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Affiliation(s)
- Reena Sidhu
- University of Sheffield
- Department of Gastroenterology & Liver Unit, Royal Hallamshire Hospital
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
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Penny HA, Aziz I, Lam C. Mast cell activation and nutritional disorders in patients with hypermobility. Curr Opin Gastroenterol 2024; 40:225-232. [PMID: 38393310 DOI: 10.1097/mog.0000000000001008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
PURPOSE OF REVIEW Individuals with joint hypermobility disorders are increasingly referred to gastroenterology services for support with the investigation and management of gastrointestinal complaints. Individuals can present with a myriad of complex coexisting diagnoses, the inter-relationship of which is unclear. This review discusses the proposed association between hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorder (HSD) with disorders of mast cell activation and provides an overview of gastrointestinal symptoms and nutritional outcomes in this patient cohort. RECENT FINDINGS It is unclear whether a true association between hEDS/HSD and mast cell activation disorders exists. There is a high prevalence of nonspecific gastrointestinal symptoms in individuals with hEDS/HSD and patients may be at risk of macro-nutrient and micro-nutrient deficiencies, although the current evidence base is limited. SUMMARY We advocate a pragmatic approach to the investigation and management of gastrointestinal symptoms in patients with hEDS/HSD. This centres on excluding organic pathology, discussing the overlap with disorders of gut-brain interactions, trialling evidence-based therapies targeting individual symptoms, and supporting nutritional deficiencies where present via the least invasive approach. Engagement with a broad multidisciplinary team is also important to support the holistic needs of this patient cohort.
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Affiliation(s)
- Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals Foundation Trust
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Imran Aziz
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals Foundation Trust
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Ching Lam
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals Foundation Trust
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
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3
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Chai S, Roney P, Fagan J, Rosario ER. Assessment of a novel Ehlers-Danlos syndromes disability index. Front Rehabil Sci 2024; 5:1280582. [PMID: 38707743 PMCID: PMC11066269 DOI: 10.3389/fresc.2024.1280582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 04/08/2024] [Indexed: 05/07/2024]
Abstract
Background The Ehlers-Danlos syndromes (EDS) are a group of inherited connective tissue disorders characterized by disruptions in collagen synthesis and processing. These disorders lead to various symptoms, including hypermobility, musculoskeletal conditions, and chronic pain that can significantly limit patients' daily living. In the absence of a curative treatment, an EDS specific disability index that tracks changes in patient-reported outcomes can facilitate the investigation of new treatment options and enhance the quality of life for EDS patients. Methods An EDS-specific disability index was created using survey data and input from clinicians. A total of 222 EDS patients in a multidisciplinary clinical program completed the index during their initial visit. Exploratory and confirmatory factor analyses were conducted to determine the index's factor solution and assess its goodness-of-fit. Paired t-tests were performed with follow-up visit data collected over the course of one year. Results The exploratory and confirmatory factor analyses indicated a two-factor solution, accounting for 42.40% of the variance. The index demonstrated adequate fit to the data, supported by Tucker and Lewis's index (0.85) and root mean square error of approximation (0.1). Data from follow-up visits showed significant improvement in three symptom related variables and one function related variable in addition to the total score and the symptom subscale score when compared to the initial visit. Conclusion The development of an EDS-specific disability index is a crucial step in creating a clinical tool that enables healthcare professionals to gain a deeper understanding of the impact EDS has on patients' lives and potentially identify new therapeutic interventions.
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Affiliation(s)
- Stephen Chai
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, United States
| | - Patricia Roney
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, United States
| | - John Fagan
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, United States
| | - Emily Rose Rosario
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, United States
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Hamilton MJ. Mast Cell Activation Syndrome and Gut Dysfunction: Diagnosis and Management. Curr Gastroenterol Rep 2024; 26:107-114. [PMID: 38353900 DOI: 10.1007/s11894-024-00924-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE OF REVIEW Mast cell activation syndrome (MCAS) is a clinical disorder that may explain irritable bowel syndrome (IBS) type symptoms as well as other allergic symptoms experienced by an individual. The diagnosis and treatment of MCAS with specific focus on gastrointestinal (GI) manifestations is reviewed. RECENT FINDINGS Although biomarkers for MCAS remain elusive, testing for baseline serum tryptase will distinguish the type of mast cell disorder and urine tests for mast cell mediator metabolites may support the diagnosis. Endoscopy and Colonoscopy with biopsies is not used to diagnose MCAS but is important to rule out other conditions that may cause symptoms. There is increased awareness of the association between MCAS and autonomic dysfunction, small fiber neuropathy, and connective tissue disorders which all impact GI symptoms. MCAS is a disorder often of unknown etiology (idiopathic) and characterized by intermittent allergy type symptoms that affect multiple organ systems after exposure to a trigger. GI symptoms including abdominal cramping and loose stool are prominent and mimic those of IBS. Diagnostic testing is performed to assess for elevations in mast cell mediators during symptoms and to rule out other conditions. A comprehensive treatment plan includes medications that target mast cells, treatments for associated conditions including autonomic dysfunction, and management of comorbid psychiatric illness and nutritional deficits.
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Affiliation(s)
- Matthew J Hamilton
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Topan R, Pandya S, Williams S, Ruffle JK, Zarate-Lopez N, Aziz Q, Fikree A. Comprehensive Assessment of Nutrition and Dietary Influences in Hypermobile Ehlers-Danlos Syndrome-A Cross-Sectional Study. Am J Gastroenterol 2024; 119:727-738. [PMID: 37970870 DOI: 10.14309/ajg.0000000000002586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Disorders of gut-brain interaction (DGBI) are common in patients with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorder (hEDS/HSD). Food is a known trigger for DGBI symptoms, which often leads to dietary alterations and, increasingly, nutrition support. We aimed to explore dietary behaviors and influencing factors in patients with hEDS/HSD. METHODS In a cross-sectional study, patients with hEDS/HSD were recruited from Ehlers-Danlos Support UK (nontertiary) and tertiary neurogastroenterology clinics to complete questionnaires characterizing the following: dietary behaviors, nutrition support, DGBI (Rome IV), gastrointestinal symptoms, anxiety, depression, avoidant restrictive food intake disorder (ARFID), mast cell activation syndrome, postural tachycardia syndrome (PoTS), and quality of life. We used stepwise logistic regression to ascertain which factors were associated with dietary behaviors and nutrition support. RESULTS Of 680 participants (95% female, median age 39 years), 62.1% altered their diet in the last year and 62.3% regularly skipped meals. Altered diet was associated with the following: reflux symptoms ( P < 0.001), functional dyspepsia ( P = 0.008), reported mast cell activation syndrome ( P < 0.001), and a positive screen for ARFID, specifically fear of eating and low interest ( P < 0.001). Approximately 31.7% of those who altered their diet required nutrition support. The strongest predictor of requiring nutrition support was a positive screen for ARFID, specifically fear of eating (OR: 4.97, 95% CI: 2.09-11.8, P < 0.001). DISCUSSION Altered diet is very common in the patients with hEDS/HSD we studied and influenced by functional dyspepsia, reflux symptoms, and ARFID. Those with ARFID have a 4-fold increased risk of requiring nutrition support, and therefore, it is paramount that psychological support is offered in parallel with dietary support in the management of DGBI in hEDS/HSD.
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Affiliation(s)
- Rabia Topan
- Blizard Institute, Wingate Institute of Neurogastroenterology, Centre for Neuroscience, Surgery and Trauma, Barts and the London School of Medicine and Dentistry, Queen Mary University, London, United Kingdom
| | - Shraya Pandya
- Blizard Institute, Wingate Institute of Neurogastroenterology, Centre for Neuroscience, Surgery and Trauma, Barts and the London School of Medicine and Dentistry, Queen Mary University, London, United Kingdom
| | - Sarah Williams
- Department of Dietetics, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - James K Ruffle
- Blizard Institute, Wingate Institute of Neurogastroenterology, Centre for Neuroscience, Surgery and Trauma, Barts and the London School of Medicine and Dentistry, Queen Mary University, London, United Kingdom
| | - Natalia Zarate-Lopez
- Gastrointestinal Physiology Unit, University College Hospitals NHS Foundation Trust, Division of Surgery and Interventional Sciences, University College London, United Kingdom
| | - Qasim Aziz
- Blizard Institute, Wingate Institute of Neurogastroenterology, Centre for Neuroscience, Surgery and Trauma, Barts and the London School of Medicine and Dentistry, Queen Mary University, London, United Kingdom
| | - Asma Fikree
- Blizard Institute, Wingate Institute of Neurogastroenterology, Centre for Neuroscience, Surgery and Trauma, Barts and the London School of Medicine and Dentistry, Queen Mary University, London, United Kingdom
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Theoharides TC, Twahir A, Kempuraj D. Mast cells in the autonomic nervous system and potential role in disorders with dysautonomia and neuroinflammation. Ann Allergy Asthma Immunol 2024; 132:440-454. [PMID: 37951572 DOI: 10.1016/j.anai.2023.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/16/2023] [Accepted: 10/06/2023] [Indexed: 11/14/2023]
Abstract
Mast cells (MC) are ubiquitous in the body, and they are critical for not only in allergic diseases but also in immunity and inflammation, including having potential involvement in the pathophysiology of dysautonomias and neuroinflammatory disorders. MC are located perivascularly close to nerve endings and sites such as the carotid bodies, heart, hypothalamus, the pineal gland, and the adrenal gland that would allow them not only to regulate but also to be affected by the autonomic nervous system (ANS). MC are stimulated not only by allergens but also many other triggers including some from the ANS that can affect MC release of neurosensitizing, proinflammatory, and vasoactive mediators. Hence, MC may be able to regulate homeostatic functions that seem to be dysfunctional in many conditions, such as postural orthostatic tachycardia syndrome, autism spectrum disorder, myalgic encephalomyelitis/chronic fatigue syndrome, and Long-COVID syndrome. The evidence indicates that there is a possible association between these conditions and diseases associated with MC activation. There is no effective treatment for any form of these conditions other than minimizing symptoms. Given the many ways MC could be activated and the numerous mediators released, it would be important to develop ways to inhibit stimulation of MC and the release of ANS-relevant mediators.
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Affiliation(s)
- Theoharis C Theoharides
- Institute for Neuro-Immune Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, Florida; Laboratory of Molecular Immunopharmacology and Drug Discovery, Department of Immunology, Tufts University School of Medicine, Boston, Massachusetts.
| | - Assma Twahir
- Institute for Neuro-Immune Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, Florida
| | - Duraisamy Kempuraj
- Institute for Neuro-Immune Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, Florida
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Midtlien JP, Curry BP, Chang E, Kiritsis NR, Aldridge JB, Fargen KM. Characterizing a new clinical phenotype: the co-existence of cerebral venous outflow and connective tissue disorders. Front Neurol 2024; 14:1305972. [PMID: 38269002 PMCID: PMC10806170 DOI: 10.3389/fneur.2023.1305972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/26/2023] [Indexed: 01/26/2024] Open
Abstract
Background There is increasing recognition of connective tissue disorders and their influence on disease in the general population. A conserved clinical phenotype involving connective tissue disorders and idiopathic intracranial hypertension (IIH) and associated cerebral venous outflow disorders (CVD) has not been previously described. Methods A single-institution retrospective review of a prospectively maintained database of patients with connective tissue disorders and CVD was performed. Results A total of 86 patients were identified. The majority of these patients carried a diagnosis of Ehlers-Danlos syndrome (55%) and most were non-obese (mean body mass index 29.7 kg/m2), Caucasian (90%) females (87%). Most prevalent presenting symptoms included pressure headache (98%), dizziness (90%), tinnitus (92%), and cognitive dysfunction (69%). Aside from CVD and IIH, the most common associated conditions were postural orthostatic tachycardia syndrome (POTS; 55.8%), cerebrospinal fluid (CSF) leaks (51.2%), dysautonomia (45.3%), cranio-cervical instability (37.2%), mast cell activation syndrome (25.6%), and tethered cord syndrome (23.3%). Allergies to medications (87.2%) and surgical tape (19.8%) were also frequent. Despite significantly lower opening pressures on lumbar puncture, headache severity and quality of life scores were reported with the same severity of classic IIH patients, suggesting an underlying hypersensitivity to intracranial pressures and cerebral venous congestion. Conclusion There is a rare but conserved clinical phenotype that has not been described previously that presents with severe IIH symptoms in predominantly young, non-obese Caucasian women with a high associated incidence of dysautonomia, POTS, craniocervical instability, and CSF leaks, among others.
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Affiliation(s)
- Jackson P. Midtlien
- Neurosurgery Department, Wake Forest School of Medicine, Winston-Salem, NC, United States
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Hulsey B. Recognizing postural orthostatic tachycardia syndrome in primary care. JAAPA 2023; 36:14-19. [PMID: 37943688 DOI: 10.1097/01.jaa.0000991396.00397.be] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
ABSTRACT Postural orthostatic tachycardia syndrome (POTS) is a complex autonomic disorder characterized by abnormal tachycardia on standing. This disorder predominantly affects young women, with a peak incidence between ages 20 and 30 years. POTS often is associated with a variety of symptoms, including dizziness, palpitations, fatigue, generalized weakness, anxiety, and exercise intolerance, which can significantly impair patient quality of life. Primary care providers (PCPs) often are the first healthcare professionals to whom patients present. This article provides an overview of POTS, including diagnostic criteria and the importance of a thorough clinical evaluation to rule out other causes of symptoms. PCPs play a critical role in the comprehensive approach to care, involving patient education, lifestyle modifications, and treatment to improve outcomes and enhance patient quality of life.
