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Habek M, Junaković A, Karić A, Crnošija L, Barun B, Gabelić T, Adamec I, Krbot Skorić M. Short- and long-term effects of siponimod on autonomic nervous system in secondary progressive multiple sclerosis. Mult Scler Relat Disord 2022; 64:103966. [PMID: 35724530 DOI: 10.1016/j.msard.2022.103966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/13/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the short- and long-term effects of siponimod on autonomic nervous system (ANS) function, in people with secondary progressive multiple sclerosis (pwSPMS) METHODS: The following ANS tests were performed in 26 pwSPMS: a 10 min supine resting position, Valsalva maneuver, deep breathing test and a 10 min tilt-up table test. Heart rate variability (HRV) was performed for the 10 min in supine resting position (M0) and for a 3 h period after siponimod treatment initiation (M0s1-6). All ANS tests were repeated after at least 6 months of treatment with siponimod (M6). RESULTS In all 6 intervals after siponimod ingestion (M0s1-6), standard deviation of NN intervals (SDNN) was higher compared to M0. After 6 months of continuous treatment with siponimod, SDNN was significantly lower compared to M0. At M6, Valsalva ratio and respiratory sinus arrhythmia were lower compared to M0 values (1.510±0.338 vs 1.864±0.456, p=0.003 and 7.969±2.865 vs 13.091±4.687, p<0.001, respectively). Cardiovagal index was significantly higher at M6 compared to M0 (1 (range 0-2) vs 0 (range 0-1), p=0.008, respectively). Active Magnetic Resonance Imaging (MRI) one year prior to starting siponimod was a positive predictor of M6 SDNN and Adrenergic Index (AI) at M0 was a negative predictor of M6 SDNN. CONCLUSION This study has shown an inverse relationship in short- versus long-term effects of siponimod on ANS function. A shift towards parasympathetic predominance was observed during the first three hours after ingestion, while after 6 or more months of continuous treatment with siponimod, a shift towards sympathetic predominance was observed.
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Affiliation(s)
- Mario Habek
- Department of Neurology, University Hospital Center Zagreb, Kišpatićeva 12, Zagreb HR-10000, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia.
| | | | - Antea Karić
- Department of Neurology, University Hospital Center Zagreb, Kišpatićeva 12, Zagreb HR-10000, Croatia
| | - Luka Crnošija
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Barbara Barun
- Department of Neurology, University Hospital Center Zagreb, Kišpatićeva 12, Zagreb HR-10000, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Tereza Gabelić
- Department of Neurology, University Hospital Center Zagreb, Kišpatićeva 12, Zagreb HR-10000, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Adamec
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Magdalena Krbot Skorić
- School of Medicine, University of Zagreb, Zagreb, Croatia; Faculty of Electrical Engineering and Computing, University of Zagreb, Zagreb, Croatia
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Findling O, Hauer L, Pezawas T, Rommer PS, Struhal W, Sellner J. Cardiac Autonomic Dysfunction in Multiple Sclerosis: A Systematic Review of Current Knowledge and Impact of Immunotherapies. J Clin Med 2020; 9:E335. [PMID: 31991711 PMCID: PMC7073977 DOI: 10.3390/jcm9020335] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 01/14/2020] [Accepted: 01/19/2020] [Indexed: 12/14/2022] Open
Abstract
Cardiac autonomic dysfunction (CAD) has been reported in patients with multiple sclerosis (MS). This systematic review summarizes the evidence for the types and prevalence of CAD in MS patients, as well as its association with MS type, disease characteristics, fatigue and immunotherapies used to treat MS. The analysis revealed that CAD is correlated with pathophysiological processes of MS, can trigger serious cardiovascular complications that may reduce life expectancy, and may have implications for treatment with immunotherapies, especially fingolimod. Numerous mainly small case-control or cohort studies have reported various measures of CAD (particularly heart rate variation) in MS patients, showing higher rates of abnormality versus controls. A smaller number of studies have reported on cardiac autonomic symptoms in MS, including orthostatic intolerance/dizziness in around 50% of patients. CAD also appears to be associated with disease duration and to be more common in progressive than relapsing-remitting MS. However, although a substantial evidence base suggests that assessing CAD in people with MS may be important, standardised methods to evaluate CAD in these patients have not yet been established. In addition, no studies have yet looked at whether treating CAD can reduce the burden of MS symptoms, disease activity or the rate of progression.
