Cardiac Autonomic Function Associated with Treatment Adherence After a Brief Intervention in Patients with Chronic Pain

The goal of this study was to investigate psychophysiological characteristics in chronic pain patients during a pain stressor (cold pressor test) and after a brief diaphragmatic breathing intervention. Laboratory procedures were designed to quantify the effects of diaphragmatic breathing training at six breaths per minute on cardiac autonomic reactivity as indexed by root mean square of successive differences (RMSSD) and sequential baroreflex sensitivity (sBRS). Participants (n = 22) completed an initial laboratory assessment including the diaphragmatic breathing training session and were instructed to practice the technique for three ten-minute sessions daily. Self-monitoring of the use of the technique along with daily pain and fatigue scores was accomplished with hand-held computers. Participants returned to the lab for a second assessment after two-weeks. Participants demonstrating improved resting physiological status as indexed by change in RMSSD and sBRS after training (improvers) were compared to those not demonstrating any change in these variables (non-improvers). After two weeks of training, the improvers showed higher tolerance (p < .05) and lower blood pressure reactivity to the cold pressor test (p < .05) compared to the non-improvers. Time spent practicing the breathing technique was significantly different between the groups with the improvers maintaining daily practice close to the intervention recommendations. These results suggest the potential for significant improvements in autonomic functioning and inhibitory response to stress after a single intervention session and two weeks of practice.     

Selenium Status in Patients with Turner Syndrome: a Biochemical Assessment Related with Body Composition

Studies about selenium status in patients with Turner syndrome (TS) are non-existent in the literature. The aim of this study was to evaluate selenium status in patients with TS, while considering the different ages of the studied population and the relation with body composition. In total, 33 patients with TS were evaluated and grouped according to their developmental stages (children, adolescents, and adults). Selenium concentrations in their plasma, erythrocytes, urine, and nails were determined by using hydride generation atomic absorption spectrometry and erythrocyte glutathione peroxidase activity were measured by using Randox commercial kits. Additionally, height, weight, body fat percentage, waist circumference, and waist-height ratio were measured to characterize the patients. No differences in the selenium concentrations in the plasma, erythrocyte, urine, and nails or in the glutathione peroxidase activity were observed among the age groups (p > 0.05). The evaluated selenium levels were less than the established normal ones. The patients with larger waist circumference, body fat percentage, body mass index, and waist-height ratio showed lower glutathione peroxidase enzyme activity (p = 0.023). The present study shows that most patients with TS are deficient in selenium and that those with a greater accumulation of body fat have a lower GPx activity.     

Phenylalanine Absorption and Metabolism in Parkinsonian Patients

Oral and intravenous L-phenylalanine loading tests were performed in 13 Parkinsonian patients and in 12 control subjects matched for age and weight. The results showed a normal intestinal absorption and a normal elimination from plasma of phenylalanine in the Parkinsonian patients.     

Administration of Dihydroxyphenylalanine to Parkinsonian Patients

Dihydroxyphenylalanine (dopa), the metabolic precursor of dopamine, was administered to 10 parkinsonian patients in oral doses of 1-5 g. and intravenous doses of 0.2-0.5 g. Increases in dopamine excretion of 100- to 1000-fold following the dopa administration indicated that dopa was being absorbed and metabolized. Only two of the 10 patients showed any objective improvement on this treatment. Although dopa did not show sufficient beneficial results in this study to be considered a useful therapeutic agent, its slight activity is consistent with other evidence suggesting that some extrapyramidal cells are sensitive to dopamine.     

Autonomic Dysregulation in Headache Patients

To analyze autonomic nervous system activity in headache subjects, measurements of heart rate variability (HRV), skin temperature, skin conductance, and respiration were compared to a matched control group. HRV data were recorded in time and frequency domains. Subjects also completed self-report questionnaires assessing psychological distress, fatigue, and sleep dysfunction. Twenty-one headache and nineteen control subjects participated. In the time domain, the number of consecutive R-to-R intervals that varied by more than 50 ms and the standard deviation of the normalized R-to-R intervals, both indices of parasympathetic nervous system activity, were significantly lower in the headache group than the control group. Groups did not differ statistically on HRV measures in the frequency domain. Self-report measures showed significantly increased somatization, hostility, anxiety, symptom distress, fatigue, and sleep problems in the headache group. The results suggest headache subjects have increased sympathetic nervous system activity and decreased parasympathetic activity compared to non-headache control subjects. Headaches subjects also showed greater emotional distress, fatigue, and sleep problems. The results indicate an association between headaches and cardiovascular functioning suggestive of sympathetic nervous system activation in this sample of mixed migraine and tension-type headache sufferers.     