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Affiliation(s)
- Brittney Hulsey
- Brittney Hulsey is an assistant professor at A.T. Still University in Mesa, Ariz., and practices at Village Medical in Gilbert, Ariz. The author has disclosed no potential conflicts of interest, financial or otherwise
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Steiner S, Fehrer A, Hoheisel F, Schoening S, Aschenbrenner A, Babel N, Bellmann-Strobl J, Finke C, Fluge Ø, Froehlich L, Goebel A, Grande B, Haas JP, Hohberger B, Jason LA, Komaroff AL, Lacerda E, Liebl M, Maier A, Mella O, Nacul L, Paul F, Prusty BK, Puta C, Riemekasten G, Ries W, Rowe PC, Sawitzki B, Shoenfeld Y, Schultze JL, Seifert M, Sepúlveda N, Sotzny F, Stein E, Stingl M, Ufer F, Veauthier C, Westermeier F, Wirth K, Wolfarth B, Zalewski P, Behrends U, Scheibenbogen C. Understanding, diagnosing, and treating Myalgic encephalomyelitis/chronic fatigue syndrome - State of the art: Report of the 2nd international meeting at the Charité Fatigue Center. Autoimmun Rev 2023; 22:103452. [PMID: 37742748 DOI: 10.1016/j.autrev.2023.103452] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 09/20/2023] [Indexed: 09/26/2023]
Abstract
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a devastating disease affecting millions of people worldwide. Due to the 2019 pandemic of coronavirus disease (COVID-19), we are facing a significant increase of ME/CFS prevalence. On May 11th to 12th, 2023, the second international ME/CFS conference of the Charité Fatigue Center was held in Berlin, Germany, focusing on pathomechanisms, diagnosis, and treatment. During the two-day conference, more than 100 researchers from various research fields met on-site and over 700 attendees participated online to discuss the state of the art and novel findings in this field. Key topics from the conference included: the role of the immune system, dysfunction of endothelial and autonomic nervous system, and viral reactivation. Furthermore, there were presentations on innovative diagnostic measures and assessments for this complex disease, cutting-edge treatment approaches, and clinical studies. Despite the increased public attention due to the COVID-19 pandemic, the subsequent rise of Long COVID-19 cases, and the rise of funding opportunities to unravel the pathomechanisms underlying ME/CFS, this severe disease remains highly underresearched. Future adequately funded research efforts are needed to further explore the disease etiology and to identify diagnostic markers and targeted therapies.
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Affiliation(s)
- Sophie Steiner
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin and Berlin Institute of Health (BIH), Berlin, Germany
| | - Annick Fehrer
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin and Berlin Institute of Health (BIH), Berlin, Germany
| | - Friederike Hoheisel
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin and Berlin Institute of Health (BIH), Berlin, Germany.
| | | | - Anna Aschenbrenner
- Systems Medicine, Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Bonn, Germany
| | - Nina Babel
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin and Berlin Institute of Health (BIH), Berlin, Germany; Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Ruhr-University Bochum, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Herne, Germany; Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, Berlin, Germany
| | - Judith Bellmann-Strobl
- Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Experimental and Clinical Research Center, A Cooperation Between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité-Universitätsmedizin Berlin, Berlin, Germany; Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany; NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Carsten Finke
- Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Øystein Fluge
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway; Department of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Laura Froehlich
- Center of Advanced Technology for Assisted Learning and Predictive Analytics (CATALPA), FernUniversität in Hagen, Germany
| | - Andreas Goebel
- Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, and Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Johannes-Peter Haas
- Deutsches Zentrum für Kinder- und Jugendrheumatologie, Zentrum für Schmerztherapie junger Menschen, Garmisch-Partenkirchen, Germany
| | - Bettina Hohberger
- Department of Ophthalmology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Leonard A Jason
- Center for Community Research, DePaul University, Chicago, IL, USA
| | - Anthony L Komaroff
- Division of General Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eliana Lacerda
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Max Liebl
- Department of Physical Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Andrea Maier
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Olav Mella
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway; Department of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Luis Nacul
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Women's Health Research Institute, British Columbia Women's Hospital, Vancouver, BC, Canada; Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Friedemann Paul
- Experimental and Clinical Research Center, A Cooperation Between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité-Universitätsmedizin Berlin, Berlin, Germany; Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany; NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Bhupesh K Prusty
- Institute for Virology and Immunobiology, Julius-Maximilians University Würzburg, Würzburg, Germany
| | - Christian Puta
- Department of Sports Medicine and Health Promotion, Friedrich-Schiller-University Jena, Jena, Germany; Center for Interdisciplinary Prevention of Diseases Related to Professional Activities, Friedrich-Schiller-University Jena, Jena, Germany; Center for Sepsis Control and Care (CSCC), Jena University Hospital/Friedrich-Schiller-University Jena, Jena, Germany
| | - Gabriela Riemekasten
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Wolfgang Ries
- Internal Medicine, Department of Nephrology, Diakonissenkrankenhaus, Flensburg, Germany
| | - Peter C Rowe
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Birgit Sawitzki
- Translational Immunology, Berlin Institute of Health (BIH) & Charité University Medicine, Berlin, Germany
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Reichman University Herzelia, Israel
| | - Joachim L Schultze
- Systems Medicine, Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Bonn, Germany; Department for Genomics & Immunoregulation, Life and Medical Sciences Institute (LIMES), University of Bonn, Bonn, Germany; PRECISE Platform for Single Cell Genomics and Epigenomics, DZNE und Universität Bonn, Bonn, Germany
| | - Martina Seifert
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin and Berlin Institute of Health (BIH), Berlin, Germany; Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, Berlin, Germany; DZHK (German Center for Cardiovascular Research), Partner Site, 10785 Berlin, Germany
| | - Nuno Sepúlveda
- Department of Mathematics & Information Science, Warsaw University of Technology, Warsaw, Poland.; CEAUL - Centro de Estatística e Aplicações da Universidade de Lisboa, Lisbon, Portugal
| | - Franziska Sotzny
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin and Berlin Institute of Health (BIH), Berlin, Germany
| | - Elisa Stein
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin and Berlin Institute of Health (BIH), Berlin, Germany
| | - Michael Stingl
- Department of Neurology, Zentrum Votivpark, Vienna, Austria
| | - Friederike Ufer
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Veauthier
- Interdisciplinary Center of Sleep Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Francisco Westermeier
- Institute of Biomedical Science, Department of Health Studies, FH, Joanneum University of Applied Sciences, Graz, Austria; Centro Integrativo de Biología y Química Aplicada (CIBQA), Universidad Bernardo O'Higgins, Santiago, Chile
| | - Klaus Wirth
- Institute of General Pharmacology and Toxicology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Bernd Wolfarth
- Department of Sports Medicine, Charité-Universitätsmedizin Berlin, Humboldt University of Berlin, Germany
| | - Pawel Zalewski
- Department of Exercise Physiology and Functional Anatomy, Ludwik Rydygier Collegium Medicum in Bydgoszcz Nicolaus Copernicus University Toruń, Toruń, Poland; Department of Experimental and Clinical Physiology, Warsaw Medical University, Stefana Banacha 2a, Warszawa 02-097, Poland
| | - Uta Behrends
- Children's Hospital, School of Medicine, Technical University of Munich, Munich, Germany; German Center for Infection Research (DZIF), Berlin, Germany; AGV Research Unit Gene Vectors, Helmholtz Munich (HMGU), Munich, Germany
| | - Carmen Scheibenbogen
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin and Berlin Institute of Health (BIH), Berlin, Germany
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Lim J, Rezaie A. Irritable Bowel Syndrome-Like Symptoms in Quiescent Inflammatory Bowel Disease: A Practical Approach to Diagnosis and Treatment of Organic Causes. Dig Dis Sci 2023; 68:4081-4097. [PMID: 37695549 PMCID: PMC10570178 DOI: 10.1007/s10620-023-08095-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/23/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Despite achieving remission in inflammatory bowel disease (IBD), persistent gastrointestinal symptoms are common in quiescent IBD. While irritable bowel syndrome (IBS) is commonly diagnosed in IBD, IBS-like symptoms of recurrent abdominal pain and altered bowel habits can also be attributed to a wide range of overlapping gastrointestinal (GI) etiologies and systemic disorders with GI manifestations that often do not respond to conventional IBS therapies. Delay in diagnosis of these conditions can lead to ongoing patient suffering, reduced quality of life, repetition of invasive testing, increased healthcare utilization, and potentially unnecessary empirical escalation of IBD-related treatments. AIMS This review provides a practical approach for the evaluation and diagnosis of IBS mimickers in IBD. We summarize the definition, pathophysiology, diagnosis and treatment of the potential etiologies causing unexplained GI symptoms. CONCLUSION Overlapping conditions can co-exist with IBD and explain IBS-like symptoms. The diagnostic work-up in this population should be individualized and tailored to the predominant symptom pattern, associated clinical signs and symptoms and predisposing conditions that can be obtained from a detailed history and physical examination.
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Affiliation(s)
- Jane Lim
- GI Motility Program, Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai, 8730 Alden Drive, Thalians Bldg, #E203, Los Angeles, CA, 90048, USA.
| | - Ali Rezaie
- GI Motility Program, Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai, 8730 Alden Drive, Thalians Bldg, #E203, Los Angeles, CA, 90048, USA
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11
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Feldman ECH, Homan KJ, Williams SE, Ting TV, Goldschneider KR, Kashikar-Zuck S. A narrative review of the literature on illness uncertainty in hypermobile ehlers-danlos syndrome: implications for research and clinical practice. Pediatr Rheumatol Online J 2023; 21:121. [PMID: 37845704 PMCID: PMC10577933 DOI: 10.1186/s12969-023-00908-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/09/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Hypermobile Ehlers-Danlos syndrome (hEDS) is characterized by joint and skin laxity, and often accompanied by chronic pain, dysautonomia, increased distress and, functional limitations. The journey to accurate diagnosis is often prolonged due to unclear etiology of symptoms. This manuscript is a narrative review of the literature on illness uncertainty (IU) in hEDS, highlighting the unique facets of IU in this population, as compared to the broader chronic pain population (given symptom overlap between these two disease groups), that warrant additional investigation. Additionally, we considered the unique challenges associated with IU in the context of the developmental nuances of pediatric populations. Specifically, we aimed to (1) map the extant literature of the IU experience in chronic pain conditions broadly including the pediatric and adult research to identify key concepts related to IU and incorporate potential developmental considerations in IU; (2) delineate and describe the IU experience specifically in patients with hEDS, with the goal of identifying gaps in the literature based on aspects of presentation in hEDS that do and do not differ from the broader chronic pain population; and (3) elucidate the potential areas of adverse impact of IU in both general chronic pain populations, and those with hEDS specifically, to provide actionable areas for future research and clinical care of individuals with hEDS. Results of this review indicate that IU has been well-studied in chronic pain generally, but inadequately evaluated in hEDS specifically. Specific features of hEDS (complexity of the disorder, involvement of multiple bodily systems, contribution of organic pathology) may uniquely contribute to IU in this population. This review suggests that ambiguities surrounding the diagnosis of hEDS, symptom course, and treatment recommendations, along with misdiagnosis, perceived dismissal of symptoms, or attribution of symptoms to mental health concerns might increase risk for IU and related distress in patients. CONCLUSION Findings from the present review suggest that distinct features of hEDS yield a set of driving factors for IU that may be somewhat different than those faced by patients with chronic pain or other medical conditions. The development of a validated measure of IU to appropriately assess this construct in patients with hEDS is a research priority. In the clinical setting, providers should be attentive to the potentially aversive diagnostic and treatment experiences reported by patients and attempt to provide clear explanations based on the extant knowledge of hEDS, and implement best-practice recommendations for multidisciplinary treatment.