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Affiliation(s)
- Oliver Findling
- Department of Neurology, Kantonsspital Aarau, 5001 Aarau, Switzerland;
- Department of Neurology, University Hospital Tulln, Karl-Landsteiner-University, 3420 Tulln, Austria;
| | - Larissa Hauer
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria;
| | - Thomas Pezawas
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria;
| | - Paulus S. Rommer
- Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Walter Struhal
- Department of Neurology, University Hospital Tulln, Karl-Landsteiner-University, 3420 Tulln, Austria;
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, 2130 Mistelbach, Austria
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, 81675 München, Germany
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria
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Küçük B, Hamamcı M, Aslan Bayhan S, Bayhan HA, Inan LE. Amplitude of Accommodation in Patients with Multiple Sclerosis. Curr Eye Res 2019; 44:1271-1277. [DOI: 10.1080/02713683.2019.1629596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Bekir Küçük
- Department of Ophthalmology, The Bozok University School of Medicine, Yozgat, Turkey
| | - Mehmet Hamamcı
- Department of Neurology, The Bozok University School of Medicine, Yozgat, Turkey
| | - Seray Aslan Bayhan
- Department of Ophthalmology, The Bozok University School of Medicine, Yozgat, Turkey
| | - Hasan Ali Bayhan
- Department of Ophthalmology, The Bozok University School of Medicine, Yozgat, Turkey
| | - Levent Ertuğrul Inan
- Department of Neurology, The Bozok University School of Medicine, Yozgat, Turkey
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Habek M, Crnošija L, Gabelić T, Barun B, Adamec I, Junaković A, Ruška B, Pavičić T, Krbot Skorić M. Longitudinal assessment of autonomic nervous system in patients with first demyelinating event suggestive of multiple sclerosis. Eur J Neurol 2019; 26:1377-1383. [PMID: 31099944 DOI: 10.1111/ene.13989] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 05/13/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE As a high proportion of people with clinically isolated syndrome (pwCIS) exhibit sympathetic adrenergic and sudomotor dysfunction, the aim of this study was to investigate the evolution of autonomic nervous system (ANS) abnormalities in pwCIS over a 2-year follow-up. METHODS This was a prospective cohort study in which 121 pwCIS were enrolled and followed for 2 years. After 2-year follow-up, data were available for 84 pwCIS. ANS symptoms were evaluated with the Composite Autonomic System Score-31 (COMPASS-31) and results of the ANS tests were expressed using the Composite Autonomic Scoring Scale (CASS) at baseline and visit at month 24. Symptomatic dysautonomia was defined if the patient had a COMPASS-31 value above the median of the whole cohort at baseline evaluation (COMPASS-31 > 6.79) and CASS score >0. RESULTS Complete CASS data at baseline and month 24 were available for 62 patients; in 24 (38.7%) patients there was worsening, in 16 (25.8%) there was improvement and in 22 (35.5%) there was no change in CASS score. In 90% of pwCIS (72 of 80) there was no change in parasympathetic nervous system tests, whereas 47.3% (35 of 74) had either worsening or improvement in sympathetic adrenergic and 28.6% (20 of 70) had either worsening or improvement in sudomotor function. A multivariable regression model identified the total number of T2 lesions as an independent predictor for worsening of symptomatic dysautonomia. No predictors for worsening or improving of CASS score were identified. CONCLUSION A substantial proportion of pwCIS experienced worsening of ANS abnormalities during the 2-year follow-up and magnetic resonance imaging parameters seemed to predict these abnormalities.
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Affiliation(s)
- M Habek
- Department of Neurology, Referral Center for Autonomic Nervous System Disorders, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - L Crnošija
- Department of Neurology, Referral Center for Autonomic Nervous System Disorders, University Hospital Center Zagreb, Zagreb, Croatia
| | - T Gabelić
- Department of Neurology, Referral Center for Autonomic Nervous System Disorders, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - B Barun
- Department of Neurology, Referral Center for Autonomic Nervous System Disorders, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - I Adamec
- Department of Neurology, Referral Center for Autonomic Nervous System Disorders, University Hospital Center Zagreb, Zagreb, Croatia
| | - A Junaković
- Department of Neurology, Referral Center for Autonomic Nervous System Disorders, University Hospital Center Zagreb, Zagreb, Croatia
| | - B Ruška
- Department of Neurology, Referral Center for Autonomic Nervous System Disorders, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - T Pavičić
- Department of Neurology, Referral Center for Autonomic Nervous System Disorders, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - M Krbot Skorić
- Department of Neurology, Referral Center for Autonomic Nervous System Disorders, University Hospital Center Zagreb, Zagreb, Croatia.,Faculty of Electrical Engineering and Computing, University of Zagreb, Zagreb, Croatia
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Habek M. Immune and autonomic nervous system interactions in multiple sclerosis: clinical implications. Clin Auton Res 2019; 29:267-275. [PMID: 30963343 DOI: 10.1007/s10286-019-00605-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/28/2019] [Indexed: 12/25/2022]
Abstract
Multiple sclerosis is characterized by a wide spectrum of clinical manifestations, among which dysfunction of the autonomic nervous system represents an important cause of multiple sclerosis-related disability. The aim of this review is to provide an overview of autonomic dysfunction in people with multiple sclerosis, and to discuss the interactions between the immune and autonomic nervous systems and the effects of these interactions on various aspects of multiple sclerosis. Autonomic dysfunction in people with multiple sclerosis can be demonstrated clinically and on a molecular level. Clinically, it can be demonstrated by measuring autonomic symptoms with the Composite Autonomic Symptom Score (COMPASS-31), and neurophysiologically, with different autonomic nervous system tests. Both symptomatic and objectively determined autonomic dysfunction can be associated with increased risk of multiple sclerosis disease activity. Further supporting these clinical observations are molecular changes in immune cells. Changes in the sympathetic autonomic system, such as different expression of dopaminergic and adrenergic receptors on immune cells, or modulation of the cholinergic anti-inflammatory pathway over different subunits of the nicotinic acetylcholine receptor in the peripheral immune system, may mediate different effects on multiple sclerosis disease activity.
