Postural Symptoms Research Articles

Visual symptoms in postural tachycardia syndrome: An investigation of position-dependent visual exploration.

Patients with postural tachycardia syndrome report position-dependent visual symptoms. Despite their impact on daily life, these symptoms have remained largely unexplored in research. The aim of this study was to investigate the nature of visual symptoms in postural tachycardia syndrome and possible underlying pathophysiological mechanisms. Fifteen patients with postural tachycardia syndrome and 15 healthy controls were included in the study. Through a comprehensive array of measurements, including haemodynamics, subjective symptom assessments, eye movement tracking and pupil diameter analysis, participants were assessed during free image exploration in both supine and 60° head-up tilt positions. During head-up tilt, patients showed a decreased number and duration of fixations, as well as a decreased number, peak velocity and amplitude of saccades compared to the supine position and the control group. This reduction in visual exploration occurred primarily in the peripheral field of view and coincided with the occurrence of subjective visual symptoms. No significant differences in the saccade main sequence were observed between the two groups in either body position. Patients with postural tachycardia syndrome have a reduced exploration of the peripheral field of view when in an upright body position, potentially leading to tunnel vision. Since the normality of the saccade main sequence in patients combined with the focus on the centre of the field of view and the lower saccade amplitudes points to an intact brainstem function, the decrease in peripheral visual exploration may be attributed to a position-dependent dysfunction of the frontal eye field.

Bioinformatics and network pharmacology discover the molecular mechanism of Liuwei Dihuang pills in treating cerebral palsy.

A collection of chronic central motor, postural, and activity restriction symptoms are referred to as cerebral palsy (CP). Previous research suggests that a number of perinatal variables, including hypoxia, may be linked to CP. And the pathophysiological process that causes brain injury in growing fetuses is mostly caused by amniotic fluid infection and intra-amniotic inflammation. Still, there is still much to learn about the molecular mechanism of CP. The goal of this study was to identify the molecular mechanism of Liuwei Dihuang pill (LWDHP) in the treatment of CP using network pharmacology and bioinformatics. The Chinese medicine database provided the LWDHP components and targets, the CP illness gene data set was gathered from a disease, and the expression profile of children with CP was chosen from anther database. Using the Kyoto Encyclopedia of Genes and Genomes and gene ontology databases, a network of interactions between proteins was created, and functional enrichment analysis was carried out. Analysis of traditional Chinese medicine found that the key active ingredients of LWDHP are quercetin, Stigmasterol and kaempferol. Through enrichment analysis, it was found that the hub genes for LWDHP treatment of CP are CXCL8, MMP9, EGF, PTGS2, SPP1, BCL2L1, MMP1, and AR. K EGG analysis found that LWDHP treatment of CP mainly regulates PI3K-Akt signaling pathway, IL-17 signaling pathway, Jak-STAT signaling pathway, NF-kappa B signaling pathway, etc. To summarize, LWDHP regulates immunological and inflammatory variables through a variety of components, targets, and signaling pathways, which plays a significant role in the development and management of CP.

Relationships between working from home, sitting postures and low back pain during COVID-19: A survey of frequent computer users.

To investigate the effects of working from home on musculoskeletal pain. An e-survey of computer workers was conducted. Multinomial logistic regression modelling examined relationships between work location (work or home office desk, dining table, other), sitting posture (diagrams with descriptors), depressive symptoms (CESD -10), sleep quality (good/average vs poor) and pain (low back pain [LBP]), other pain without LBP, asymptomatic). Of 634 respondents, most (91%, n = 578) worked partially at home and had pain (91%, n = 576; 342 LBP, 234 other pain, 58 asymptomatic). Sitting posture ("trunk a little bent forward" vs "straight up, back against back rest": OR = 2.9; 95% CI 1.3-6.5, p = .008), being female (2.2; 1.2-4.1, p = .008), and depressive symptoms (3.4; 1.7-6.6; p < .001) were associated with LBP. Poor sleep quality related to LBP but correlated with depressive symptoms. Working from home and location were not associated with pain. Sitting postures, but not working from home, are associated with LBP.

Treating Lows: Management of Orthostatic Hypotension.