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Affiliation(s)
- Estée C H Feldman
- Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Kendra J Homan
- Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sara E Williams
- Anesthesiology, Perioperative and Pain Medicine, Department of Anesthesia, Stanford University Medical School, Palo Alto, CA, USA
| | - Tracy V Ting
- Division of Rheumatology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Kenneth R Goldschneider
- Pain Management Center, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Susmita Kashikar-Zuck
- Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Pain Management Center, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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12
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Teran-Wodzinski P, Kumar A. Clinical characteristics of patients with hypermobile type Ehlers-Danlos syndrome (hEDS) and generalized hypermobility spectrum disorders (G-HSD): an online survey. Rheumatol Int 2023; 43:1935-1945. [PMID: 37378685 DOI: 10.1007/s00296-023-05378-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023]
Abstract
To examine the perspective of individuals with Hypermobile Ehlers-Danlos Syndrome (hEDS) and Generalized Hypermobility Spectrum Disorder (G-HSD), needed to help identify priorities and improve the lives of people living with these conditions. We conducted an online survey between November 2021 and January 2023. Participants were recruited through the Ehlers-Danlos Society's Research Surveys website. We obtained 483 responses and 396 were analyzed. 80% of the survey's respondents were individuals with hEDS, 90% were females, 30% were between 21 and 30, and 76% lived in North America, with 85% of the participants living in North America indicated being White or European American. Participants reported exercising from none to less than three times per week, with no physical therapy treatment. Ninety-eight percent of participants reported pain mainly at the neck (76%), lower (76%) and upper back (66%), knees (64%), shoulders (60%), and hips (60%). Approximately 80% of participants reported fatigue, joint hypermobility, joint instability, interference with daily activities, gastrointestinal problems, orthostatic hypotension, muscle weakness, and emotional distress. About 60% of respondents indicated walking issues, balance issues, and reduced joint proprioception. Nearly 40% of participants reported pelvic floor dysfunction and cardiovascular problems. Participants with hEDS and G-HSD reported pain on an average (SD) of 6.4 (± 1.3) and 5.9 (± 1.5) days in a typical week, respectively. People with hEDS and G-HSD desperately need more effective treatment options, a better diagnostic process, and education among health care providers.
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Affiliation(s)
- Patricia Teran-Wodzinski
- School of Physical Therapy and Rehabilitation Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Ambuj Kumar
- Department of Internal Medicine and Office of Research, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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13
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Gutowski Ł, Kanikowski S, Formanowicz D. Mast Cell Involvement in the Pathogenesis of Selected Musculoskeletal Diseases. Life (Basel) 2023; 13:1690. [PMID: 37629547 PMCID: PMC10455104 DOI: 10.3390/life13081690] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
In recent years, there has been a noteworthy revival of interest in the function of mast cells (MCs) in the human body. It is now acknowledged that MCs impact a wide array of processes beyond just allergies, leading to a shift in research direction. Unfortunately, some earlier conclusions were drawn from animal models with flawed designs, particularly centered around the receptor tyrosine kinase (Kit) pathway. Consequently, several subsequent findings may have been unreliable. Thus, what is now required is a re-examination of these earlier findings. Nevertheless, the remaining data are fascinating and hold promise for a better comprehension of numerous diseases and the development of more effective therapies. As the field continues to progress, many intriguing issues warrant further investigation and analysis. For instance, exploring the bidirectional action of MCs in rheumatoid arthritis, understanding the extent of MCs' impact on symptoms associated with Ehlers-Danlos syndrome, and unraveling the exact role of the myofibroblast-mast cell-neuropeptides axis in the joint capsule during post-traumatic contractures are all captivating areas for exploration. Hence, in this review, we summarize current knowledge regarding the influence of MCs on the pathogenesis of selected musculoskeletal diseases, including rheumatoid arthritis, spondyloarthritis, psoriatic arthritis, gout, muscle and joint injuries, tendinopathy, heterotopic ossification, and Ehlers-Danlos syndrome. We believe that this review will provide in-depth information that can guide and inspire further research in this area.
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Affiliation(s)
- Łukasz Gutowski
- Department of Medical Chemistry and Laboratory Medicine, Poznan University of Medical Sciences, Rokietnicka 8, 60-806 Poznan, Poland;
| | - Szymon Kanikowski
- Department of Medical Chemistry and Laboratory Medicine, Poznan University of Medical Sciences, Rokietnicka 8, 60-806 Poznan, Poland;
| | - Dorota Formanowicz
- Department of Medical Chemistry and Laboratory Medicine, Poznan University of Medical Sciences, Rokietnicka 8, 60-806 Poznan, Poland;
- Department of Stem Cells and Regenerative Medicine, Institute of Natural Fibres and Medicinal Plants—National Research Institute, Kolejowa 2, 62-064 Plewiska, Poland
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14
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Ramírez-Paesano C, Rodiera Clarens C, Sharp Segovia A, Coila Bustinza A, Rodiera Olive J, Juanola Galceran A. Perioperative opioid-minimization approach as a useful protocol in the management of patients with Ehlers-Danlos syndrome-hypermobility type, craniocervical instability and severe chronic pain who are to undergo occipito-cervical fixation. Orphanet J Rare Dis 2023; 18:214. [PMID: 37491286 PMCID: PMC10369693 DOI: 10.1186/s13023-023-02829-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/12/2023] [Indexed: 07/27/2023] Open
Abstract
Patients suffering from connective tissue disorders like Ehlers-Danlos syndrome hypermobility type/joint hypermobility syndrome (EDS-HT/JHS) may be affected by craniocervical instability (CCI). These patients experience myalgic encephalomyelitis, chronic fatigue, depression, extreme occipital-cervical pain, and severe widespread pain that is difficult to relieve with opioids. This complex and painful condition can be explained by the development of chronic neuroinflammation, opioid-induced hyperalgesia, and central sensitization. Given the challenges in treating such severe physical pain, we evaluated all the analgesic methods previously used in the perioperative setting, and updated information was presented. It covers important physiopathological aspects for the perioperative care of patients with EDS-HT/JHS and CCI undergoing occipital-cervical/thoracic fixation/fusion. Moreover, a change of paradigm from the current opioid-based management of anesthesia/analgesia in these patients to the perioperative opioid minimization strategies used by the authors was analyzed and proposed as follow-up considerations from our previous case series. These strategies are based on total-intravenous opioid-free anesthesia, multimodal analgesia, and a postoperative combination of anti-hyperalgesic coadjuvants (lidocaine, ketamine, and dexmedetomidine) with an opioid-sparing effect.
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Affiliation(s)
- Carlos Ramírez-Paesano
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain.
| | - Claudia Rodiera Clarens
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Allan Sharp Segovia
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Alan Coila Bustinza
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Josep Rodiera Olive
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Albert Juanola Galceran
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
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15
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Mihele DM, Nistor PA, Bruma G, Mitran CI, Mitran MI, Condrat CE, Tovaru M, Tampa M, Georgescu SR. Mast Cell Activation Syndrome Update-A Dermatological Perspective. J Pers Med 2023; 13:1116. [PMID: 37511729 PMCID: PMC10381535 DOI: 10.3390/jpm13071116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
Mast cells (MCs) are infamous for their role in potentially fatal anaphylaxis reactions. In the last two decades, a more complex picture has emerged, as it has become obvious that MCs are much more than just IgE effectors of anaphylaxis. MCs are defenders against a host of infectious and toxic aggressions (their interactions with other components of the immune system are not yet fully understood) and after the insult has ended, MCs continue to play a role in inflammation regulation and tissue repair. Unfortunately, MC involvement in pathology is also significant. Apart from their role in allergies, MCs can proliferate clonally to produce systemic mastocytosis. They have also been implicated in excessive fibrosis, keloid scaring, graft rejection and chronic inflammation, especially at the level of the skin and gut. In recent years, the term MC activation syndrome (MCAS) was proposed to account for symptoms caused by MC activation, and clear diagnostic criteria have been defined. However, not all authors agree with these criteria, as some find them too restrictive, potentially leaving much of the MC-related pathology unaccounted for. Here, we review the current knowledge on the physiological and pathological roles of MCs, with a dermatological emphasis, and discuss the MCAS classification.
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Affiliation(s)
- Dana Mihaela Mihele
- Dermatology Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
- Dermatology Department, Victor Babes Clinical Hospital of Infectious and Tropical Diseases, 030303 Bucharest, Romania
| | - Paul Andrei Nistor
- Internal Medicine Department, Emergency University Hospital Bucharest, 169 Independence Blvd, 050098 Bucharest, Romania
| | - Gabriela Bruma
- Dermatology Department, Victor Babes Clinical Hospital of Infectious and Tropical Diseases, 030303 Bucharest, Romania
| | - Cristina Iulia Mitran
- Microbiology Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Madalina Irina Mitran
- Microbiology Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Carmen Elena Condrat
- Fetal Medicine Excellence Research Center, Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Mihaela Tovaru
- Dermatology Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
- Dermatology Department, Victor Babes Clinical Hospital of Infectious and Tropical Diseases, 030303 Bucharest, Romania
| | - Mircea Tampa
- Dermatology Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
- Dermatology Department, Victor Babes Clinical Hospital of Infectious and Tropical Diseases, 030303 Bucharest, Romania
| | - Simona Roxana Georgescu
- Dermatology Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
- Dermatology Department, Victor Babes Clinical Hospital of Infectious and Tropical Diseases, 030303 Bucharest, Romania
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16
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Carroll MB. Hypermobility spectrum disorders: A review. Rheumatol Immunol Res 2023; 4:60-68. [PMID: 37637226 PMCID: PMC10457547 DOI: 10.2478/rir-2023-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/21/2023] [Indexed: 08/29/2023]
Abstract
It remains a clinical challenge identifying when joint hypermobility (JH) is responsible for pain. Previous nomenclature utilized terms such as (benign) joint hypermobility syndrome (JHS) but this was updated in 2017 as advances in genetics provide a basis for nearly all variants of Ehlers-Danlos syndrome (EDS) with the exception of hypermobile EDS (hEDS). New terminology describes hypermobility spectrum disorders (HSDs) as the updated term for JHS. Diagnosis of a subtype of HSDs should be considered in patients who have JH coupled with the presence of secondary musculo-skeletal manifestations (trauma, chronic pain, disturbed proprioception, and other manifestations) and at the exclusion of hEDS. Extra-articular manifestations are common. Treatment relies on management strategies for other chronic pain syndromes with a multidisciplinary approach likely optimal. Lifestyle modifications focus on weight loss and exercise. Physical therapy helps strengthen periarticular muscles, improving mobility. Pharmacologic therapies focus on judicious use of non-steroidal anti-inflammatory drugs and acetaminophen. Serotonin and norepinephrine reuptake inhibitor may help widespread pain. Avoidance of opioids remains prudent. The purpose of this review is to provide clinicians the rationale for the update in nomenclature, understand the musculoskeletal and extra-articular manifestations of the subtypes of HSDs, considerations when making the diagnosis, and treatment.
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Affiliation(s)
- Matthew B Carroll
- Rheumatology, Singing River Health System, 3603 Bienville Blvd, Ocean Springs, MS 39564, USA
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17
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Vasavada AM, Verma D, Sheggari V, Ghetiya S, Chirumamilla PC, Kotak RA, Mahapatra SS, Patel T, Jain M. Choices and Challenges With Drug Therapy in Postural Orthostatic Tachycardia Syndrome: A Systematic Review. Cureus 2023; 15:e38887. [PMID: 37313107 PMCID: PMC10259876 DOI: 10.7759/cureus.38887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/15/2023] Open
Abstract
The literature on pharmacologic treatments for postural orthostatic tachycardia syndrome (POTS) is inconsistent and unstandardized. Therefore, we aimed to evaluate choices in pharmacologic treatment options for POTS and the challenges encountered in the studies. We searched numerous databases like PubMed, Scopus, Embase, Web of Science, and Google Scholar for literature published before April 8, 2023. The search was done to retrieve potential peer-reviewed articles that explored drug therapy in POTS. Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines were used to conduct the systematic review. Of the 421 potential articles assessed, 17 met the inclusion criteria. Results demonstrated that pharmacologic treatment options for POTS were effective in reducing symptoms of POTS, but most of the studies were underpowered. Several were terminated due to various reasons. Midodrine ivabradine, bisoprolol, fludrocortisone, droxidopa, desmopressin, propranolol, modafinil, methylphenidate, and melatonin have been studied with positive impact but sample sizes that were low in the range of 10-50 subjects. Therefore, we concluded the treatment options effectively improve symptoms of POTS and increase orthostatic tolerance, but more evidence is needed as most studies had a low sample size and thus are underpowered.