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Affiliation(s)
- Mario Habek
- Department of Neurology, Referral Center for Autonomic Nervous System Disorders, University Hospital Center Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia. .,School of Medicine, University of Zagreb, Zagreb, Croatia.
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Characterisation of cardiac autonomic function in multiple sclerosis based on spontaneous changes of heart rate and blood pressure. Mult Scler Relat Disord 2018; 22:120-127. [DOI: 10.1016/j.msard.2018.03.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/08/2018] [Accepted: 03/23/2018] [Indexed: 12/12/2022]
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Ferreira D, Castro P, Videira G, Filipe JP, Santos R, Sá MJ, Azevedo E, Abreu P. Cerebral autoregulation is preserved in multiple sclerosis patients. J Neurol Sci 2017; 381:298-304. [PMID: 28991702 DOI: 10.1016/j.jns.2017.09.009] [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: 07/02/2017] [Revised: 08/23/2017] [Accepted: 09/06/2017] [Indexed: 11/16/2022]
Abstract
Multiple sclerosis (MS) is an inflammatory disease that may also be associated with vascular dysfunction. One master component of vascular regulation is cerebral autoregulation (CA). We aimed to investigate the integrity of CA in MS patients and study its relationship with autonomic dysfunction (AD), magnetic-resonance-imaging (MRI) lesion load and hemodynamic parameters. We enrolled 20 relapsing-remitting MS and 20 healthy subjects. CA was assessed by transfer function analysis parameters (coherence, gain and phase), as obtained in the very low, low and high-frequency domains (VLF, LF, HF, respectively). We evaluated the autonomic parameters heart rate variability and spontaneous baroreflex sensitivity (BRS). There were no significant differences in CA parameters between MS and controls (p>0.05). Lesion load was not correlated with any CA parameter. LF gain was positively correlated with BRS in both groups (MS: p=0.017; controls: p=0.025). Brainstem lesion load in MS was associated with higher systolic blood pressure (SBP; p=0.009). Our findings suggest that CA is preserved in our MS cohort. On the other hand, AD in MS patients with brainstem lesions could contribute to the increase of supine SBP. Whether this systemic deregulation could contribute to disease burden remains to be investigated.
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Affiliation(s)
- Daniel Ferreira
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, 4200-319 Porto, Portugal.
| | - Pedro Castro
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, 4200-319 Porto, Portugal; Department of Neurology, São João Hospital Center, 4200-319 Porto, Portugal
| | - Gonçalo Videira
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, 4200-319 Porto, Portugal
| | - João Pedro Filipe
- Department of Neuroradiology, Hospital Center São João, 4200-319 Porto, Portugal
| | - Rosa Santos
- Department of Neurology, São João Hospital Center, 4200-319 Porto, Portugal
| | - Maria José Sá
- Department of Neurology, São João Hospital Center, 4200-319 Porto, Portugal; Faculty of Health Sciences, University Fernando Pessoa, 4249-004 Porto, Portugal
| | - Elsa Azevedo
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, 4200-319 Porto, Portugal; Department of Neurology, São João Hospital Center, 4200-319 Porto, Portugal
| | - Pedro Abreu
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, 4200-319 Porto, Portugal; Department of Neurology, São João Hospital Center, 4200-319 Porto, Portugal
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Mikkola A, Ojanen A, Hartikainen JEK, Remes AM, Simula S. The impact of multiple sclerosis onset symptom on cardiac repolarization. Brain Behav 2017; 7:e00742. [PMID: 28729944 PMCID: PMC5516612 DOI: 10.1002/brb3.742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 04/29/2017] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Multiple sclerosis is associated with prolonged cardiac repolarization but the underlying physiology has remained unknown. In this study, we compared cardiac repolarization during the relapsing-remitting multiple sclerosis (RRMS) disease course in patients with motor and sensory onset symptom. METHODS Twenty-five RRMS patients with motor and 33 RRMS patients with sensory onset symptom having 12-lead electrocardiogram (ECG) recorded at the time of the first demyelinating event (ECG1) as well as at the later disease course (ECG2) were identified from the patient records. The average time interval between ECG1 and ECG2 was 8.6 ± 5.9 y. Heart rate-corrected QT intervals reflecting cardiac repolarization were calculated by Bazett (QTcBaz), Fridericia (QTcFri), and Karjalainen (QTcKar) formulas. RESULTS Heart rate-corrected QT intervals as well as heart rate were similar in patients with motor and sensory onset symptom in ECG1. However, QTcBaz (p = .002), QTcFri (p = .019), and QTcKar (p = .026) were longer and heart rate was higher (p = .035) in patients with motor than sensory onset symptom in ECG2. Correspondingly, QTcBaz (p = .002), QTcFri (p = .033), and QTcKar (p = .043) prolonged and heart rate tended to increase (p = .060) during the disease course only in the patients with motor onset symptom. CONCLUSIONS Cardiac repolarization prolonged and heart rate increased during the disease course in RRMS patients with motor but not with sensory onset symptom. This suggests different traits in RRMS according to its initial manifestation and also association of motor onset symptom with more unfavorable cardiovascular prognostic determinants.