Orthostatic hypotension is a prevalent clinical condition, caused by heterogenous etiologies and associated with significant morbidity and mortality. Management is particularly challenging in patients with uncontrolled hypertension. A thorough assessment is needed to draw an appropriate management plan. The treatment aims to improve postural symptoms while minimizing side effects and reducing iatrogenic exacerbation of supine hypertension. A personalized management plan including rationalizing medications, patient education, identification, and avoidance of triggers, as well as nonpharmacological therapies such as compression devices, dietary modifications, and postural aids, make the first steps. Among pharmacological therapies, midodrine and fludrocortisone are the most prescribed and best studied; pyridostigmine, atomoxetine, and droxidopa are considered next. Yohimbine remains an investigational agent. A multidisciplinary team may be required in some patients with multiple comorbidities and polypharmacy. However, there is a lack of robust efficacy and safety evidence for all therapies. Building robust real-world and stratified clinical trials based on underlying pathophysiology may pave the way for further drug development and better clinical strategies and in this challenging unmet medical need.

Expert consensus on the terminology, diagnostics and management of persisting symptoms after concussion with a focus on mental health, postural stability, electroencephalogram and balance testing: A cross-sectional Delphi-like survey.

Persisting symptoms after concussion (PSaC) are a pathological manifestation of head injuries that present with symptoms after the acute phase of head trauma has subsided. Insufficient research about PSaC has led to gaps in knowledge and incorrect terminology being applied. Furthermore, gaps exist in standardised assessment protocols and understanding of mental health symptoms associated with sports. The study aimed to; 1) Determine expert consensus on appropriate terminology for symptoms lasting >4 weeks, 2) Investigate associations with mental health and postural stability symptoms, 3) Evaluate experts' views on quantitative balance and electroencephalogram (EEG) testing. A Delphi-like survey was designed in REDCap and sent to identified experts in the field of sports-related concussions (SRC). Expert consensus was defined as ≥75% agreement. Expert consensus identified the following mood and motor control symptoms being associated with PSaC: increases in emotional state (80%), irritability (87%), nervousness (87%), sadness (80%), balance impairment (80%), dizziness (87%) and feeling slow (80%). Numbness and tingling were not considered longer-term effects (80%). Additionally, 93% of respondents acknowledged mental health symptoms as potential longer-term effects, with 80% agreeing on inadequate current management. Respondents indicated PSaC are only somewhat adequately managed (73%) or not managed well enough (27%). The use of EEG and quantitative balance testing remains open for debate. The survey response rate was 21%. Improving mental health management for athletes with PSaC and standardising terminology is crucial. Future research is required to establish effective diagnosis and treatment methods. Addressing these issues may result in better care and safer return to play for athletes.

Low-intensity vestibular noise stimulation improves postural symptoms in progressive supranuclear palsy

BackgroundPostural imbalance and falls are an early disabling symptom in patients with progressive supranuclear palsy (PSP) of multifactorial origin that may involve abnormal vestibulospinal reflexes. Low-intensity noisy galvanic vestibular stimulation (nGVS) is a non-invasive treatment to normalize deficient vestibular function and attenuate imbalance in Parkinson’s disease. The presumed therapeutic mode of nGVS is stochastic resonance (SR), a mechanism by which weak sensory noise stimulation can enhance sensory information processing.ObjectiveTo examine potential treatment effects of nGVS on postural instability in 16 patients with PSP with a clinically probable and [18F]PI-2620 tau-PET-positive PSP.MethodsEffects of nGVS of varying intensity (0–0.7 mA) on body sway were examined, while patients were standing with eyes closed on a posturographic force plate. We assumed a bell-shaped response curve with maximal sway reductions at intermediate nGVS intensities to be indicative of SR. An established SR-curve model was fitted on individual patient outcomes and three experienced human raters had to judge whether responses to nGVS were consistent with the exhibition of SR.ResultsWe found nGVS-induced reductions of body sway compatible with SR in 9 patients (56%) with optimal improvements of 31 ± 10%. In eight patients (50%), nGVS-induced sway reductions exceeded the minimal clinically important difference (improvement: 34 ± 5%), indicative of strong SR.ConclusionnGVS yielded clinically relevant reductions in body sway compatible with the exhibition of SR in vestibular sensorimotor pathways in at least half of the assessed patients. Non-invasive vestibular noise stimulation may be thus a well-tolerated treatment strategy to ameliorate postural symptoms in PSP.