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Affiliation(s)
| | - Deepak Verma
- Internal Medicine, Sri Guru Ram Das Institute Of Medical Sciences and Research, Amritsar, IND
| | - Vineetha Sheggari
- Internal Medicine, Dr Vizarath Rasool Khan (VRK) Women's Medical College, Hyderabad, IND
| | - Srushti Ghetiya
- Internal Medicine, Gujarat Medical and Education Research Society (GMERS) Medical College, Junagadh, IND
| | | | - Radhika A Kotak
- Internal Medicine, DY Patil University, School of Medicine, Navi Mumbai, IND
| | - Shruti Sagar Mahapatra
- Internal Medicine, Srirama Chandra Bhanja (SCB) Medical College and Hospital, Cuttack, IND
| | - Tirath Patel
- Surgery, American University of Antigua, St John's, ATG
| | - Manisha Jain
- Internal Medicine, Shri Bhausaheb Hire Government Medical College, Dhule, IND
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18
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Rozenberg D, Al Kaabi N, Camacho Perez E, Nourouzpour S, Lopez-Hernandez L, McGillis L, Goligher E, Reid WD, Chow CW, Ryan CM, Kumbhare D, Huszti E, Champagne K, Raj S, Mak S, Santa Mina D, Clarke H, Mittal N. Evaluation and Management of Dyspnea in Hypermobile Ehlers-Danlos Syndrome and Generalized Hypermobility Spectrum Disorder: Protocol for a Pilot and Feasibility Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e44832. [PMID: 36939815 PMCID: PMC10131980 DOI: 10.2196/44832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Dyspnea is a prevalent symptom in individuals with hypermobile Ehlers-Danlos Syndrome (hEDS) and generalized hypermobility spectrum disorder (G-HSD), yet its contributors have not been identified. One known contributor to dyspnea is respiratory muscle weakness. The feasibility and effectiveness of inspiratory muscle training (IMT) in combination with standard-of-care rehabilitation (aerobic, resistance, neuromuscular stabilization, and balance and proprioception exercises) in improving respiratory muscle strength and patient-reported outcomes in patients with hEDS or G-HSD have not been evaluated. OBJECTIVE This study aims to evaluate dyspnea, respiratory muscle strength, and patient-reported outcome measures (PROMs) in hEDS or G-HSD compared with healthy controls and to assess the feasibility of a randomized controlled trial of IMT and standard-of-care rehabilitation for improving respiratory muscle strength, exercise capacity, and PROMs compared with standard-of-care rehabilitation in hEDS and G-HSD. METHODS The study will include 34 participants with hEDS or G-HSD and 17 healthy, age- and sex-matched controls to compare respiratory muscle structure and function and PROMs. After baseline assessments, participants with hEDS or G-HSD will be randomized into the intervention group and provided IMT combined with Ehlers-Danlos Syndrome standard-of-care rehabilitation or into the usual care group, and provided only standard-of-care rehabilitation for 8 weeks. The intervention group will be prescribed IMT in their home environment using the POWERbreathe K5 IMT device (POWERbreathe International Ltd). IMT will comprise 2 daily sessions of 30 breaths for 5 days per week, with IMT progressing from 20% to 60% of the baseline maximal inspiratory pressure (MIP) over an 8-week period. Feasibility will be assessed through rates of recruitment, attrition, adherence, adverse events, and participant satisfaction. The primary pilot outcome is MIP change over an 8-week period in hEDS or G-HSD. Secondary outcomes will include the evaluation of dyspnea using Medical Research Council Scale and 18-point qualitative dyspnea descriptors; diaphragmatic thickening fraction using ultrasound; respiratory muscle endurance; pulmonary function; prefrontal cortical activity using functional near-infrared spectroscopy; aerobic capacity during cardiopulmonary exercise testing; quality of life using Short Form-36; and scores from the Depression, Anxiety, and Stress scale-21. These measures will also be performed once in healthy controls to compare normative values. Multivariable regression will be used to assess the contributors to dyspnea. Paired 2-tailed t tests will be used to assess the changes in MIP and secondary measures after 8 weeks of IMT. RESULTS Study recruitment began in August 2021 and, with several disruptions owing to COVID-19, is expected to be completed by December 2023. CONCLUSIONS This study will provide a better understanding of the factors associated with dyspnea and the feasibility and effectiveness of IMT combined with standard-of-care rehabilitation. IMT may be a novel therapeutic strategy for improving respiratory muscle function and patient-reported outcomes in individuals with hEDS or G-HSD. TRIAL REGISTRATION ClinicalTrials.gov NCT04972565; https://clinicaltrials.gov/ct2/show/NCT04972565. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/44832.
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Affiliation(s)
- Dmitry Rozenberg
- Respirology and Lung Transplantation, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
| | - Noor Al Kaabi
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Encarna Camacho Perez
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Sahar Nourouzpour
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Laura Lopez-Hernandez
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
| | - Laura McGillis
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
| | - Ewan Goligher
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - W Darlene Reid
- KITE-Toronto Rehab, University Health Network, Toronto, ON, Canada
- Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Chung-Wai Chow
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Respirology, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Clodagh M Ryan
- KITE-Toronto Rehab, University Health Network, Toronto, ON, Canada
| | - Dinesh Kumbhare
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- KITE-Toronto Rehab, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | | | - Satish Raj
- Department of Cardiac Sciences, Cumming School of Medicine, Calgary, AB, Canada
| | - Susanna Mak
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Cardiology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Daniel Santa Mina
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Hance Clarke
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Nimish Mittal
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- GoodHope Ehlers-Danlos Syndrome Clinic, University Health Network, Toronto, ON, Canada
- KITE-Toronto Rehab, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
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19
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Benattia A, Benistan K, Frank M, Boussouar S. [Respiratory manifestations of Ehlers-Danlos syndromes]. Rev Mal Respir 2023; 40:254-264. [PMID: 36740495 DOI: 10.1016/j.rmr.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/01/2023] [Indexed: 02/07/2023]
Abstract
Ehlers-Danlos syndromes (EDS) represent a heterogeneous group of heritable connective tissue disorders characterized by the clinical "triad" consisting in joint hypermobility, skin hyperextensibility and tissue fragility. Respiratory manifestations associated with EDS are frequent and variable. They vary mainly according to the type of EDS. In hypermobile and classical EDS, the most frequent non-vascular types, dyspnea is a common symptom. Its etiologies are wide-ranging and can coexist in the same patient: asthma, respiratory muscle weakness, chest wall abnormalities, upper and lower airway collapse. The prevalence of obstructive sleep apnea syndrome in nvEDS is high. Identification of the relevant dyspnea mechanism is essential to providing appropriate therapeutic measures. In vascular EDS (vEDS), the main pulmonary complications are pneumothorax, hemothorax and hemoptysis. As they frequently precede the diagnosis of vEDS by several years, it is imperative to raise the possibility of vEDS in a young patient with spontaneous pneumothorax or hemothorax. The presence of suggestive computed tomography parenchymal abnormalities (emphysema, clusters of calcified nodules, cavitated nodule) can be an aid to diagnosis. Treatment is based on the usual approaches, which must be carried out with caution by an experienced operator fully informed of the diagnosis. Better knowledge of respiratory manifestations of EDS by the pneumological community would improve patient care and pave the way for further research.
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Affiliation(s)
- A Benattia
- Service de pneumologie, hôpital Saint-Louis, AP-HP, Paris, France.
| | - K Benistan
- Centre de référence des syndromes d'Ehlers-Danlos non vasculaires, hôpital Raymond-Poincaré, AP-HP, Garches, France; UMR U1179 Inserm, université Versailles Saint-Quentin, Montigny-le-Bretonneux, France
| | - M Frank
- Département de génétique, centre national de référence pour les maladies vasculaires rares, centre de référence européen VASCERN MSA, hôpital européen Georges-Pompidou, AP-HP, Paris, France; Inserm, U970 PARCC, université de Paris, Paris, France
| | - S Boussouar
- Service d'imagerie cardio-vasculaire et thoracique, hôpital Pitié-Salpêtrière, AP-HP, Paris, France; Inserm, laboratoire d'imagerie biomédicale, CNRS, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
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20
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Muacevic A, Adler JR, Fry E, Tiesenga F. Removal of Polymer Clips From the Gallbladder Fossa in a Patient With Ehlers-Danlos Syndrome (EDS) to Treat Mast Cell Activation Syndrome (MCAS): A Case Report. Cureus 2023; 15:e33704. [PMID: 36788923 PMCID: PMC9922053 DOI: 10.7759/cureus.33704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 01/13/2023] Open
Abstract
Ehlers-Danlos syndrome (EDS) is a group of hereditary disorders characterized by fragility of connective tissue. Clinical manifestations of the disorder involve the skin, joints, blood vessels, and other internal organs. We report the case of a 29-year-old female suffering from EDS and mast cell activation syndrome (MCAS). Her history includes multiple orthopedic surgeries leading to the worsening of her symptoms. This was determined to be due to medical implants placed during her multiple procedures predisposing her to severe immunological reactions. This case report emphasizes the importance of meticulous surgical intervention when managing patients with EDS.
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21
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Morgan K, Smith A, Blitshteyn S. POTS and Pregnancy: A Review of Literature and Recommendations for Evaluation and Treatment. Int J Womens Health 2022; 14:1831-1847. [PMID: 36590760 PMCID: PMC9795856 DOI: 10.2147/ijwh.s366667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/06/2022] [Indexed: 12/25/2022] Open
Abstract
Postural Orthostatic Tachycardia Syndrome (POTS) is a disorder of the autonomic nervous system most commonly affecting women of reproductive age. Studies on POTS and pregnancy are limited, and there is a lack of clinical guidelines regarding assessment and management of pregnant women with POTS. The purpose of this review is to summarize data from the available studies on the topic of pregnancy in POTS and common comorbid conditions and to provide the clinical recommendations regarding evaluation and treatment of POTS in pregnant women, based on the available studies and clinical experience. We conclude that pregnancy appears to be safe for women with POTS and is best managed by a multi-disciplinary team with knowledge of POTS and its various comorbidities. Importantly, large, prospective studies are needed to better delineate the course and outcomes of pregnancy, as well as possible pregnancy-related complications in women with POTS. Clinicians should be aware of the clinical presentation, diagnostic criteria, and treatment options in pregnant women with POTS to optimize outcomes and improve medical care during pregnancy and post-partum period.
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Affiliation(s)
- Kate Morgan
- School of Medicine and Public Health, Faculty of Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Angela Smith
- HNE Health Libraries, Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Svetlana Blitshteyn
- Department of Neurology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA,Dysautonomia Clinic, Williamsville, NY, USA,Correspondence: Svetlana Blitshteyn, 300 International Drive, Suite 100, Williamsville, NY, 14221, USA, Tel +1-716-531-4598, Fax +1-716-478-6917, Email
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22
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Knez R, Niksic M, Omerovic E. Orexin/hypocretin system dysfunction in patients with Takotsubo syndrome: A novel pathophysiological explanation. Front Cardiovasc Med 2022; 9:1016369. [PMID: 36407467 PMCID: PMC9670121 DOI: 10.3389/fcvm.2022.1016369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/05/2022] [Indexed: 09/19/2023] Open
Abstract
Takotsubo syndrome (TTS) is an acute heart failure syndrome. Emotional or physical stressors are believed to precipitate TTS, while the pathophysiological mechanism is not yet completely understood. During the coronavirus disease (COVID-19) pandemic, an increased incidence of TTS has been reported in some countries; however, the precise pathophysiological mechanism for developing TTS with acute COVID-19 infection is unknown. Nevertheless, observing the symptoms of COVID-19 might lead to new perspectives in understanding TTS pathophysiology, as some of the symptoms of the COVID-19 infection could be assessed in the context of an orexin/hypocretin-system dysfunction. Orexin/hypocretin is a cardiorespiratory neuromodulator that acts on two orexin receptors widely distributed in the brain and peripheral tissues. In COVID-19 patients, autoantibodies against one of these orexin receptors have been reported. Orexin-system dysfunction affects a variety of systems in an organism. Here, we review the influence of orexin-system dysfunction on the cardiovascular system to propose its connection with TTS. We propose that orexin-system dysfunction is a potential novel explanation for the pathophysiology of TTS due to direct or indirect dynamics of orexin signaling, which could influence cardiac contractility. This is in line with the conceptualization of TTS as a cardiovascular syndrome rather than merely a cardiac abnormality or cardiomyopathy. To the best of our knowledge, this is the first publication to present a plausible connection between TTS and orexin-system dysfunction. We hope that this novel hypothesis will inspire comprehensive studies regarding orexin's role in TTS pathophysiology. Furthermore, confirmation of this plausible pathophysiological mechanism could contribute to the development of orexin-based therapeutics in the treatment and prevention of TTS.
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Affiliation(s)
- Rajna Knez
- Gillberg Neuropsychiatry Centre, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research and Development, Department of Women's and Child Health, Skaraborg Hospital, Skövde, Sweden
- Institution for Health, School of Health Sciences, University of Skövde, Skövde, Sweden
| | - Milan Niksic
- Department of Cardiology, Skaraborg Hospital, Skövde, Sweden
| | - Elmir Omerovic
- Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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23
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Mayuga KA, Fedorowski A, Ricci F, Gopinathannair R, Dukes JW, Gibbons C, Hanna P, Sorajja D, Chung M, Benditt D, Sheldon R, Ayache MB, AbouAssi H, Shivkumar K, Grubb BP, Hamdan MH, Stavrakis S, Singh T, Goldberger JJ, Muldowney JAS, Belham M, Kem DC, Akin C, Bruce BK, Zahka NE, Fu Q, Van Iterson EH, Raj SR, Fouad-Tarazi F, Goldstein DS, Stewart J, Olshansky B. Sinus Tachycardia: a Multidisciplinary Expert Focused Review. Circ Arrhythm Electrophysiol 2022; 15:e007960. [PMID: 36074973 PMCID: PMC9523592 DOI: 10.1161/circep.121.007960] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sinus tachycardia (ST) is ubiquitous, but its presence outside of normal physiological triggers in otherwise healthy individuals remains a commonly encountered phenomenon in medical practice. In many cases, ST can be readily explained by a current medical condition that precipitates an increase in the sinus rate, but ST at rest without physiological triggers may also represent a spectrum of normal. In other cases, ST may not have an easily explainable cause but may represent serious underlying pathology and can be associated with intolerable symptoms. The classification of ST, consideration of possible etiologies, as well as the decisions of when and how to intervene can be difficult. ST can be classified as secondary to a specific, usually treatable, medical condition (eg, pulmonary embolism, anemia, infection, or hyperthyroidism) or be related to several incompletely defined conditions (eg, inappropriate ST, postural tachycardia syndrome, mast cell disorder, or post-COVID syndrome). While cardiologists and cardiac electrophysiologists often evaluate patients with symptoms associated with persistent or paroxysmal ST, an optimal approach remains uncertain. Due to the many possible conditions associated with ST, and an overlap in medical specialists who see these patients, the inclusion of experts in different fields is essential for a more comprehensive understanding. This article is unique in that it was composed by international experts in Neurology, Psychology, Autonomic Medicine, Allergy and Immunology, Exercise Physiology, Pulmonology and Critical Care Medicine, Endocrinology, Cardiology, and Cardiac Electrophysiology in the hope that it will facilitate a more complete understanding and thereby result in the better care of patients with ST.