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Affiliation(s)
- Alma Mikkola
- Department of NeurologyKuopio University HospitalKuopioFinland
- Institute of Clinical Medicine – NeurologyUniversity of Eastern FinlandKuopioFinland
| | - Aku Ojanen
- Department of Clinical Physiology and Nuclear MedicineMikkeli Central HospitalMikkeliFinland
| | - Juha E. K. Hartikainen
- Heart CenterKuopio University HospitalKuopioFinland
- Institute of Clinical Medicine – MedicineUniversity of Eastern FinlandKuopioFinland
| | - Anne M. Remes
- Department of NeurologyKuopio University HospitalKuopioFinland
- Institute of Clinical Medicine – NeurologyUniversity of Eastern FinlandKuopioFinland
- Medical Research CenterOulu University HospitalOuluFinland
- Research Unit of Clinical Neuroscience, NeurologyUniversity of OuluOuluFinland
| | - Sakari Simula
- Department of NeurologyMikkeli Central HospitalMikkeliFinland
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Huang M, Allen DR, Keller DM, Fadel PJ, Frohman EM, Davis SL. Impaired carotid baroreflex control of arterial blood pressure in multiple sclerosis. J Neurophysiol 2016; 116:81-7. [PMID: 27075533 DOI: 10.1152/jn.00003.2016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/08/2016] [Indexed: 11/22/2022] Open
Abstract
Multiple sclerosis (MS), a progressive neurological disease, can lead to impairments in the autonomic control of cardiovascular function. We tested the hypothesis that individuals with relapsing-remitting MS (n = 10; 7 females, 3 males; 13 ± 4 yr from diagnosis) exhibit impaired carotid baroreflex control of blood pressure and heart rate compared with sex, age, and body weight-matched healthy individuals (CON: n = 10; 7 females, 3 males). At rest, 5-s trials of neck pressure (NP; +40 Torr) and neck suction (NS; -60 Torr) were applied to simulate carotid hypotension and hypertension, respectively, while mean arterial pressure (MAP; finger photoplethysmography), heart rate (HR), cardiac output (CO; Modelflow), and total vascular conductance (TVC) were continuously measured. In response to NP, there was a blunted increase in peak MAP responses (MS: 5 ± 2 mmHg) in individuals with MS compared with healthy controls (CON: 9 ± 3 mmHg; P = 0.005), whereas peak HR responses were not different between groups. At the peak MAP response to NP, individuals with MS demonstrated an attenuated decrease in TVC (MS, -10 ± 4% baseline vs. CON, -15 ± 4% baseline, P = 0.012), whereas changes in CO were similar between groups. Following NS, all cardiovascular responses (i.e., nadir MAP and HR and percent changes in CO and TVC) were not different between MS and CON groups. These data suggest that individuals with MS have impaired carotid baroreflex control of blood pressure via a blunted vascular conductance response resulting in a diminished ability to increase MAP in response to a hypotensive challenge.
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Affiliation(s)
- Mu Huang
- Applied Physiology and Wellness, Southern Methodist University, Dallas, Texas
| | - Dustin R Allen
- Applied Physiology and Wellness, Southern Methodist University, Dallas, Texas; Kinesiology, University of Texas at Arlington, Arlington, Texas; and
| | - David M Keller
- Kinesiology, University of Texas at Arlington, Arlington, Texas; and
| | - Paul J Fadel
- Kinesiology, University of Texas at Arlington, Arlington, Texas; and
| | - Elliot M Frohman
- Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Scott L Davis
- Applied Physiology and Wellness, Southern Methodist University, Dallas, Texas; Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
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Cortez M, Nagi Reddy S, Goodman B, Carter J, Wingerchuk D. Autonomic symptom burden is associated with MS-related fatigue and quality of life. Mult Scler Relat Disord 2015; 4:258-63. [DOI: 10.1016/j.msard.2015.03.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 01/19/2015] [Accepted: 03/27/2015] [Indexed: 10/28/2022]
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Autonomic dysfunction in multiple sclerosis: implications for exercise. Auton Neurosci 2014; 188:82-5. [PMID: 25458432 DOI: 10.1016/j.autneu.2014.10.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 09/11/2014] [Accepted: 10/13/2014] [Indexed: 01/17/2023]
Abstract
Multiple sclerosis (MS), a progressive neurological disease, can result in autonomic dysfunction. Impairments in the autonomic control of cardiovascular and thermoregulatory function during exercise have been observed in MS. Attenuated elevations in blood pressure during exercise in MS patients can negatively impact blood flow to skeletal muscle. Diminished sweating during exercise may impair heat dissipation likely limiting the exercise intensity that can be performed before detrimental core temperatures are reached. Further understanding the physiologic mechanisms of autonomic dysfunction during exercise in MS may lead to the development of novel therapeutic strategies targeted at improving quality of life in individuals with this disease.