P095 Association between autism and chronic musculoskeletal pain; a single tertiary adolescent rheumatology centre experience

Abstract Background/Aims Autism is a common neurodevelopmental disorder and can present with atypical sensorimotor function and altered pain response. Evidence suggests that patients with autism have a different processing mechanism which can alter pain perception. Pain evaluation and management is often insufficient in patients with autism. Chronic musculoskeletal pain in adolescents is common and is frequently associated with other co-morbidities. The adolescent musculoskeletal pain service at University College London Hospital uses a multidisciplinary approach to provide treatment and ongoing support for young people with chronic musculoskeletal pain up to the age of 19 years, bridging significant and often stressful life events such as exams and moving away from home. Methods A retrospective review of patient records was conducted between October 2021 and October 2023. New patients attending the adolescent chronic musculoskeletal pain clinic at University College London Hospital were identified and the prevalence of autism was noted. The presence of other co-morbidities and symptoms was also recorded. Statistical analysis was undertaken using GraphPad Prism (Fisher’s exact test) to determine any differences between patients with and without a diagnosis of autism. Results Retrospective data was obtained on 82 new patients aged between 13 and 18 years seen in the adolescent chronic musculoskeletal pain clinic. 28 patients (34%) had a diagnosis of autism. A higher proportion of autistic patients with chronic musculoskeletal pain were male compared to those without autism (36% vs 11%, p = 0.016). More patients with autism reported co-existing mental health difficulties, especially anxiety and depression (68% vs 37%, p = 0.011). Conversely, patients without autism reported a higher incidence of postural orthostatic tachycardia symptoms (POTS) or symptoms of postural dizziness (57% vs 25%, p = 0.009). Other co-morbidities and symptoms were found to be similar between patients with and without autism (headaches 18% vs 39%, abdominal pain 36% vs 54%, fatigue 61% vs 46%, sleep difficulties 68% vs 54%, attention deficit hyperactivity disorder 18% vs 9%). Conclusion This small retrospective study demonstrates that over a third of new patients seen in the adolescent chronic musculoskeletal pain service are autistic. This suggests a possible link between autism and chronic pain but more research is needed to evaluate this and larger studies are required. Patients with chronic musculoskeletal pain and autism were more likely to be male and have mental health difficulties compared to those without autism. The high incidence of mental health difficulties highlights the need for multidisciplinary team working, in particular psychological support. The results of this study have important implications for training and suggest that novel treatment strategies are needed to help advance therapies for chronic musculoskeletal pain in young people with autism. Disclosure E. Williams: None. S. Mavrommatis: None. J. Glanville: None. M. Leandro: None. D. Sen: None. C. Fisher: None.

Orthostatic hypotension in Parkinson's disease: Sit-to-stand vs. supine-to-stand protocol and clinical correlates

BackgroundScreening for orthostatic hypotension (OH) is integral in Parkinson's disease (PD) management, yet evidence-based guidelines on best practice methods for diagnosing OH in PD are lacking. MethodsWe investigated the frequency and correlates of OH, symptomatic OH, and neurogenic OH, in a large consecutively recruited PD cohort (n = 318), and compared the diagnostic performance of the sit-to-stand vs. the supine-to-stand blood pressure (BP) test. We evaluated the utility of continuous BP monitoring and tilt table testing in patients with postural symptoms or falls who were undetected to have OH with clinic-based BP measurements. Disease severity, fluid intake, orthostatic and overactive bladder symptoms, falls, comorbidities and medication history were evaluated. ResultsPatients’ mean age was 66.1 ± 9.5years, with mean disease duration 7.8 ± 5.5years. OH frequency was 35.8 % based on the supine-to-stand test. OH in PD was significantly associated with older age, lower body mass index, longer disease duration, worse motor, cognitive and overactive bladder symptoms and functional disabilities, falls, and lower fluid intake. A similar profile was seen with asymptomatic OH. Three quarters of OH were neurogenic, with the majority also having supine hypertension. The sit-to-stand test had a sensitivity of only 0.39. One quarter of patients were additionally diagnosed with OH during continuous BP monitoring. ConclusionsThe sit-to-stand test substantially underdiagnoses OH in PD, with the important practice implication that supine-to-stand measurements may be preferred. Screening for OH is warranted even in asymptomatic patients. Adequate fluid intake, treatment of urinary dysfunction and falls prevention are important strategies in managing PD patients with OH.