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Affiliation(s)
- Kenneth A. Mayuga
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Artur Fedorowski
- Karolinska Institutet & Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G.d’Annunzio” University of Chieti-Pescara, Chieti Scalo, Italy
| | | | | | | | | | | | - Mina Chung
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Phoenix, AZ
| | - David Benditt
- University of Minnesota Medical School, Minneapolis, MN
| | | | - Mirna B. Ayache
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Hiba AbouAssi
- Division of Endocrinology, Metabolism, and Nutrition, Duke University Medical Center, Durham, NC
| | | | | | | | | | - Tamanna Singh
- Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | | | - James A. S. Muldowney
- Vanderbilt University Medical Center &Tennessee Valley Healthcare System, Nashville Campus, Department of Veterans Affairs, Nashville, TN
| | - Mark Belham
- Cambridge University Hospitals NHS FT, Cambridge, UK
| | - David C. Kem
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Cem Akin
- University of Michigan, Ann Arbor, MI
| | | | - Nicole E. Zahka
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Qi Fu
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas & University of Texas Southwestern Medical Center, Dallas, TX
| | - Erik H. Van Iterson
- Section of Preventive Cardiology & Rehabilitation, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic Cleveland, OH
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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24
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Nicholson LL, Simmonds J, Pacey V, De Wandele I, Rombaut L, Williams CM, Chan C. International Perspectives on Joint Hypermobility: A Synthesis of Current Science to Guide Clinical and Research Directions. J Clin Rheumatol 2022; 28:314-20. [PMID: 35661088 DOI: 10.1097/RHU.0000000000001864] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
ABSTRACT There is exponential clinical and research interest in joint hypermobility due to recognition of the complexity of identification, assessment, and its appropriate referral pathways, ultimately impacting management. This state-of-the-science review provides an international, multidisciplinary perspective on the presentation, etiology, and assessment of joint hypermobility, as it presents in those with and without a systemic condition. We synthesize the literature, propose standardizing the use of terminology and outcome measures, and suggest potential management directions. The major topics covered are (i) historical perspectives; (ii) current definitions of hypermobility, laxity, and instability; (iii) inheritance and acquisition of hypermobility; (iv) traditional and novel assessments; (v) strengths and limitations of current assessment tools; (vi) age, sex, and racial considerations; (vii) phenotypic presentations; (viii) generalized hypermobility spectrum disorder and hypermobility Ehlers-Danlos syndrome; and (ix) clinical implications and research directions. A thorough understanding of these topics will equip the reader seeking to manage individuals presenting with joint hypermobility, while mindful of its etiology. Management of generalized joint hypermobility in the context of a complex, multisystem condition will differ from that of acquired hypermobility commonly seen in performing artists, specific athletic populations, posttrauma, and so on. In addition, people with symptomatic hypermobility present predominantly with musculoskeletal symptoms and sometimes systemic symptoms including fatigue, orthostatic intolerance, and gastrointestinal or genitourinary issues. Some also display skeletal deformities, tissue and skin fragility, and structural vascular or cardiac differences, and these warrant further medical follow-up. This comprehensive review on the full spectrum of joint hypermobility will assist clinicians, coaches/sports trainers, educators, and/or researchers in this area.
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25
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Monaco A, Choi D, Uzun S, Maitland A, Riley B. Association of mast-cell-related conditions with hypermobile syndromes: a review of the literature. Immunol Res 2022; 70:419-431. [PMID: 35449490 PMCID: PMC9022617 DOI: 10.1007/s12026-022-09280-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 04/11/2022] [Indexed: 11/26/2022]
Abstract
Ehlers-Danlos syndrome (EDS) is a group of related connective tissue disorders consisting of 13 subtypes, each with its own unique phenotypic and genetic variation. The overlap of symptoms and multitude of EDS variations makes it difficult for patients to achieve a diagnosis early in the course of their disease. The most common form, hypermobile type EDS (hEDS) and its variant, hypermobile spectrum disorder (HSD), are correlated with rheumatologic and inflammatory conditions. Evidence is still needed to determine the pathophysiology of hEDS; however, the association among these conditions and their prevalence in hEDS/HSD may be explained through consideration of persistent chronic inflammation contributing to a disruption of the connective tissue. Aberrant mast cell activation has been shown to play a role in disruption of connective tissue integrity through activity of its mediators including histamine and tryptase which affects multiple organ systems resulting in mast cell activation disorders (MCAD). The overlap of findings associated with MCAD and the immune-mediated and rheumatologic conditions in patients with hEDS/HSD may provide an explanation for the relationship among these conditions and the presence of chronic inflammatory processes in these patients. It is clear that a multidisciplinary approach is required for the treatment of patients with EDS. However, it is also important for clinicians to consider the summarized symptoms and MCAD-associated characteristics in patients with multiple complaints as possible manifestations of connective tissue disorders, in order to potentially aid in establishing an early diagnosis of EDS.
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Affiliation(s)
- Ashley Monaco
- Department of Family Medicine, NYIT College of Osteopathic Medicine, Northern Boulevard, Old Westbury, NY, 11568, USA.
| | - Diane Choi
- Department of Family Medicine, NYIT College of Osteopathic Medicine, Northern Boulevard, Old Westbury, NY, 11568, USA
| | - Serife Uzun
- Department of Family Medicine, NYIT College of Osteopathic Medicine, Northern Boulevard, Old Westbury, NY, 11568, USA
| | - Anne Maitland
- Division of Medicine, Icahn School of Medicine at Mount Sinai, Gustave L. Levy Place, New York, NY, 10029, USA
| | - Bernadette Riley
- Department of Family Medicine, NYIT College of Osteopathic Medicine, Northern Boulevard, Old Westbury, NY, 11568, USA
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26
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Coffin B, Duboc H. Review article: diagnostic and therapeutic approach to persistent abdominal pain beyond irritable bowel syndrome. Aliment Pharmacol Ther 2022; 56:419-435. [PMID: 35656644 DOI: 10.1111/apt.17064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/01/2021] [Accepted: 05/18/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Persistent abdominal pain (PAP) poses substantial challenges to patients, physicians and healthcare systems. The possible aetiologies of PAP vary widely across organ systems, which leads to extensive and repetitive diagnostic testing that often fails to provide satisfactory answers. As a result, widely recognised functional disorders of the gut-brain interaction, such as irritable bowel syndrome and functional dyspepsia, are often diagnosed in patients with PAP. However, there are a number of less well-known differential diagnoses that deserve consideration. AIM To provide a comprehensive update on causes of PAP that are relatively rare in occurrence. METHODS A literature review on the diagnosis and management of some less well-known causes of PAP. RESULTS Specific algorithms for the diagnostic work-up of PAP do not exist. Instead, appropriate investigations tailored to patient medical history and physical examination findings should be made on a case-by-case basis. After a definitive diagnosis has been reached, some causes of PAP can be effectively treated using established approaches. Other causes are more complex and may benefit from a multidisciplinary approach involving gastroenterologists, pain specialists, psychologists and physiotherapists. This list is inclusive but not exhaustive of all the rare or less well-known diseases potentially associated with PAP. CONCLUSIONS Persistent abdominal pain (PAP) is a challenging condition to diagnose and treat. Many patients undergo repeated diagnostic testing and treatment, including surgery, without achieving symptom relief. Increasing physician awareness of the various causes of PAP, especially of rare diseases that are less well known, may improve patient outcomes.
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Affiliation(s)
- Benoit Coffin
- Université de Paris-Cité, équipe PIMS, Paris, France.,AP-HP, DMU Esprit, Gastroenterology Unit, Hôpital Louis Mourier, Colombes, France
| | - Henri Duboc
- Université de Paris-Cité, équipe PIMS, Paris, France.,AP-HP, DMU Esprit, Gastroenterology Unit, Hôpital Louis Mourier, Colombes, France
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27
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Lam C, Amarasinghe G, Zarate-Lopez N, Fikree A, Byrne P, Kiani-Alikhan S, Gabe S, Paine P. Gastrointestinal symptoms and nutritional issues in patients with hypermobility disorders: assessment, diagnosis and management. Frontline Gastroenterol 2022; 14:68-77. [PMID: 36561778 PMCID: PMC9763642 DOI: 10.1136/flgastro-2022-102088] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/20/2022] [Indexed: 02/04/2023] Open
Abstract
Patients diagnosed with hypermobile Ehlers-Danlos syndrome and hypermobile spectrum disorders are increasingly presenting to secondary and tertiary care centres with gastrointestinal (GI) symptoms and nutritional issues. Due to the absence of specific guidance, these patients are investigated, diagnosed and managed heterogeneously, resulting in a growing concern that they are at increased risk of iatrogenic harm. This review aims to collate the evidence for the causes of GI symptoms, nutritional issues and associated conditions as well as the burden of polypharmacy in this group of patients. We also describe evidence-based strategies for management, with an emphasis on reducing the risk of iatrogenic harm and improving multidisciplinary team care.
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Affiliation(s)
- Ching Lam
- Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Gehanjali Amarasinghe
- Gastroenterology, St Marks Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Natalia Zarate-Lopez
- Gastoenterology and GI physiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Asma Fikree
- Gastroenterology, Barts Health NHS Trust, London, UK
| | - Peter Byrne
- Psychiatry, East London NHS Foundation Trust, London, UK
| | | | - Simon Gabe
- Gastroenterology, St Marks Hospital, London North West University Healthcare NHS Trust, Harrow, UK,Intestinal Failure Unit, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Peter Paine
- Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK
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28
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Jenkins H. Recommendations for the recognition, diagnosis, and management of long COVID. Br J Gen Pract 2022; 72:259. [PMID: 35618472 PMCID: PMC9172232 DOI: 10.3399/bjgp22x719537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Huw Jenkins
- British Society for Allergy and Clinical Immunology (BSACI), London.
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29
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Rattray C. Idiopathic osteoporosis, Ehlers–Danlos syndrome, postural orthostatic tachycardia syndrome, and mast cell activation disorder in a 27‐year‐old male patient: A unique case presentation. Clin Case Rep 2022; 10:e05887. [PMID: 35600027 PMCID: PMC9122800 DOI: 10.1002/ccr3.5887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/25/2022] [Accepted: 05/04/2022] [Indexed: 11/22/2022] Open
Abstract
A young male patient presents with widespread pain and varying chronic inflammatory symptoms for three years and idiopathic low bone density for more than ten years. Based on the patient’s clinical history, the patient has been diagnosed with an hypermobile Ehlers–Danlos syndrome, postural orthostatic tachycardia syndrome, and mast cell activation disorder trifecta with affiliated inflammation‐induced osteoporosis.
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Affiliation(s)
- Cameron Rattray
- St. George’s University School of Medicine St. George Grenada, West Indies
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30
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Kennedy M, Loomba K, Ghani H, Riley B. The psychological burden associated with Ehlers-Danlos syndromes: a systematic review. J Osteopath Med 2022; 122:381-392. [PMID: 35420002 DOI: 10.1515/jom-2021-0267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/16/2022] [Indexed: 11/15/2022]
Abstract
CONTEXT Ehlers-Danlos syndromes (EDS) are disorders of connective tissue that lead to a wide range of clinical presentations. While we are beginning to understand the association between EDS and psychological manifestations, it is critical that we further elucidate the relationship between the two. Understanding the correlation between EDS and mental health will better ensure swift diagnosis and effective treatment for patients. OBJECTIVES This study aims to systematically examine and report the prevalence of psychiatric disorders in the EDS population. METHODS The PubMed database was searched on June 14, 2021 for articles published from January 2011 to June 2021. We included original, evidence-based, peer-reviewed journal articles in English that reported information on psychiatric disorders among EDS patients. Psychiatric disorders and psychological conditions were limited to those included in the "psychology" and "mental disorders" Medical Subject Headings (MeSH) search terms defined by the National Library of Medicine. Publications identified utilizing this search strategy by M.K. were imported into the Covidence system, where they first underwent a title and abstract screening process by three independent reviewers (M.K., K.L., H.G.). During the full-text review, two independent reviewers read the full text of the questionable articles to assess their eligibility for inclusion. Studies were excluded if they did not meet our target objective or if they were not in English or if they were opinion pieces, conference abstracts, or review articles. Data were extracted from the shortlisted studies by reviewers. During the data extraction phase, the quality and risk of publication bias were assessed by two independent reviewers utilizing the National Institutes of Health (NIH) Study Quality Assessment Tools. Any disagreements in study selection, data extraction, or quality assessment were adjudicated via discussion between the two reviewers, utilizing a third reviewer as a decider if necessary. RESULTS Out of 73 articles identified, there were no duplicates. A total of 73 records were screened, but only 40 articles were assessed in full text for eligibility. A total of 23 articles were ultimately included, which collectively discussed 12,298 participants. Ten (43.5%) of the included studies were cross-sectional in design, three (13.0%) were case reports, and three (13.0%) were retrospective chart reviews. The remaining seven (30.4%) articles were either case-control, cohort, qualitative, controlled observational, or validation studies. Twelve (52.2%) of the studies reported data on depression disorders, six of which reported prevalence data. Nine (39.1%) of the studies reported data on anxiety disorders, five of which reported prevalence data. Studies that reported nonprevalence data presented odds-ratio, mean scores on psychiatric evaluations, and other correlation statistics. Psychiatric disorders that were most reported in these articles were mood disorders (n=11), anxiety disorders (n=9), and neurodevelopmental disorders (n=7). Although the reports varied, the highest psychiatric prevalence reports in EDS patients involved language disorders (63.2%), attention-deficit/hyperactivity disorder (ADHD) (52.4%), anxiety (51.2%), learning disabilities (42.4%), and depression (30.2%). CONCLUSIONS Although mood disorders were cited in more articles, the highest reported prevalence was for language disorders and ADHD. This discrepancy highlights the importance of performing more research to better understand the relationship between EDS and psychiatric disorders.