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Abstract
Multiple sclerosis (MS) is the leading cause of neurological disability in young adults. Since the pathophysiology of MS is characterized by dissemination in space, as well as in time, the autonomic nervous system is inevitably damaged in the course of the disease in many patients and the proportion of affected patients increases with disease duration. Autonomic dysfunction (AD) in MS is explained by lesions in regions responsible for autonomic regulation such as nuclei in the periventricular region of fourth ventricle in the brainstem as well as medullar lesions. Reports about frequency of AD in MS patients vary notably between groups. Nevertheless its impact on quality of life is substantial but, unfortunately, often overlooked. The aim of this article is to present a concise review of various symptoms and signs of autonomic system dysfunction in MS.
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Affiliation(s)
- Ivan Adamec
- University Hospital Center Zagreb, Department of Neurology, Refferal Center for Demyelinating Diseases of the Central Nervous System, Zagreb, Croatia.
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13
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Reduced spontaneous sympathetic nerve activity in multiple sclerosis patients. J Neurol Sci 2014; 344:210-4. [PMID: 25034056 DOI: 10.1016/j.jns.2014.06.053] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 06/17/2014] [Accepted: 06/24/2014] [Indexed: 01/12/2023]
Abstract
For the first time, we obtained direct intra-neural measurements of muscle sympathetic nerve activity (MSNA) in relapsing-remitting multiple sclerosis (MS) patients to test the hypothesis that spontaneous resting MSNA is reduced in MS patients compared to age, sex-matched healthy controls. Spontaneous MSNA (microneurography; peroneal nerve), plasma norepinephrine, arterial blood pressure (finger photoplethysmography), and heart rate were measured at rest in three groups: 1) relapsing-remitting MS patients on disease modifying therapy only (MS-DT; n=6); 2) relapsing-remitting MS patients on disease modifying therapy and medications for MS-related symptoms that are known to effect the central nervous system (MS-DT/ST; n=5), and 3) healthy age and sex-matched controls (CON; n=6). Compared to the CON group, MSNA burst frequency (bursts/min) was significantly lower in both MS-DT (P=0.027) and MS-DT/ST groups (P=0.003). Similarly, MSNA burst incidence (bursts/100 heartbeats) was significantly reduced in both MS-DT (P=0.049) and MS-DT/ST groups (P=0.004) compared to the CON group. Burst frequency and burst incidence were not different between MS-DT and MS-DT/ST groups. Resting plasma norepinephrine was also significantly lower in both MS-DT (P=0.039) and MS-DT/ST groups (P=0.021) compared to the CON group. Reduced MSNA may signify an important dysfunction in autonomic control of cardiovascular function in patients with MS.
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Mezei Z, Olah L, Kardos L, Kovacs RK, Csiba L, Csepany T. Cerebrovascular hemodynamic changes in multiple sclerosis patients during head-up tilt table test: effect of high-dose intravenous steroid treatment. J Neurol 2013; 260:2335-42. [PMID: 23760630 DOI: 10.1007/s00415-013-6977-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 05/09/2013] [Accepted: 05/25/2013] [Indexed: 11/30/2022]
Abstract
Demyelination in multiple sclerosis (MS) may cause damage to the vegetative nervous system. Our objective was to examine cerebral autoregulation assessed via blood pressure and cerebral blood flow velocity fluctuations during head-up tilt table testing. We also investigated the effects of high-dose intravenous corticosteroid treatment. Transcranial Doppler registration of middle cerebral artery blood flow velocity and continuous blood pressure and heart rate monitoring were performed at rest and during tilt table testing in 30 MS patients. Ten age-matched healthy subjects were also examined as controls. Correlations between mean arterial blood pressure (MBP) and cerebral blood flow velocity (CBF) fluctuations were averaged, yielding the correlation coefficient index Mx. For a subgroup of 11 patients with acute exacerbations, results were also evaluated before and after methylprednisolone treatment (1 g/day intravenously for 5 days). No significant differences in the autoregulatory indices were seen between patients and controls, or between pre- and post-steroid results. Modeling CBF velocity changes associated with a 1-mmHg increase in MBP, significant differences (p < 0.05) were detected in patients vs. controls, and also after vs. before steroid administration. We conclude that cerebrovascular autoregulation impairments are detectable in early phase MS. Corticosteroid treatment has a significant effect on hemodynamic changes in acute exacerbations.