The Contribution of Psychological Symptoms to Cognitive Difficulties in Youth With Postural Orthostatic Tachycardia Syndrome and Chronic Pain.

Subjectively experienced cognitive difficulties are common in youth with postural orthostatic tachycardia syndrome. The pathophysiological and psychological contributions of these cognitive impairments remain unclear. Participants were 96 adolescents and young adults diagnosed with postural orthostatic tachycardia syndrome and admitted to an intensive pain treatment program. Participants completed cognitive assessment and measures of postural orthostatic tachycardia syndrome symptoms, pain intensity, pain catastrophizing, anxiety, depression, and functional disability. Self-reported autonomic symptom intensity, but not severity of heart rate change, was associated with cognitive performance. Symptoms of depression were associated with decreases in most measures of cognitive functioning. Pain intensity, pain catastrophizing, and depression but not cognitive scores and physiological measures, were significant predictors of disability. Depression appears to be a significant contributor to the cognitive difficulties in youth with postural orthostatic tachycardia syndrome. These findings highlight the importance of assessing and treating affective symptoms in this population along with medical and lifestyle approaches to treating postural orthostatic tachycardia syndrome symptoms.

Improved postural symptoms in patients with progressive supranuclear palsy in response to low-intensity vestibular noise stimulation

Improved postural symptoms in patients with progressive supranuclear palsy in response to low-intensity vestibular noise stimulation

Extracorporeal membrane oxygenation in the surgical management of large mediastinal masses: a narrative review.

The management of large mediastinal tumors requires a complex multidisciplinary approach, particularly in the perioperative setting due to increased risk of hemodynamic compromise. The utilization of extracorporeal membrane oxygenation (ECMO) provides a useful adjunct in the surgical management for biopsy and resection of these mediastinal masses. The objective of this article is to review indications and implementation of ECMO in the surgical management of mediastinal disease. A literature review of the PubMed database was completed evaluating articles discussing 'extracorporeal circulation', 'cardiopulmonary bypass', 'anesthesia', 'mediastinal disease', and 'mediastinal cancer'. These articles were evaluated for contribution to the discussion of indications and implementation of ECMO in the management of these patients. Large mediastinal tumors place patients at risk of hemodynamic collapse on induction of anesthesia due to compression of vascular structures, tracheobronchial tree and creation of V/Q mismatch. Patients may be stratified regarding their risk of perioperative complications by evaluation of postural symptoms, cross sectional imaging findings and pulmonary function tests. Those patients at elevated perioperative risk may benefit from the utilization of ECMO, most commonly veno-arterial (V-A) ECMO. Guidewires or ECMO cannulas may be placed under local anesthesia prior to induction. Those patients with hemodynamic compromise may receive mechanical circulatory support to allow completion of the operation. The use of a multidisciplinary team consisting of surgeons, anesthesiologists, perfusionists and OR team is critical to the success in the use of ECMO in the resection of mediastinal masses. With diligent preparation, these high-risk patients may be optimally managed at the time of resection.

Determinants of fatigue in emergency department clinicians who wear personal protective equipment.

To determine the independent predictors for clinician fatigue and decline in cognitive function following a shift in the ED during early stages of the COVID-19 pandemic. This was a prospective, quasi-experimental study conducted in a metropolitan adult tertiary-referral hospital ED over 20 weeks in 2021. The participants were ED doctors and nurses working clinical shifts in an ED isolation area or high-risk zone (HRZ) with stringent personal protective equipment (PPE). The participants' objective and subjective fatigue was measured by the Samn-Perelli fatigue score and a psychomotor vigilance 'smart game' score, respectively. Postural signs/symptoms and urine specific gravity (SG) were measured as markers of dehydration. Sixty-three participants provided data for 263 shifts. Median (interquartile range) age was 33 (28-38) years, 73% were female. Worsening fatigue score was associated with working afternoon shifts (afternoon vs day, adjusted odds ratio [aOR] 5.16 [95% confidence interval (CI) 1.32-20.02]) and in non-HRZ locations (HRZ vs non-HRZ, aOR 0.23 [95% CI 0.06-0.87]). Worsening cognitive function (game score) was associated with new onset postural symptoms (new vs no symptoms, aOR 4.14 [95% CI 1.34-12.51]) and afternoon shifts (afternoon vs day, aOR 3.13 [95% CI 1.16-8.44]). Working in the HRZ was not associated with declining cognitive function. Thirty-four (37%) of the 92 participants had an end of shift urine SG >1.030. Working afternoon shifts was associated with fatigue. There was no association between HRZ allocation and fatigue, but our study was limited by a low COVID workload and fluctuating PPE requirements in the non-HRZs. Workplace interventions that target the prevention of fatigue in ED clinicians working afternoon shifts should be prioritised.