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Affiliation(s)
- Matthew Kennedy
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Katherine Loomba
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Hira Ghani
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Bernadette Riley
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
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31
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Lee A, Liu X, Rosenberg C, Borle S, Hwang D, Chen LS, Li X, Merz NB, Chen CP. Skin sympathetic nerve activity in patients with chronic orthostatic intolerance. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/25/2022] [Accepted: 03/11/2022] [Indexed: 01/23/2023]
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32
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Saps M. Building the Case for Interdisciplinary Care, One Patient at a Time. JPGN Rep 2022; 3:e148. [PMID: 37168747 PMCID: PMC10158300 DOI: 10.1097/pg9.0000000000000148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/10/2021] [Indexed: 05/13/2023]
Affiliation(s)
- Miguel Saps
- From the Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Miami, Mailman Center, Miami, FL
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Wang Y, Du J, Li X, Liu P, Wang Y, Liao Y, Jin H. Impact of Comorbidities on the Prognosis of Pediatric Postural Tachycardia Syndrome. Int J Gen Med 2021; 14:8945-8954. [PMID: 34866935 PMCID: PMC8636694 DOI: 10.2147/ijgm.s339805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/29/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To investigate the influence of comorbidities on the prognosis of pediatric postural tachycardia syndrome (POTS). METHODS In this retrospective cohort study, 275 children with POTS admitted to the Department of Pediatrics at Peking University First Hospital were recruited from 2016 to 2019 and followed up. The participants were divided into simple POTS (S-POTS, n=156 cases) and POTS with comorbidities (Co-POTS, n=119 cases) groups according to whether they were complicated with comorbidities. A Cox regression analysis was used to identify the prognostic risk factors for children with POTS, while Kaplan-Meier curves were applied to compare the cumulative symptom remission rate (CSRR) between the two groups. The rehospitalization of the children between the two groups was also compared to explore the influence of comorbidities. RESULTS Twenty-one participants (7.6%) were lost during a median follow-up of 24 months. The Cox regression model showed that comorbidities and body mass index (BMI) were associated with the CSRR of the children with POTS. The CSRR of pediatric POTS alone was 1.748 times higher than that of patients with comorbidities, and the CSRR was decreased by 5.1% for each 1 kg/m2 increase in BMI. The most common comorbidity in children with POTS in this study was allergic disorders, followed by the psychological diseases. The patients in the Co-POTS group had a lower CSRR than those in the S-POTS group (log rank P=0.0001). In addition, compared with those of the S-POTS group, the total number of rehospitalizations was high (P=0.001), and the total hospital stays were long in the Co-POTS group (P<0.001). CONCLUSION Complicating with comorbidities, pediatric patients with POTS had lower CSRR and more rehospitalizations than those without comorbidities. More attention should be given to comorbidities when managing pediatric POTS.
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Affiliation(s)
- Yaru Wang
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, People’s Republic of China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, People’s Republic of China
- Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, 100034, People’s Republic of China
| | - Xueying Li
- Department of Medical Statistics, Peking University First Hospital, Beijing, 100034, People’s Republic of China
| | - Ping Liu
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, People’s Republic of China
| | - Yuli Wang
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, People’s Republic of China
| | - Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, People’s Republic of China
| | - Hongfang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, People’s Republic of China
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Mathias CJ, Owens A, Iodice V, Hakim A. Dysautonomia in the Ehlers-Danlos syndromes and hypermobility spectrum disorders-With a focus on the postural tachycardia syndrome. Am J Med Genet C Semin Med Genet 2021; 187:510-519. [PMID: 34766441 DOI: 10.1002/ajmg.c.31951] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 10/22/2021] [Indexed: 12/14/2022]
Abstract
Dysautonomia (autonomic dysfunction) occurs in the Ehlers-Danlos syndromes (EDS) and hypermobility spectrum disorders (HSD). Symptoms include palpitations, dizziness, presyncope, and syncope, especially when standing upright. Symptoms of orthostatic intolerance are usually relieved by sitting or lying and may be exacerbated by stimuli in daily life that cause vasodilatation, such as food ingestion, exertion, and heat. Neurocardiovascular dysautonomia may result in postural tachycardia syndrome (PoTS), a major cause of orthostatic intolerance. It is defined by a rise in heart rate of >30 beats per minute (bpm) in adults and >40 bpm in teenagers while upright, without a fall in blood pressure (BP; orthostatic hypotension). In some, it can be compounded by the presence of low BP. For many, there is delay in clinicians recognizing the nature of the symptoms, and recognizing EDS or HSD, leading to delays in treatment. The onset of PoTS may be linked to an event such as infection, trauma, surgery, or stress. Gastrointestinal and urinary bladder involvement may occur, along with thermoregulatory dysfunction. In some, the mast cell activation syndrome may be contributary, especially if it causes vasodilatation. This paper reviews neurocardiovascular dysautonomia with an emphasis on PoTS, its characteristics, associations, pathophysiology, investigation, and treatment.
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Affiliation(s)
- Christopher J Mathias
- UCL Queen Square Institute of Neurology, University College London, London, UK.,The Lindo Wing, St Mary's Hospital, Imperial College NHS Healthcare Trust, London, UK.,Autonomic Unit, National Hospital Neurology and Neurosurgery, UCLH NHS Trust, London, UK
| | - Andrew Owens
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Valeria Iodice
- UCL Queen Square Institute of Neurology, University College London, London, UK.,Autonomic Unit, National Hospital Neurology and Neurosurgery, UCLH NHS Trust, London, UK
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35
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Brock I, Prendergast W, Maitland A. Mast cell activation disease and immunoglobulin deficiency in patients with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorder. Am J Med Genet C Semin Med Genet 2021; 187:473-481. [PMID: 34747107 DOI: 10.1002/ajmg.c.31940] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 10/16/2021] [Indexed: 12/17/2022]
Abstract
Mast cell activation disease (MCAD) includes single organ disease such as asthma, urticaria, and gastroenteritis, as well as multiorgan system involvement such as mast cell activation syndrome and anaphylaxis. Reports link MCAD with hypermobile Ehlers-Danlos syndrome (hEDS), hypermobility spectrum disorder (HSD), and with primary immune deficiencies such as complement and immunoglobulin deficiencies (Ig Def). This study assesses the concurrence of these syndromes. We undertook a cohort analysis of patients seen in a community-based Allergy/Immunology clinic from 2015 to 2019. We searched for diagnostic codes for Ig Def disorders, hypermobility syndrome, hypermobile/Ehlers-Danlos syndrome, and MCADs. Of 974 patients with suspected MCAD, 449 (46%) had a diagnosis of MCAD; 496 (51%) of cases had a combination of at least two of hEDS/HSD, MCAD, and Ig Def. Ig Def was present in 417 (43%) of patients; 188 (19.3%) had hEDS/HSD with an Ig Def with or without MCAD and accounted for 45% of all the cases with Ig Def. Of 974 cases, 101 (10%) had hEDS/HSD and MCAD; 207 (21%) had Ig Def and MCAD; 7 (0.7%) had Ig Def and hEDS/HSD; and 181 (19%) had a combination of all three syndromes. Most patients (74%) with these comorbidities were female. The presence of MCAD and Ig Def should be explored in patients with hEDS/HSD. Identifying underlying contributors to recurrent/chronic inflammation and tissue injury is needed to tailor and personalize therapies. This, in turn, can reduce tissue damage, iatrogenic intervention, and optimize health outcomes.
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Affiliation(s)
- Isabelle Brock
- Comprehensive Asthma and Allergy, Tarrytown, New York, USA.,Qolify, New York, New York, USA.,Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Anne Maitland
- Comprehensive Asthma and Allergy, Tarrytown, New York, USA.,Department of Neurology, Mount Sinai-South Nassau, Hewlett, New York, USA
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36
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Choudhary A, Fikree A, Aziz Q. Overlap between irritable bowel syndrome and hypermobile Ehlers-Danlos syndrome: An unexplored clinical phenotype? Am J Med Genet C Semin Med Genet 2021; 187:561-569. [PMID: 34741491 DOI: 10.1002/ajmg.c.31938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 10/18/2021] [Accepted: 10/22/2021] [Indexed: 12/11/2022]
Abstract
Irritable bowel syndrome (IBS) is common, but its cause remains unknown. IBS patients present with gastrointestinal (GI) symptoms such as abdominal pain with altered bowel habits; however, some patients also have non-GI symptoms including muscle and joint pains. It is thus plausible that within large IBS cohorts, subgroups exist with distinct clinical phenotypes. Yet, these subgroups have not been clearly identified or characterized. Due to lack of segmentation, treatment-focused symptomatic management is similar for all with IBS and follows indiscriminate algorithms regardless of possible differing clinical phenotype. This universal approach to IBS management may account for the reported lack of efficacy of treatment. One emerging subgroup receiving increasing attention is that with overlap IBS and the underlying heritable connective tissue disorder, hypermobile Ehlers-Danlos syndrome (hEDS). Current evidence suggests that up to 62% of patients with hEDS suffer from IBS. However, despite recognition of the presence of IBS in hEDS, this overlap IBS/hEDS group has not been characterized and these patients are managed in a similar way to those with IBS alone. Future studies are required to characterize and deep phenotype in this overlap IBS/hEDS group.
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Affiliation(s)
- Anisa Choudhary
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Asma Fikree
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Qasim Aziz
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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37
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Aubry-Rozier B, Schwitzguebel A, Valerio F, Tanniger J, Paquier C, Berna C, Hügle T, Benaim C. Are patients with hypermobile Ehlers-Danlos syndrome or hypermobility spectrum disorder so different? Rheumatol Int 2021; 41:1785-1794. [PMID: 34398260 PMCID: PMC8390400 DOI: 10.1007/s00296-021-04968-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/06/2021] [Indexed: 01/04/2023]
Abstract
Diagnosing hypermobile Ehlers–Danlos syndrome (hEDS) remains challenging, despite new 2017 criteria. Patients not fulfilling these criteria are considered to have hypermobile spectrum disorder (HSD). Our first aim was to evaluate whether patients hEDS were more severely affected and had higher prevalence of extra-articular manifestations than HSD. Second aim was to compare their outcome after coordinated physical therapy. Patients fulfilling hEDS/HSD criteria were included in this real-life prospective cohort (November 2017/April 2019). They completed a 16-item Clinical Severity Score (CSS-16). We recorded bone involvement, neuropathic pain (DN4) and symptoms of mast cell disorders (MCAS) as extra-articular manifestations. After a standardized initial evaluation (T0), all patients were offered the same coordinated physical therapy, were followed-up at 6 months (T1) and at least 1 year later (T2), and were asked whether or not their condition had subjectively improved at T2. We included 97 patients (61 hEDS, 36 HSD). Median age was 40 (range 18–73); 92.7% were females. Three items from CSS-16 (pain, motricity problems, and bleeding) were significantly more severe with hEDS than HSD. Bone fragility, neuropathic pain and MCAS were equally prevalent. At T2 (20 months [range 18–26]) 54% of patients reported improvement (no difference between groups). On multivariable analysis, only family history of hypermobility predicted (favorable) outcome (p = 0.01). hEDS and HDS patients showed similar disease severity score except for pain, motricity problems and bleeding, and similar spectrum of extra-articular manifestations. Long-term improvement was observed in > 50% of patients in both groups. These results add weight to a clinical pragmatic proposition to consider hEDS/HSD as a single entity that requires the same treatments.
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Affiliation(s)
| | | | - Flore Valerio
- Rheumatology, HFR Fribourg, Villars-sur-Glâne, Switzerland
| | - Joelle Tanniger
- Physiotherapy, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Célia Paquier
- Physiotherapy, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Chantal Berna
- Center for Integrative and Complementary Medicine & Pain Center, Division of Anesthesiology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Thomas Hügle
- Rheumatology and Rehabilitation, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Charles Benaim
- Rheumatology and Rehabilitation, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland. .,Department of Medical Research, Clinique Romande de Réadaptation, Sion, Switzerland.