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Affiliation(s)
- Zsolt Mezei
- Department of Neurology, University of Debrecen, Moricz Zs. 22, Debrecen 4032, Hungary.
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Habek M. Evaluation of brainstem involvement in multiple sclerosis. Expert Rev Neurother 2013; 13:299-311. [DOI: 10.1586/ern.13.18] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Autonomic dysfunction presenting as postural orthostatic tachycardia syndrome in patients with multiple sclerosis. Int J Med Sci 2010; 7:62-7. [PMID: 20309394 PMCID: PMC2840604 DOI: 10.7150/ijms.7.62] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Accepted: 03/10/2010] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Autonomic dysfunction is common in patients suffering from multiple sclerosis (MS) and orthostatic dizziness occurs in almost 50% of these patients. However, there have been no reports on postural orthostatic tachycardia syndrome (POTS) in patients suffering from MS. METHODS The patients were included for analysis in this study if they had POTS with either a prior history of MS or having developed MS while being followed for POTS. Postural orthostatic tachycardia (POTS) is defined as symptoms of orthostatic intolerance(>6 months) accompanied by a heart rate increase of at least 30 beats/min (or a rate that exceeds 120 beats/min) that occurs in the first 10 minutes of upright posture or head up tilt test (HUTT) occurring in the absence of other chronic debilitating disorders. We identified nine patients with POTS who were suffering from MS as well. Each of these patients had been referred from various other centers for second opinions. RESULTS The mean age at the time of diagnosis of POTS was 49+/-9 years and eight of the 9 patients were women. Five patients (55%) had hyperlipidemia, 3 (33%) migraine and 2 (22%) patients had coronary artery disease and diabetes each. Fatigue and palpitations (on assuming upright posture) were the most common finding in our patients (9/9). All patients also had orthostatic dizziness. Syncope was seen in 5/9(55%) of patients. Four patients (44%), who did not have clear syncope, were having episodes of near syncope. The presence of POTS in our study population resulted in substantial limitation of daily activities. Following recognition and treatment of POTS, 6/9(66%), patients were able to resume daily activities of living. Their symptoms (especially fatigue and orthostatic intolerance) improved. The frequency and severity of syncope also improved. Three (33%) patients failed to show a good response to treatment. CONCLUSION Patients suffering from MS may manifest autonomic dysfunction by developing POTS. Early recognition and proper management may help improve the symptoms of POTS.
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Affiliation(s)
- Khalil Kanjwal
- Department of Medicine, Division of Cardiology Section of Electrophysiology, The University of Toledo, Toledo, OH 43614, USA
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Fjeldstad C, Frederiksen C, Fjeldstad AS, Bemben M, Pardo G. Arterial Compliance in Multiple Sclerosis: A Pilot Study. Angiology 2009; 61:31-6. [DOI: 10.1177/0003319709334120] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A reduction in arterial compliance in patients with autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus has been previously reported. It is caused by the effect that systemic inflammation has on the cardiovascular system. Multiple sclerosis (MS), an immune-mediated disease that exclusively affects the central nervous system (CNS), has a significant inflammatory component that is limited to that compartment. The potential effects of its inflammatory mediators in the cardiovascular system are largely unknown. Purpose: To examine large (C1) and small arterial compliance (C2) in patients with MS and compare them with healthy age-matched controls. To also determine whether any differences in C1 and C2 indices between participants diagnosed with relapsing remitting MS (RR-MS), secondary progressive MS (SP-MS), and controls exist. Methods: A total of 26 men and women between the ages of 18 and 64 diagnosed with MS and 25 healthy controls volunteered for this study. Arterial compliance was measured by using pulse contour analysis (PCA), which records and analyzes the blood pressure waveform data from the Arterial Pulse Wave Sensors. Results: Significant differences in C1 and C2 were found between young RR-MS and healthy young controls (P < .05), with the MS group showing lower arterial C1 and C2 compliance. No significant differences (P > .05) were seen for C1 or C2 values between older RR-MS, SP-MS, and healthy controls. Conclusion: Arterial compliance is significantly compromised in young individuals with MS, compared with age-matched controls, but not for older individuals, suggesting a systemic effect of an inflammatory process that predominantly affects the CNS.
