen Nederland, Heemstede, The Netherlands
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44
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Wieling W, Kaufmann H. What is the best method to diagnose a vasovagal syncope? Clin Auton Res 2021; 31:347-349. [PMID: 33961160 DOI: 10.1007/s10286-021-00809-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 01/21/2023]
Affiliation(s)
- Wouter Wieling
- Department of Internal Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Secretary D3, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, USA
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45
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Saal DP, Thijs RD, Bootsma M, Brignole M, van Dijk JG. Five cases of complete atrioventricular block induced by bending forward: unusual but not unique. Europace 2021; 23:1487-1492. [PMID: 33693701 DOI: 10.1093/europace/euab044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 02/17/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS We describe five patients with syncope caused by a complete atrioventricular block (AVB) while they were bending forward, not rising after bending, and aim to describe the occurrence and the association between bending forward and AVB. METHODS AND RESULTS In two patients, bending forward was the exclusive trigger for syncope, while in the remaining three, other postural changes (sitting down, standing up, and exertion) could also provoke syncope. Complete AVB as the cause of syncope was documented using ECG monitoring in two cases and an implantable loop recorder in the other three. Ectopic beats without preceding sinus slowing occurred before syncope in four cases. Two cases had a left bundle branch block. All patients responded favourably to cardiac pacing. CONCLUSION This is the first case series on complete AVB provoked by bending forward. Syncope during bending forward should suggest a search for an AVB. Arguments in favour of a vagal mechanism were syncope triggered by bending forward, and that other triggers could also evoke syncope. However, the absence of sinus slowing before syncope in some cases and the fact that bending forward did not seem to provoke reflex syncope without AVB, cast doubts on a reflex mechanism. There were also arguments favouring conduction disorder: i.e. ectopic beats before syncope and pre-existing conduction disturbances in two cases. The cases are reminiscent of paroxysmal AVB. Discrimination between paroxysmal AVB and vagal AVB is important because a pacemaker is warranted in arrhythmic complete AVB, while the benefit is limited or absent in reflex AVB.
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Affiliation(s)
- Dirk P Saal
- Department of Neurology & Clinical Neurophysiology, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Neurology, Franciscus Gasthuis en Vlietland Hospital, PO 215, 3100 AE Rotterdam/Schiedam, The Netherlands
| | - Roland D Thijs
- Department of Neurology & Clinical Neurophysiology, Leiden University Medical Centre, Leiden, The Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - Marianne Bootsma
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Ospedale San Luca, Milano, Italy.,Arrhythmology Centre and Syncope Unit, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - J Gert van Dijk
- Department of Neurology & Clinical Neurophysiology, Leiden University Medical Centre, Leiden, The Netherlands
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