Postural orthostatic tachycardia syndrome-like symptoms following COVID-19 vaccination: An overview of clinical literature.

Postural Orthostatic Tachycardia Syndrome (POTS) is a common condition affecting more than 170 people per 100,000 population. However, POTS following COVID-19 vaccination remains a rare reporting in the medical literature. We, herein, summarize and highlight the evidence that has been reported regarding POTS-like symptoms following COVID-19 vaccination. We conducted a literature search and summarized the findings in the form of a narrative commentary. All types of publications (case reports/series, original articles, letters to editors, brief communications etc.) in English language were included. Whilst the exact pathogenetic mechanism behind POTS is yet to elucidated, there has been increasing evidence pointing towards an autoimmune dysfunction. Females were found to be predominantly affected (72%) with age range from 17 years to 52 years. Additionally, it seems that POTS-like symptoms could be triggered after immunization with Pfizer- BioNTech, Moderna, and Oxford-AstraZeneca COVID-19 vaccines. The symptoms typically appear within the first week, depending upon previous exposure to the virus and presence of other systemic conditions. In some patients, the condition is self-resolving. However, in others, non-pharmacological interventions coupled with negative ionotropic medications can be used for symptomatic management of the patients. Timely diagnosis and proper treatment are quintessential for ensuring early alleviation (and in some cases complete resolution) of symptoms. Furthermore, there may be episodes of relapse. Overall prognosis of the new-onset POTS-like symptoms is difficult to predict based on current literature.

Behavioral Variant Frontotemporal Dementia like Syndrome –Atypical Presentation of Intracranial Hypotension

Spontaneous Intracranial Hypotension (SIH) is an uncommon syndrome which may result from a Cerebrospinal Fluid (CSF) leak. Atypical SIH may present with neurobehavioral symptoms similar to those observed in behavioral variant Frontotemporal Dementia (bvFTD). We present a case of a 55-year-old male with postural headache and behavioral symptoms who was initially diagnosed with bvFTD. On re-evaluation in our clinic, imaging revealed caudal displacement of the midline structures suggestive of Cerebrospinal Fluid (CSF) hypotension. We hypothesized that with unmitigated CSF loss over a long period of time, the patient developed brain sagging clinically resulting in neurobehavioral, frontal lobe dysfunction. After multitude of investigative procedures, a CSF venous fistula originating from a T7 nerve root cyst was found and repaired. Surgical intervention and restoration of CSF volume resulted in resolution of cognitive as well as neurobehavioral symptoms.

Symptoms of postural orthostatic tachycardia syndrome in pregnancy: a cross-sectional, community-based survey.

To evaluate the relationship between postural orthostatic tachycardia syndrome (POTS) and pregnancy. Cross-sectional survey. International. A total of 8941 female patients with a diagnosis of POTS. Data from the survey were analysed using descriptive measures and stratified for comparisons. Symptom course of POTS during pregnancy. Secondary outcomes included pregnancy loss, POTS onset during pregnancy and the impacts of a comorbid diagnosis of Ehlers-Danlos syndrome or an autoimmune disorder on symptoms during pregnancy. Overall, 40.8% (n=3652) of participants reported one or more pregnancies. Most participants experienced worsening of symptoms in the first (62.6%) and third (58.9%) trimesters and 3months after pregnancy (58.7%), and 81.1% experienced worsening symptoms at any point in their pregnancy. Most participants with worsening symptoms in the first trimester also experienced worsening symptoms in the second (61.6%) and third (68.1%) trimesters, but if they improved in the first trimester then this improvement persisted in the second and third trimesters. Of participants who reported that POTS was triggered by a specific event (41.3%), 8.1% reported pregnancy as the trigger for the onset. Postural orthostatic tachycardia syndrome symptoms in the first trimester of pregnancy may help predict symptom course throughout the duration of pregnancy. Some individuals may experience an initial onset of POTS during pregnancy. This novel information may guide clinicians in counselling patients with POTS who are planning pregnancy.