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Affiliation(s)
- Cecilie Fjeldstad
- MS Center of Oklahoma, Mercy NeuroScience Institute, Oklahoma City, Oklahoma,
| | | | - Anette S. Fjeldstad
- Department of Medicine, Division of Geriatrics, University of Utah and GRECC, Utah
| | - Michael Bemben
- Department of Health and Exercise Science, University of Oklahoma, Norman, Oklahoma
| | - Gabriel Pardo
- MS Center of Oklahoma, Mercy NeuroScience Institute, Oklahoma City, Oklahoma
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Abstract
Multiple sclerosis (MS) is the most frequent chronic neurological disease affecting young persons in developed countries. MS is, however, considered as a secondary cause, of central origin, for autonomic dysfunction. The most common autonomic symptoms in MS are disorders of micturation, impotence, sudomotor and gastrointestinal disturbances, orthostatic intolerance as well as sleep disorders. The majority of the patients suffer at some period of the disease from lower urinary tract symptoms and sexual dysfunction. Awareness and treatment of these conditions is vital to improving health and quality of life in patients with MS. The increased understanding of the pathophysiological mechanisms in autonomic dysfunction in MS, along with technological and pharmaceutical developments has advanced our ability to treat the multiple aspects complicating autonomic failure in MS.
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Affiliation(s)
- Carl-Albrecht Haensch
- Dept. of Neurology, HELIOS Klinikum Wuppertal, Heusnerstr. 40, 42283, Wuppertal, Germany.
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Sanya EO, Tutaj M, Brown CM, Goel N, Neundörfer B, Hilz MJ. Abnormal heart rate and blood pressure responses to baroreflex stimulation in multiple sclerosis patients. Clin Auton Res 2005; 15:213-8. [PMID: 15944871 DOI: 10.1007/s10286-005-0274-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2003] [Accepted: 02/28/2005] [Indexed: 10/25/2022]
Abstract
Cardiovascular autonomic neuropathy has been previously reported in patients with multiple sclerosis (MS) using standard reflex tests. However, no study has separately evaluated both parasympathetic and sympathetic cardiovascular autonomic regulation. We therefore assessed the baroreflex-mediated vagal and sympathetic control of the heart rate and sympathetic control of the blood vessels in MS patients using sinusoidal neck stimulation. We studied 13 multiple sclerosis patients aged 28-58 years and 18 healthy controls aged 26-58 years. The carotid baroreflex was stimulated by sinusoidal neck suction (0 to -30 mmHg) at 0.1 Hz to assess the autonomic control of the heart and blood vessels, and at 0.2 Hz to assess the vagal control of the heart. Continuous recordings were made of blood pressure, electrocardiographic RR-interval and respiration, with breathing paced at 0.25 Hz. Spectral analysis was used to evaluate the magnitude of the low frequency (LF, 0.03-0.14 Hz) and high frequency (HF, 0.15-0.50 Hz) oscillations in RR-interval and blood pressure in response to the sinusoidal baroreceptor stimulation. Responses to the applied stimulus were assessed as the change in the spectral power of the RR-interval and blood pressure fluctuations at the stimulating frequency from the baseline values. The increase in the power of 0.1 Hz RR-interval oscillations during the 0.1 Hz neck suction was significantly smaller (p<0.01) in the MS patients (4.47+/-0.27 to 5.62+/-0.25 ln ms(2)) than in the controls (4.12+/-0.37 to 6.82+/-0.33 ln ms(2)). The increase in the power of 0.1 Hz systolic BP oscillations during 0.1 Hz neck suction was also significantly smaller (p<0.01) in the MS patients (0.99+/-0.19 to 1.96+/-0.39 mmHg(2)) than in the healthy controls (1.27+/-0.34 to 9.01+/-4.10 mmHg(2)). Neck suction at 0.2 Hz induced RR-interval oscillations at 0.2 Hz that were significantly smaller (p<0.05) in the patients (3.22+/-0.45 ln ms(2)) than in the controls (5.27+/-0.29 ln ms(2)). These results indicate that in MS patients, baroreflex dysfunction is not only restricted to the cardiovagal limb of the baroreflex, but that the sympathetic modulation of the blood vessels is also affected.
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Affiliation(s)
- Emmanuel O Sanya
- Autonomic Laboratory, Dept. of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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Egg R, Högl B, Glatzl S, Beer R, Berger T. Autonomic instability, as measured by pupillary unrest, is not associated with multiple sclerosis fatigue severity. Mult Scler 2002; 8:256-60. [PMID: 12120699 DOI: 10.1191/1352458502ms793oa] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Multiple sclerosis (MS) fatigue is one of the most common symptoms in MS, but its pathophysiology is still not understood Sympathovagal imbalance was suggested as a reason for fatigue in chronic fatigue syndrome. We examined the role of an imbalance in the central autonomic nervous system (ANS) as a cause of MS fatigue in 51 MS patients and a control group of 22 healthy volunteers. Fatigue was assessed with the revised MS Fatigue Severity Scale (FSS) and the Modified Fatigue Impact Scale (MFIS). Depression was evaluated with the Beck Depression Inventory (BDI). Disintegration of the central ANS expressed by pupillary fatigue waves was measured with pupillography and documented in the pupillary unrest index (PUI). All subjects had less than five points on the seven-point Stanford Sleepiness Scale and were therefore not sleepy. MS patients had significant higher mean FSS scores (p=0.001) and mean MFIS scores (p=0.003) than our control group. Mean BDI scores were significant higher (p=0.001) in the MS group, but were in the lowest score range (0-10 points) in both groups. Surprisingly, we found a statistically significant inverse correlation between PUI values and either FSS scores (p=0.001; r=-0.521) or MFIS scores (p=0.002; r=-0.423) in the MS group, but not in healthy participants. We therefore conclude that autonomic instability, as measured by pupillary unrest is not associated with MS fatigue severity.