Cognitive Function in Peripheral Autonomic Disorders

Objective

aims of the current study were 1) to evaluate global cognitive function in patients with autonomic failure (AF) of peripheral origin and 2) to investigate the effect of a documented fall in blood pressure (BP) fulfilling the criteria for orthostatic hypotension (OH) on cognitive performances.

Methods

we assessed 12 consecutive patients (10 males, 68±7 years old) with pure AF (PAF) or autoimmune autonomic neuropathy (AAN) and 12 age- and gender-matched controls. All patients had no clinical signs of central nervous system involvement and normal brain CT/MRI scan. Cognitive function was assessed on two consecutive days in 3 conditions: on day 1, while sitting, by means of a comprehensive battery of neuropsychological tests; on day 2, while tilted (HUT) and during supine rest (supine) in a randomized manner. BP and heart rate (HR) were continuously recorded non-invasively for the whole duration of the examination.

Results

patients with PAF or AAN displayed a preserved global cognitive function while sitting. However, compared to supine assessment, during HUT patients scored significantly worse during the Trail Making Test A and B, Barrage test, Analogies test, Immediate Visual Memory, Span Forward and Span Backward test. Pathological scores, with regard to Italian normative range values, were observed only during HUT in the Barrage test and in the Analogies test in 3 and 6 patients respectively. On the contrary, in healthy controls, results to neuropsychological tests were not significantly different, during HUT compared to supine rest.

Conclusions

these data demonstrate that patients with PAF and AAN present a normal sitting global cognitive evaluation. However, their executive functions worsen significantly during the orthostatic challenge, possibly because of transient frontal lobes hypoperfusion.     

Assessment of Vascular Function in Patients With Chronic Kidney Disease

Patients with chronic kidney disease (CKD) have significantly increased risk of cardiovascular disease (CVD) compared to the general population, and this is only partially explained by traditional CVD risk factors. Vascular dysfunction is an important non-traditional risk factor, characterized by vascular endothelial dysfunction (most commonly assessed as impaired endothelium-dependent dilation [EDD]) and stiffening of the large elastic arteries. While various techniques exist to assess EDD and large elastic artery stiffness, the most commonly used are brachial artery flow-mediated dilation (FMD_BA) and aortic pulse-wave velocity (aPWV), respectively. Both of these noninvasive measures of vascular dysfunction are independent predictors of future cardiovascular events in patients with and without kidney disease. Patients with CKD demonstrate both impaired FMD_BA, and increased aPWV. While the exact mechanisms by which vascular dysfunction develops in CKD are incompletely understood, increased oxidative stress and a subsequent reduction in nitric oxide (NO) bioavailability are important contributors. Cellular changes in oxidative stress can be assessed by collecting vascular endothelial cells from the antecubital vein and measuring protein expression of markers of oxidative stress using immunofluorescence. We provide here a discussion of these methods to measure FMD_BA, aPWV, and vascular endothelial cell protein expression.     

Oral Phenylalanine and Tyrosine Tolerance Tests in Parkinsonian Patients

Reduction of dopamine concentrations in the brains of patients with Parkinsonism, together with reported clinical improvement after the administration of dihydroxyphenylalanine, has led to the hypothesis that impaired hydroxylation of tyrosine may be associated with the disease. To test this hypothesis oral loading tests with L-phenylalanine and tyrosine were carried out in patients and controls. After phenylalanine lower blood levels of this were found in Parkinsonian patients than in controls, but tyrosine levels were the same. After tyrosine lower levels of this were also found in patients compared with controls. It is suggested that these findings indicate a decreased rate of tyrosine utilization in Parkinson''s disease together with intestinal malabsorption; the latter is supported by the finding of abnormal D-xylose tolerance in these patients.     

Assessment of Atrial Fibrillation and Vulnerability in Patients with Wolff-Parkinson-White Syndrome Using Two-Dimensional Speckle Tracking Echocardiography

Purpose

The aim was to assess atrial fibrillation (AF) and vulnerability in Wolff-Parkinson-White (WPW) syndrome patients using two-dimensional speckle tracking echocardiography (2D-STE).

Methods

All patients were examined via transthoracic echocardiography and 2D-STE in order to assess atrial function 7 days before and 10 days after RF catheter ablation. A postoperative 3-month follow-up was performed via outpatient visit or telephone calls.