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38
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Kohno R, Cannom DS, Olshansky B, Xi SC, Krishnappa D, Adkisson WO, Norby FL, Fedorowski A, Benditt DG. Mast Cell Activation Disorder and Postural Orthostatic Tachycardia Syndrome: A Clinical Association. J Am Heart Assoc 2021; 10:e021002. [PMID: 34398691 PMCID: PMC8649306 DOI: 10.1161/jaha.121.021002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Recently there has been increased interest in a possible association between mast cell activation (MCA) disorder and postural orthostatic tachycardia syndrome (POTS). This study examined the frequency with which symptoms and laboratory findings suggesting MCA disorder occurred in patients diagnosed with POTS. Methods and Results Data were obtained from patients in whom symptoms and orthostatic testing were consistent with a POTS diagnosis. Individuals with <4 months symptom duration, evident ongoing inflammatory disease, suspected volume depletion, or declined consent were excluded. All patients had typical POTS symptoms; some, however, had additional nonorthostatic complaints not usually associated with POTS. The latter patients underwent additional testing for known MCA biochemical mediators including prostaglandins, histamine, methylhistamine, and plasma tryptase. The study comprised 69 patients who met POTS diagnostic criteria. In 44 patients (44/69, 64%) additional nonorthostatic symptoms included migraine, allergic complaints, skin rash, or gastrointestinal symptoms. Of these 44 patients, 29 (66%) exhibited at least 1 laboratory abnormality suggesting MCA disorder, and 11/29 patients had 2 or more such abnormalities. Elevated prostaglandins (n=16) or plasma histamine markers (n=23) were the most frequent findings. Thus, 42% (29/69) of patients initially diagnosed with POTS exhibited both additional symptoms and at least 1 elevated biochemical marker suggesting MCA disorder. Conclusions Laboratory findings suggesting MCA disorder were relatively common in patients diagnosed with POTS and who present with additional nonorthostatic gastrointestinal, cutaneous, and allergic symptoms. While solitary abnormal laboratory findings are not definitive, they favor MCA disorder being considered in such cases.
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Affiliation(s)
- Ritsuko Kohno
- Cardiac Arrhythmia Center Cardiovascular Division University of Minnesota Minneapolis MN
| | - David S Cannom
- Hospital of the Good Samaritan Los Angeles CA.,University of Southern California Keck School of Medicine Los Angeles CA
| | | | - Shijun Cindy Xi
- University of Southern California Keck School of Medicine Los Angeles CA
| | - Darshan Krishnappa
- Cardiac Arrhythmia Center Cardiovascular Division University of Minnesota Minneapolis MN
| | - Wayne O Adkisson
- Cardiac Arrhythmia Center Cardiovascular Division University of Minnesota Minneapolis MN
| | - Faye L Norby
- Smidt Heart Institute Cedars-Sinai Heart System Los Angeles CA
| | - Artur Fedorowski
- Departments of Cardiology and Medicine (Karolinska) Karolinska University Hospital, Karoloinska Instiute, and Lund University Stockholm Sweden.,Department of Clinical Sciences (Lund) Karolinska University Hospital, Karoloinska Instiute, and Lund University Malmo Sweden
| | - David G Benditt
- Cardiac Arrhythmia Center Cardiovascular Division University of Minnesota Minneapolis MN
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Chohan K, Mittal N, McGillis L, Lopez-Hernandez L, Camacho E, Rachinsky M, Mina DS, Reid WD, Ryan CM, Champagne KA, Orchanian-Cheff A, Clarke H, Rozenberg D. A review of respiratory manifestations and their management in Ehlers-Danlos syndromes and hypermobility spectrum disorders. Chron Respir Dis 2021; 18:14799731211025313. [PMID: 34291699 PMCID: PMC8312172 DOI: 10.1177/14799731211025313] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Ehlers-Danlos Syndromes (EDS) and Hypermobility Spectrum Disorders (HSD) are a heterogeneous group of heritable genetic connective tissue disorders with multiple characteristics including joint hypermobility, tissue fragility, and multiple organ dysfunction. Respiratory manifestations have been described in EDS patients, but have not been systematically characterized. A narrative review was undertaken to describe the respiratory presentations and management strategies of individuals with EDS and HSD. METHODS A broad literature search of Medline, Embase, Cochrane Database of Systematic Reviews, and Cochrane CENTRAL was undertaken from inception to November 2020 of all study types, evaluating EDS/ HSD and pulmonary conditions. This narrative review was limited to adult patients and publications in English. RESULTS Respiratory manifestations have generally been described in hypermobile EDS (hEDS), classical and vascular EDS subtypes. Depending on EDS subtype, they may include but are not limited to dyspnea, dysphonia, asthma, sleep apnea, and reduced respiratory muscle function, with hemothorax and pneumothorax often observed with vascular EDS. Respiratory manifestations in HSD have been less frequently characterized in the literature, but exertional dyspnea is the more common symptom described. Respiratory symptoms in EDS can have an adverse impact on quality of life. The respiratory management of EDS patients has followed standard approaches with thoracotomy tubes and pleurodesis for pleural manifestations, vocal cord strengthening exercises, continuous positive pressure support for sleep apnea, and exercise training. Reduced respiratory muscle function in hEDS patients responds to inspiratory muscle training. CONCLUSION Respiratory symptoms and manifestations are described in EDS and HSD, and have generally been managed using conservative non-surgical strategies. Research into the prevalence, incidence and specific respiratory management strategies in EDS and HSD is needed to mitigate some of the associated morbidity.
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Affiliation(s)
- Karan Chohan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nimish Mittal
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,KITE-Toronto Rehab-University Health Network, Toronto, Ontario, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada.,Department of Anaesthesia and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - Laura McGillis
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura Lopez-Hernandez
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Encarna Camacho
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Maxim Rachinsky
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Daniel Santa Mina
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada.,Department of Anaesthesia and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - W Darlene Reid
- KITE-Toronto Rehab-University Health Network, Toronto, Ontario, Canada.,Physical Therapy, University of Toronto, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Clodagh Mai Ryan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,KITE-Toronto Rehab-University Health Network, Toronto, Ontario, Canada.,Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | | | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Hance Clarke
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Anaesthesia and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - Dmitry Rozenberg
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada.,Division of Respirology, University Health Network, Toronto, Ontario, Canada
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40
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Martin SM, Zlotoff BJ. A 15-year-old girl with transient patches of erythema. Pediatr Dermatol 2021; 38:937-938. [PMID: 34448230 DOI: 10.1111/pde.14587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Seth M Martin
- Department of Dermatology, University of Virginia, Charlottesville, VA, USA
| | - Barrett J Zlotoff
- Department of Dermatology, University of Virginia, Charlottesville, VA, USA
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41
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Abstract
Background: Mast cells (MCs) have been implicated in a spectrum of allergic, immunologic, and infectious inflammatory conditions that involve different organ systems. MC activation can occur through several different surface receptors other than the well known IgE mediated pathway. Methods: We use two representative case reports from our practice to summarize what is currently known about MCAS disorders (reality) so that the clinician can more easily differentiate these conditions from other complex unexplained conditions that are being associated with MC activation (myth). Results: Many complex MC-related conditions, such as clonal MC diseases, have been well characterized but other MC-related disorders, such as MC activation syndrome (MCAS) and idiopathic anaphylaxis, still remain poorly defined. The current consensus recommendations for a diagnosis of MCAS require clinical symptoms of anaphylaxis that correlate with elevation of a MC activation biomarker(s), which improves with H1-antihistamines. Conclusion: Clinical symptoms of MCAS can overlap with other conditions, including neurogenic disorders, e.g., dysautonomia, which necessitate the importance for the clinician to render an accurate diagnosis so that appropriate treatment is provided.
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42
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Wang E, Ganti T, Vaou E, Hohler A. The relationship between mast cell activation syndrome, postural tachycardia syndrome, and Ehlers-Danlos syndrome. Allergy Asthma Proc 2021; 42:243-246. [PMID: 33980338 DOI: 10.2500/aap.2021.42.210022] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Postural tachycardia syndrome (POTS), hypermobile Ehlers-Danlos syndrome (EDS), and mast cell activation syndrome (MCAS) can occur in the same patient. In this study, we investigated the relationship among these three syndromes. Objective: To establish the relationship of MCAS in patients diagnosed with POTS and hypermobile EDS as well as characterize the demographics of the patients affected by these syndromes. Methods: A total of 195 medical records of patients by using a diagnostic codes data base search for disorders of autonomic dysfunction were identified. The demographics of the patients and diagnoses of POTS, EDS, or MCAS were recorded. Confidence intervals of the proportion of patients MCAS within a population of patients with POTS and EDS were compared with the proportion of patients with MCAS and without POTS and EDS. Odds ratios were also calculated within these groups. Results: The percentage of MCAS within the group of POTS and EDS was 31% in comparison with 2% within the non-POTS and EDS group. The 95% confidence interval calculated for the MCAS in the POTS and EDS group did not overlap with 2%, which showed a statistically significant result. The odds ratio between the two groups was found to be 32.46. Conclusion: There was a marked percentage of MCAS among the patients with diagnoses of POTS and EDS.
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Affiliation(s)
- Edwin Wang
- From the Tufts University School of Medicine, Boston, Massachusetts and
| | - Tej Ganti
- From the Tufts University School of Medicine, Boston, Massachusetts and
| | - Eleni Vaou
- From the Tufts University School of Medicine, Boston, Massachusetts and
| | - Anna Hohler
- From the Tufts University School of Medicine, Boston, Massachusetts and
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43
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Ramírez-Paesano C, Juanola Galceran A, Rodiera Clarens C, Gilete García V, Oliver Abadal B, Vilchez Cobo V, Ros Nebot B, Julián González S, Cao López L, Santaliestra Fierro J, Rodiera Olivé J. Opioid-free anesthesia for patients with joint hypermobility syndrome undergoing craneo-cervical fixation: a case-series study focused on anti-hyperalgesic approach. Orphanet J Rare Dis 2021; 16:172. [PMID: 33849631 PMCID: PMC8045305 DOI: 10.1186/s13023-021-01795-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/30/2021] [Indexed: 12/31/2022] Open
Abstract
Background Patients with Ehlers-Danlos Syndrome/Hypermobility Type (EDS-HT/JHS) and Craneo-Cervical Instability frequently suffer from severe widespread pain which is difficult to control. Chronic neuroinflammation, opioid-induced hyperalgesia, and central sensitization may explain this painful condition. The aim of this study was to determine if opioid-free anesthesia plus the postoperative administration of lidocaine, ketamine and dexmedetomidine can reduce postoperative pain and the need of methadone rescues in comparison with opioid-based management in these patients undergoing Craneo-Cervical Fixation (CCF). The secondary aim was to assess the needs of opioids at hospital-discharge, incidence of gastrointestinal complications and the requirement of anxiolytic. Methods A retrospective, consecutive case series study was designed. 42 patients with EDS-HT/JHS undergoing CCF were enrolled in two groups: an OFA-plus Group that received opioid-free anesthesia with propofol, lidocaine, ketamine and dexmedetomidine, and OP Group, opioid-based anesthesia-analgesia. The main variables: Preoperative Visual Analogue Score (VAS), postoperative VAS on the 1st, 2nd, 4th and 6th days, sufentanil or morphine requirements, need for methadone rescue, and VAS at hospital-discharge. Data was presented by mean ± SD, percentage, median or interquartile range. Chi-squared or Fisher’s test. 95% C.I and P values < 0.05. Results Nineteen patients in OFA-plus, and 23 patients in OP group. VAS was lower in OFA-plus on the postoperative days evaluated (p < 0.001).VAS at hospital-discharge was lower in OFA-plus: 4.96 (4.54–5.37) vs. OP 6.39 (6.07–6.71) (p < 0.001). Methadone requirement was lower in the OFA-plus (p < 0.001). 78% of patients in OFA-plus didn’t need methadone rescue. 95% in OP group needed methadone rescues at high doses(> 15 mg/day). No differences regarding equivalent doses of sufentanil or morphine consumption on the 2nd, 4th, and 6th postoperative days were found. OFA-plus decreased ileus, nausea and vomiting (p < 0.001). 60.9% in OFA-plus group decreased opioid requirements at hospital-discharge compared with preoperative values. A 77% reduction of anxiolytics requirements was shown. Conclusion OFA-plus management for patients undergoing CCF with EDS-HT/JHS shows significant reduction in postoperative pain and at hospital-discharge compared with opioid-based anesthesia. OFA-plus management decreases the total doses of methadone rescues, reduces anxiolytic requirements and gastrointestinal side-effects, except for constipation. OFA-plus management is a feasible option to improve postoperative pain control, reducing the opioids’ use and their postoperative side-effects in patients undergoing CCF with EDS-HT/JHS.