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Affiliation(s)
- R Egg
- Department of Neurology, University Hospital Innsbruck, Austria
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Flachenecker P, Reiners K, Krauser M, Wolf A, Toyka KV. Autonomic dysfunction in multiple sclerosis is related to disease activity and progression of disability. Mult Scler 2001; 7:327-34. [PMID: 11724449 DOI: 10.1177/135245850100700509] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Autonomic dysfunction is frequently observed in patients with multiple sclerosis (MS) but the evolution over time and the relationship to clinical characteristics are not yet established. OBJECTIVES We investigated the correlation of disease activity and progression of disability with composite scores of cardiovascular autonomic dysfunction and serum levels of catecholamines in a cross-sectional study of patients with clinically active and clinically stable MS. In a longitudinal study of clinically active MS patients, we performed cardiovascular reflex tests for up to 2 years. METHODS Twenty-six patients with clinically active relapsing-remitting MS, age 33.0 +/- 7.3 years, and nine patients with clinically stable MS, age 41.3 +/- 10.9 were studied. Twenty-four healthy volunteers served as controls. Standard autonomic tests were repeated at 3, 6, 12, 18 and 24 months in 18 of the 26 active patients participating in a placebo-controlled trial with interferon-beta-1a. Parasympathetic dysfunction was assessed by heart rate response to the Valsalva manoeuvre, deep breathing and active change of posture, while sympathetic dysfunction was analysed by blood pressure response to active change of posture and to sustained handgrip, and by measuring levels of norepinephrine and epinephrine in serum obtained in the supine position. RESULTS In the cross-sectional study, the number of patients with at least one abnormal sympathetic test was higher in the 'active' patient group (39%) than in healthy controls (8%, P< 0.02) or 'stable' patients (0%, P< 0.04), while no difference was seen in the parasympathetic score. Median catecholamine levels were significantly lower in 'active' MS patients than in those with stable disease (norepinephrine, 204 ng/l (interquartile range 158-310 ng/l) vs 363 ng/l (269-507 ng/l), P<0.02 and epinephrine, 23 ng/l (16-28 ng/l) vs 32 ng/l (24-107 ng/l), P<0.04). In the subgroup of patients studied longitudinally, parasympathetic but not sympathetic dysfunction increased slightly during the follow-up period, with a significant correlation to the increase in clinical disability (r=0.7, P<0.002). No difference was seen for any of the autonomic scores between patients treated with interferon-beta (n=12) and those receiving placebo (n=6). During acute exacerbations, only parasympathetic dysfunction tended to increase in parallel with a deterioration in the EDSS. CONCLUSIONS Parasympathetic dysfunction was closely related to the progression of disability in patients with MS. In contrast, sympathetic dysfunction was associated to the clinical activity of MS. This is in line with previous observations suggesting that the autonomic nervous system may be intimately linked with the disordered immune regulation in MS.
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Affiliation(s)
- P Flachenecker
- Department of Neurology, Julius-Maximilians-Universität Würzburg, Germany
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Nasseri K, Uitdehaag BM, van Walderveen MA, Ader HJ, Polman CH. Cardiovascular autonomic function in patients with relapsing remitting multiple sclerosis: a new surrogate marker of disease evolution? Eur J Neurol 1999; 6:29-33. [PMID: 10209346 DOI: 10.1046/j.1468-1331.1999.610029.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Twenty patients with active relapsing remitting multiple sclerosis (MS) were examined annually for 2 years with a set of autonomic function tests (AFT) consisting of heart rate variability during deep breathing (IE), standing-up, and ratios of Valsalva manoeuvre (VR). Disease characteristics, including T2-weighted magnetic resonance imaging (MRI) of the brain and the expanded disability status scale (EDSS) score were documented each year within 1 week of the AFT. The EDSS score, MRI load lesion and VR did not change significantly over the follow-up period. The IE and initial heart-rate on standing during the first 30 s (DeltaHRMAX) showed significant worsening during follow-up. No relationship was found between deterioration of AFT and EDSS score, number of exacerbations, duration of disease, gender, age, size and number of lesions on MRI. We conclude that patients with active relapsing remitting MS show progression of autonomic dysfunction over a relatively short time. Therefore, in the absence of changes in clinical disability or brain MRI lesion load, AFT might be useful as a sensitive surrogate outcome measure for demonstrating subclinical change in MS.
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Affiliation(s)
- K Nasseri
- Department of Neurology, Free University Hospital, Amsterdam, The Netherlands
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