Results

Results showed significant differences in both body mass index (BMI) and supraventricular tachycardia (SVT) duration between WPW patients and DAVNP patients (both P<0.05). Echocardiography revealed that the maximum left atrial volume (LAV_max) and the left ventricular mass index (LVMI) in diastole increased noticeably in patients with WPW compared to patients with DAVNP both before and after ablation (all P<0.05). Before ablation, there were obvious differences in the levels of SRs, SRe, and SRa from the 4-chamber view (LA) in the WPW patients group compared with patients in the DAVNP group (all P<0.05). In the AF group, there were significant differences in the levels of systolic strain rate (SRs), early diastolic strain rate (SRe), and late diastolic strain rate (SRa) from the 4-chamber view (LA) both before and after ablation (all P<0.05). In the non-AF group, there were decreased SRe levels from the 4-chamber view (LA/RA) pre-ablation compared to post-ablation (all P<0.05).

Conclusion

Our findings provide convincing evidence that WPW syndrome may result in increased atrial vulnerability and contribute to the development of AF. Further, RF catheter ablation of AAV pathway can potentially improve atrial function in WPW syndrome patients. Two-dimensional speckle tracking echocardiography imaging in WPW patients would be necessary in the evaluation and improvement of the overall function of RF catheter ablation in a long-term follow-up period.     

Monoamine Oxidase Activity and Monoamine Metabolism in Brains of Parkinsonian Patients Treated with l-Deprenyl

Monoamine oxidase (MAO) type A and type B were measured using kynuramine, 3,4-dihydroxyphenylethylamine (dopamine, DA), and 5-hydroxytryptamine (5-HT, serotonin) in 20 brain areas. The highest activities were found in the striatum (caudate nucleus, putamen, globus pallidus, and substantia nigra), hypothalamus, and c-mammilare. The ratio of DA to 5-HT deamination varied in the different regions, being in favor of DA in the striatum. With kynuramine as the substrate IC50 values of a number of inhibitors indicated that l-deprenyl was far more potent an inhibitor of human brain MAO than clorgyline or harmaline. N-Desmethylpropargylindane hydrochloride (AGN 1135) was also shown to have MAO-B inhibitory selectivity similar to that of l-deprenyl. Brains obtained at autopsy from l-deprenyl-treated Parkinsonian patients showed that, whereas MAO-B was fully inhibited by the therapeutic doses of l-deprenyl, substantial MAO-A activity was still evident. These results are matched by the significant increases of DA noted in caudate nucleus, globus pallidus, putamen, and substantia nigra and the unaltered 5-HT and 5-hydroxyindoleacetic acid (5-HIAA) in the same regions. These data indicate that the therapeutic actions of l-deprenyl may lie in its selective inhibition of MAO-B resulting in increased brain levels of DA formed from L-dihydroxyphenylacetic acid (L-DOPA).     

Interrelations between EEG Parameters and Personality Characteristics in Parkinsonian Patients

We studied a number of EEG parameters and indices of personality characteristics (evaluated with the use of the MMPI questionnaire) in sixty 44- to 73-year-old patients with Parkinson's disease (PD). According to the intensity of the symptoms, they were classified into groups 1 and 2, with an initial or moderate level of disease manifestation. In group-2 patients, the powers of the - and -range rhythms were greater, as compared with those in group 1. This was combined with higher indices in scales 2 (depression, D), 8 (individualism, Sc), and 0 (introversion/extraversion, Si). A clear correlations between the EEG parameters and indices of personality structure were found. There were positive correlations between the normalized power of ₂-rhythm and values of a few MMPI scales: 1 (supercontrol, Hs), 2 (depression, D), 4 (impulsivity, Pd), 7 (anxiety, Pt), 8 (individualism, Sc), and 0 (introversion/extraversion, Si). We also found negative correlations between the frequency of -rhythm and indices of supercontrol and anxiety scales. Correlations between different EEG parameters and MMPI scale indices depended on the level of disease manifestation. Our results allow us to assume a certain generality of the neurophysiological mechanisms determining modifications of the integral electrical activity of the brain and formation of individual psychological characteristics in parkinsonian patients.     