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Affiliation(s)
- Carlos Ramírez-Paesano
- Servei Central D'Anestesiología (Anestalia), Centro Médico Teknon, Carrer Vilana 12, 08022, Barcelona, Spain.
| | - Albert Juanola Galceran
- Servei Central D'Anestesiología (Anestalia), Centro Médico Teknon, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Claudia Rodiera Clarens
- Hospital Universitari Dexeus, Grupo Quironsalud, Carrer Sabino Arana, 5, 19, 08028, Barcelona, Spain
| | - Vicenҫ Gilete García
- Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | | | - Verónica Vilchez Cobo
- Postoperative Pain Management Team of Servei Central D'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Bibiana Ros Nebot
- Postoperative Pain Management Team of Servei Central D'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Sara Julián González
- Servei Central D'Anestesiología (Anestalia), Centro Médico Teknon, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Lucía Cao López
- Postoperative Pain Management Team of Servei Central D'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Jesús Santaliestra Fierro
- Servei Central D'Anestesiología (Anestalia), Centro Médico Teknon, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Josep Rodiera Olivé
- Servei Central D'Anestesiología (Anestalia), Centro Médico Teknon, Carrer Vilana 12, 08022, Barcelona, Spain
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Lam CY, Palsson OS, Whitehead WE, Sperber AD, Tornblom H, Simren M, Aziz I. Rome IV Functional Gastrointestinal Disorders and Health Impairment in Subjects With Hypermobility Spectrum Disorders or Hypermobile Ehlers-Danlos Syndrome. Clin Gastroenterol Hepatol 2021; 19:277-287.e3. [PMID: 32109633 DOI: 10.1016/j.cgh.2020.02.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/14/2020] [Accepted: 02/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Individuals with hypermobility spectrum disorder or hypermobile Ehlers-Danlos Syndrome (HSD/hEDS) are increasingly encountered by gastroenterologists and pose complex clinical challenges. Uncontrolled studies have found functional gastrointestinal disorders (FGIDs) to be common in patients with HSD/hEDS. Some patients have somatic symptoms (medically unexplained symptoms) that might affect FGIDs. We performed a case-control study to determine the prevalence of and factors associated with Rome IV FGIDs in subjects with HSD/hEDS compared with age- and sex- matched population-based controls. METHODS An online general health survey was completed by 603 individuals with HSD/hEDS in October 2018 (cases) and 603 matched individuals from the population of the United Kingdom (controls) in 2015. The mean participant age was 39 yrs, and 96% were women. The survey included questions about Rome IV FGIDs, non-GI and non-musculoskeletal somatic symptoms (maximum number, 10), quality of life, medical history and healthcare use. The prevalence of FGIDs was compared between cases and controls, with subsequent logistic regression models - adjusting for the number of somatic symptoms - used to determine the associations for FGIDs in HSD/hEDS compared with controls. RESULTS Nearly all subjects (98%) with HSD/hEDS fulfilled symptom-based criteria for 1 or more Rome IV FGIDs, compared with 47% of controls (P < .0001). The gastrointestinal regions most commonly affected by FGIDs in individuals with HSD/hEDS and control subjects were the bowel (90% vs 40% of controls), gastroduodenal (70% vs 13% of controls), esophageal (56% vs 6% of controls), and anorectal (53% vs 9% of controls); P < .0001. A higher proportion of subjects with HSD/hEDS had FGIDs in 2 or more regions (84% vs 15% of controls; P < .0001). Subjects with HSD/hEDS also reported a significantly higher number of non-GI and non-musculoskeletal somatic symptoms (7.1 vs 3.3 in controls), lower quality of life, and greater healthcare use, including abdominal surgeries and medication use (for example, 84% used analgesics compared with 29% of controls). Almost 40% of subjects with HSD/hEDS reported a diagnosis of chronic fatigue syndrome and/or fibromyalgia. Following adjustments for somatic symptoms, the association for FGIDs in subjects with HSD/hEDS was reduced by as much as 4-fold and in some instances was eliminated. CONCLUSIONS In a large case-control study of persons with HSD/hEDS, almost all of the cases met criteria for Rome IV FGIDs, incurred considerable health impairment, and had high healthcare use. Patients with HSD/hEDS frequently have somatic symptoms that should be treated to reduce the high burden of gastrointestinal illness in this population.
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Affiliation(s)
- Ching Y Lam
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom
| | - Olafur S Palsson
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina
| | - William E Whitehead
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina
| | - Ami D Sperber
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Hans Tornblom
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simren
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina; Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Imran Aziz
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.
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Islam M, Chang C, Gershwin ME. Ehlers-Danlos Syndrome: Immunologic contrasts and connective tissue comparisons. J Transl Autoimmun 2021; 4:100077. [PMID: 33437956 DOI: 10.1016/j.jtauto.2020.100077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/12/2020] [Accepted: 12/17/2020] [Indexed: 11/21/2022] Open
Abstract
Ehlers-Danlos Syndrome (EDS) is a family of multisystemic hereditary connective tissue disorders now comprised of 13 recognized subtypes, classical, classical-like, cardiac-valvular, vascular, hypermobile, arthrochlasia, dermosparaxis, kyphoscoliotic, brittle cornea syndrome, spondylodysplastic, musculocontractural, myopathic, and periodontal, as designated by the most recent 2017 International classification system. Clinical presentation of this disease can range from mild manifestations including skin hyperextensibility and joint hypermobility, to more severe complications such as vascular and organ rupture. While there may be accompanying inflammation in some of the subtypes of EDS, the pathogenic mechanisms have not been clearly defined. Thorough evaluation incorporates clinical examination, family history, laboratory testing, and imaging. In recent years, studies have identified multiple gene variants involved in the pathogenesis of specific EDS subtypes as well as elaborate clinical diagnostic criteria and classification models used to differentiate overlapping conditions. The differential diagnosis of EDS includes hypermobility spectrum disorders, Marfan syndrome, Loey-Dietz syndrome, Cutis laxa syndromes, autosomal dominant polycystic kidney disease, osteogenesis Imperfecta Type 1, fibromyalgia, depression, and chronic fatigue syndrome. Surgical treatment is reserved for complications, or emergencies involving vascular or orthopedic injury because of the risk of poor wound healing. Management techniques each have their own consequences and benefits, which will also be discussed in this review article. Patients affected by this spectrum of disorders are impacted both phenotypically and psychosocially, diminishing their quality of life. There are 13 of EDS as defined by the International EDS Consortium, some with an identified genetic etiology. Skin hyperextensibility, joint hypermobility, easy bruising, and organ rupture are common features of EDS. Hypermobile EDS is a poorly defined entity that has been associated with MCAS and POTs. The association of hEDS, MCAS and POTS has not been confirmed. There is a paucity of evidence for an immunological mechanism for EDS.
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Abstract
In this review, we explore the challenges of chronic pain and fatigue in clinical practice. Both pain and fatigue are common, troubling and frequently overlapping symptoms, and we describe both the clinical burden and the 'clinical problem'. We explore commonly associated symptoms and possible pathological associations, including variant connective tissue (joint hypermobility), small fibre neuropathy, mast cell activation, dysregulated inflammatory and interoceptive processes, which may inform treatment targets. We suggest a multidisciplinary management approach.
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Affiliation(s)
- Jessica A Eccles
- Brighton and Sussex Medical School, Falmer, UK, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK and Sussex Partnership Foundation NHS Trust, Brighton, UK
| | - Kevin A Davies
- Brighton and Sussex Medical School, Falmer, UK and medical director, The Advisory Committee on Clinical Excellence Awards (ACCEA), Leeds, UK
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Abstract
INTRODUCTION: The pathophysiology underlying functional dyspepsia (FD) is multifactorial and focuses on gastric sensorimotor dysfunction. Recent studies demonstrated that joint hypermobility syndrome (JHS) is strongly associated with unexplained dyspeptic symptoms in patients attending gastrointestinal clinics. We aimed to study the relationship between symptoms, gastric sensorimotor function, and JHS in FD patients. METHODS: Tertiary care FD patients who underwent a gastric barostat study and a gastric emptying breath test with 13C-octanoic acid were recruited for assessment of JHS. The presence of JHS was evaluated by a 2-phase interview and clinical examination that included major and minor criteria of the Brighton classification. RESULTS: A total of 62 FD patients (68% women, age 44 ± 1.8 years, and body mass index: 21.7 ± 0.7 kg/m2) accepted to participate in the study. JHS was diagnosed in 55% of FD patients. Assessed symptom profiles during the visit did not differ between the groups. Delayed gastric emptying was not significantly more common in JHS group compared with non-JHS group (JHS group 32% vs non-JHS group 16%, P = 0.31). Prevalence of hypersensitivity to distention (JHS group 24% vs non-JHS group 29%, P = 0.76) and impaired gastric accommodation (JHS group 38% vs non-JHS group 42%, P = 0.79) was similar in patients with or without JHS. No correlations were found between the Beighton hypermobility score and gastric compliance (r = 0.09). DISCUSSION: A large subset of this study cohort of tertiary care FD patients has coexisting JHS. We did not identify any specific differences in gastric sensorimotor function between patients with and without JHS. Further prospective research will be required to elucidate the relationship between JHS, a multisystemic disorder with widespread manifestations, and FD symptoms.
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Tai FWD, Palsson OS, Lam CY, Whitehead WE, Sperber AD, Tornblom H, Simren M, Aziz I. Functional gastrointestinal disorders are increased in joint hypermobility-related disorders with concomitant postural orthostatic tachycardia syndrome. Neurogastroenterol Motil 2020; 32:e13975. [PMID: 32803794 DOI: 10.1111/nmo.13975] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/08/2020] [Accepted: 07/27/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Individuals with hypermobility spectrum disorders/hypermobile Ehlers-Danlos syndrome (HSD/hEDS) frequently fulfill criteria for Rome IV functional gastrointestinal disorders (FGIDs). Postural orthostatic tachycardia syndrome (POTS) is also commonly reported in HSD/hEDS and may impact on co-morbidity with and severity of FGIDs, although this remains to be studied. We determined the impact of concomitant POTS and HSD/hEDS on their association with Rome IV FGIDs. METHODS With the help of the charity organization Ehlers-Danlos Support UK, an online cross-sectional health survey was completed by individuals with HSD/hEDS. The survey enquired for (a) self-reported doctor diagnosis of POTS, chronic fatigue syndrome, and fibromyalgia, (b) the presence and symptom frequency of Rome IV FGIDs, and (c) anxiety and depression scores. KEY RESULTS Of 616 subjects with HSD/hEDS, 37.5% reported a doctor diagnosis of POTS. POTS-positive individuals were significantly younger than POTS-negative subjects (37 vs 40 years, P = 0.002), more likely to report chronic fatigue syndrome (44% vs 31%, P < 0.0001), and showed a trend toward increased prevalence of fibromyalgia (44% vs 37%, P = 0.06) and higher depression score (P = 0.07). POTS-positive subjects were also more likely to fulfill criteria for Rome IV FGIDs across various organ domains and experienced both upper and lower gastrointestinal symptoms significantly more frequently. The increased associations for FGIDs and GI symptom frequency remained unchanged in HSD/hEDS subjects with POTS following adjustments for age, chronic fatigue syndrome, fibromyalgia, and depression scores. CONCLUSIONS AND INFERENCES The high FGID burden in HSD/hEDS is further amplified in the presence of POTS. Future studies should elucidate the mechanism by which POTS arises in HSD/hEDS and is associated with increased GI symptoms.
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Affiliation(s)
- Foong Way David Tai
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Olafur S Palsson
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Ching Y Lam
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | - William E Whitehead
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Ami D Sperber
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Hans Tornblom
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simren
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA.,Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Imran Aziz
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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Cimolai N. Mast Cell Biology and Linkages for Non-clonal Mast Cell Activation and Autoimmune/Inflammatory Syndrome Induced by Adjuvants. ACTA ACUST UNITED AC 2020; 2:2310-23. [DOI: 10.1007/s42399-020-00494-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
In recent years, mold has been blamed for many symptoms or a constellation of symptoms. These symptoms are usually vague and subjective and difficult or impossible to measure or quantify. Moreover, there is no scientific evidence that mold has anything to do with these symptoms. In particular, the concept of toxic mold syndrome has permeated the public consciousness, and mycotoxins have falsely been associated with autoimmune diseases and a variety of other conditions. In fact, there is no evidence that the presence of mycotoxins in the air is enough to cause any disease known to man. Molds legitimately can cause allergies and can be a trigger for asthma. Certain specific molds such as Aspergillus can be a cause of hypersensitivity pneumonitis. In immunocompromised hosts, both dermatologic and systemic infections can result from various fungi and can be associated with significant morbidity or even mortality. However, the existence of toxic mold syndrome has been disproven, despite the numerous disreputable practices such as testing homes for mold spores, measuring "mycotoxins" in the urine, and testing patients for IgG to mold. In truth, none of these techniques have been validated, nor do they have any relevance to any clinical disease. All that these tests that are being performed by laboratories of disrepute does is to further propagate misinformation and inflict unnecessary and often exorbitant costs on patients desperate for a clinical diagnosis, right or wrong, for their constellation of maladies.
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Affiliation(s)
- Christopher Chang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, 95616, USA. .,Division of Pediatric Immunology and Allergy, Joe DiMaggio Children's Hospital, Hollywood, FL, 33021, USA.
| | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, 95616, USA.
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