Electromyographic Characteristics of Muscle Fatigue in Parkinsonian Patients Exposed to General Heating

Surface electromyography and turn–amplitude analysis were used to study muscle fatigue after exposure to heating (40°C, 60 min) and under thermoneutral conditions (22°C) in 12 parkinsonian patients from 57 to 65 years of age treated with Nacom, Bromocryptin, and Cyclodol. In the patients, heating caused a twofold increase in the motor performance (number of contractions until exhaustion and nerve conduction velocity) and a decrease in the mean electromyogram (EMG) amplitude and number of turns of spontaneous muscle activity. The spontaneous EMG activity was fully inhibited after exposure to heating and fatigue, suggesting a thermoregulatory dependence of the spontaneous muscle tone (rigidity) in parkinsonian patients. After exposure to heating, fatigue also caused a decrease in the peak ratio with a shift of the mean EMG amplitude to lower values. After-load recovery of the mean EMG amplitude was slower under heating versus thermoneutral conditions and was compensated for by an increased number of turns.     

Effect of Rhythmic Auditory Stimulation on Gait in Parkinsonian Patients with and without Freezing of Gait

Freezing of gait (FOG) in Parkinson''s disease (PD) rises in prevalence when the effect of medications decays. It is known that auditory rhythmic stimulation improves gait in patients without FOG (PD-FOG), but its putative effect on patients with FOG (PD+FOG) at the end of dose has not been evaluated yet. This work evaluates the effect of auditory rhythmic stimulation on PD+FOG at the end of dose. 10 PD+FOG and 9 PD-FOG patients both at the end of dose periods, and 10 healthy controls were asked to perform several walking tasks. Tasks were performed in the presence and absence of auditory sensory stimulation. All PD+FOG suffered FOG during the task. The presence of auditory rhythmic stimulation (10% above preferred walking cadence) led PD+FOG to significantly reduce FOG. Velocity and cadence were increased, and turn time reduced in all groups. We conclude that auditory stimulation at the frequency proposed may be useful to avoid freezing episodes in PD+FOG.     

Pituitary-Thyroid Function in Pendred's Syndrome

Pendred''s syndrome is reported in three siblings. All were euthyroid, with large goitres and deaf mutism and all had an unusual deposition of pigment in the retina. All had raised circulating levels of triiodothyronine (T-3) and an exaggerated response of thyroid-stimulating hormone (TSH) to thyrotrophin-releasing hormone (TRH). It appears that their compensated euthyroid state was maintained by the raised T-3 levels. We suggest that preferential T-3 production is maintained by increased TSH secretion in subjects with intrathyroidal iodine deficiency secondary to thyroid organification defect.     

Assessing Right Ventricular Function in Patients with Hypertrophic Cardiomyopathy with Cardiac MRI: Correlation with the New York Heart Function Assessment (NYHA) Classification

Purpose

To determine whether 3.0-T magnetic resonance imaging (MRI) could assess right ventricular (RV) function in patients with hypertrophic cardiomyopathy (HCM), and if this assessment is correlated with the New York Heart Function Assessment (NYHA) classification.

Materials and Methods

Forty-six patients with HCM and 23 normal individuals were recruited. Left and right ventricular function parameters including end-diastolic and end-systolic volumes (EDV, ESV), stroke volume (SV) and ejection fraction (EF) and dimensions were measured and compared using 3.0-T MRI. RV function parameters between HCM patients and controls were compared using independent sample t tests. A one way ANOVA test with Bonferroni correction was used to determine significant differences among different NYHA groups. Receiver operating characteristic analyses calculated the sensitivity and specificity of RV dysfunction on MRI for the prediction of HCM severity.

Results

Statistical analysis revealed significant differences of left ventricular (LV) and RV volumetric values and masses between the HCM patients and controls (all p<0.05). Within the HCM group, the simultaneously decreased maximum RVEDD correlated well with the LVEDD (r = 0.53; p<0.001). The function and dimension parameters among Class I to III were not determined to be significantly different (all p>0.05). However, significant differences between the Class IV and I-III groups (all P<0.0167) indicated that the diastolic and systolic function in both the RV and LV were impaired in Class IV patients. ROC analyses identified the EDV, ESV and EDD of both the LV and RV with a high sensitivity cutoff value to predict the HCM patients with severe heart failure (Class IV) with high sensitivity and specificity.

Conclusions

RV involvements were comparable to those of LV global function impairments in patients with HCM. The presence of RV dysfunction and decreased dimension on the MRI helped to predict the severe symptomatic HCM with high sensitivity and specificity.     

Evaluation of Psychophysiological Asymmetry in Patients with Fibromyalgia Syndrome

Fibromyalgia syndrome (FMS) is characterized by systemic pain of unknown etiology, and is often accompanied by various psychological symptoms. In the present study, differences in surface electromyographic (SEMG) levels of the trapezius muscle, skin temperature (TEMP) and skin conductance level (SCL) were compared between the right and left side of the body in 31 FMS and 47 control subjects (Control Group). We observed significant asymmetries of SEMG level, TEMP and SCL in the FMS Group. These asymmetries might be related to central, peripheral and autonomic nervous system dysfunctions. Marked increase of SEMG levels, and a decrease of TEMP and SCL were observed at the dominant side in the FMS Group, and a negative correlation of SEMG levels with TEMP and SCL was found. These results suggest that continued antalgic postures in response to pain at the dominant side in FMS patients might lead to asymmetries of SEMG level, TEMP and SCL. Thus, a focus on pain related behaviors and muscle asymmetry might be a useful therapeutic approach.     

Carpal Tunnel Syndrome Assessment with Ultrasonography: Value of Inlet-to-Outlet Median Nerve Area Ratio in Patients versus Healthy Volunteers

Objective

To evaluate the diagnostic value of the Inlet-to-outlet median nerve area ratio (IOR) in patients with clinically and electrophysiologically confirmed carpal tunnel syndrome (CTS).

Methods

Forty-six wrists in 46 consecutive patients with clinical and electrodiagnostic evidence of CTS and forty-four wrists in 44 healthy volunteers were examined with ultrasonography. The cross-sectional area (CSA) of the median nerve was measured at the carpal tunnel inlet (the level of scaphoid-pisiform) and outlet (the level of the hook of the hamate), and the IOR was calculated for each wrist. Ultrasonography and electrodiagnostic tests were performed under blinded conditions. Electrodiagnostic testing combined with clinical symptoms were considered to be the gold standard test. Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic value between the inlet CSA and IOR.

Results

The study population included 16 men and 30 women (mean age, 45.3 years; range, 18–83 years). The control population included 18 men and 26 women (mean age, 50.4 years; range, 18–79 years). The mean inlet CSA was 8.7 mm² in healthy controls and 14.6mm² in CTS group (P<0.001). The mean IOR in healthy volunteers (1.0) was smaller than that in patients (1.6, P<0.001). Receiver operating characteristic analysis revealed a diagnostic advantage to using the IOR rather than the inlet CSA (P<0.01). An IOR cutoff value of ≥ 1.3 would yield 93% specificity and 91% sensitivity in the diagnosis of CTS.

Conclusion

The IOR of median nerve area promises to be an effective means in the diagnosis of CTS. A large-scale, randomized controlled trial is required to determine how and when this parameter will be used.     

Assessment of Renal Function in Patients with Unilateral Ureteral Obstruction Using Whole-Organ Perfusion Imaging with 320-Detector Row Computed Tomography

Background

Obstructed nephropathy is a common complication of several disease processes. Accurate evaluation of the functional status of the obstructed kidney is important to achieve a good outcome. The purpose of this study was to investigate renal cortical and medullary perfusion changes associated with unilateral ureteral obstruction (UUO) using whole-organ perfusion imaging with 320-detector row computed tomography (CT).

Methodology/Principle Findings

Sixty-four patients with UUO underwent whole-organ CT perfusion imaging. Patients were divided into 3 groups, mild, moderate, and severe, based on hydronephrosis severity. Twenty sex- and age-matched patients without renal disease, who referred to abdominal CT, were chosen as control subjects. Mean cortical and medullary perfusion parameters of obstructed and contralateral kidneys were compared, and mean perfusion ratios between obstructed and contralateral kidneys were calculated and compared. Mean cortical or medullary blood flow (BF) and blood volume (BV) of the obstructed kidneys in the moderate UUO and BF, BV, and clearance (CL) in the severe UUO were significantly lower than those of the contralateral kidneys (p < 0.05). The mean cortical or medullary BF of the obstructed kidney in the moderate UUO, and BF, BV, and CL in the severe UUO were significantly lower than those of the kidneys in control subjects (p < 0.05). Mean cortical or medullary BF of the non-obstructed kidneys in the severe UUO were statistically greater than that of normal kidneys in control subjects (p < 0.05). An inverse correlation was observed between cortical and medullary perfusion ratios and grades of hydronephosis (p < 0.01).

Conclusions/Significance

Perfusion measurements of the whole kidney can be obtained with 320-detector row CT, and estimated perfusion ratios have potential for quantitatively evaluating UUO renal injury grades.