Sleep Problems After Concussion Are Associated With Poor Balance and Persistent Postconcussion Symptoms.

We examined the association of self-reported sleep problems with clinical measures of postural stability, memory performance, symptom burden, and symptom duration following youth concussion. Patients 6-18 years of age presenting ≤21 days postconcussion underwent a clinical evaluation including modified Balance Error Scoring System, single- and dual-task tandem gait, immediate and delayed recall, and symptom severity. We calculated time from injury until symptom resolution and determined the proportion of patients who developed persistent postconcussion symptoms, defined as a symptom duration >28 days postconcussion. We grouped patients based on whether they reported sleep problems at their postconcussion clinical evaluation and compared symptom-based and functional outcomes between groups. Of the 207 patients included, n = 97 (14.3 ± 2.9 years; 49% female; initial visit 10.2 ± 5.8 days postconcussion) reported sleep problems postconcussion and n = 110 (14.3 ± 2.4 years; 46% female; initial visit 9.3 ± 5.4 days postinjury) did not. Those reporting sleep problems postconcussion had significantly more modified Balance Error Scoring System errors than those without (8.4 ± 5.5 vs 6.7 ± 4.7; P = .01), but similar tandem gait and memory performance. A significantly greater proportion of those who reported sleep problems postconcussion experienced persistent postconcussion symptoms than those who did not (53% vs 31%; P = .004). After adjusting for time from concussion to clinical visit and preconcussion sleep problems, postconcussion sleep problems were associated with a 2 times greater odds of developing persistent postconcussion symptoms (adjusted odds ratio = 2.02, 95% CI = 1.01, 4.06; P = .049). Identifying sleep problems early following concussion may allow clinicians to implement targeted treatment recommendations to improve sleep and provide an optimal recovery environment.

Essential tremor-Parkinson's disease syndrome: clinical characteristics and subtypes using cluster analysis.

Essential tremor (ET) and Parkinson's disease (PD) are common movement disorders. ET-PD syndrome is characterized by the occurrence of PD in patients with a previous history of ET, which may be an independent phenotype distinct from PD. This study aims to identify clinical characteristics and subtypes in ET-PD. A total of 93 newly diagnosed ET-PD patients and 93 newly diagnosed PD patients matched for age, sex, education, and disease duration of PD were selected using propensity score matching analysis. The K-means cluster analysis was performed for 11 variables derived from the ET-PD group, and cluster profiles were established through statistical analysis of demographic and clinical variables. The ET-PD group consisted of a high number of patients with a family history of ET exhibiting evident tremor with milder hypokinesia and postural instability symptoms, as compared to the PD group. Through the cluster analysis, two clusters of ET-PD patients were identified. The ET-PD cluster 1 ( n = 34) had a shorter ET duration before PD onset, lower number of patients with a family history of ET, higher unified PD rating scale instability scores, higher non-motor symptoms scores (non-motor symptoms scale D1 scores, Hamilton depression scale scores, Hamilton anxiety scale scores, and PD sleep scale-2 scores), and higher Chinese version of the PD questionnaire-39 scores relative to the ET-PD cluster 2 ( n = 59). ET-PD patients had significantly different characteristics for motor symptoms as compared to PD patients, and may be distinctly divided into two clinical subtypes, namely, the ET-PD complex type and the ET-PD simple type.

Subthalamic stimulation modulates motor network in Parkinson's disease: recover, relieve and remodel.

Aberrant dynamic switches between internal brain states are believed to underlie motor dysfunction in Parkinson's disease. Deep brain stimulation of the subthalamic nucleus is a well-established treatment for the motor symptoms of Parkinson's disease, yet it remains poorly understood how subthalamic stimulation modulates the whole-brain intrinsic motor network state dynamics. To investigate this, we acquired resting-state functional magnetic resonance imaging time-series data from 27 medication-free patients with Parkinson's disease (mean age: 64.8 years, standard deviation: 7.6) who had deep brain stimulation electrodes implanted in the subthalamic nucleus, in both on and off stimulation states. Sixteen matched healthy individuals were included as a control group. We adopted a powerful data-driven modelling approach, known as a hidden Markov model, to disclose the emergence of recurring activation patterns of interacting motor regions (whole-brain intrinsic motor network states) via the blood oxygen level-dependent signal detected in the resting-state functional magnetic resonance imaging time-series data from all participants. The estimated hidden Markov model disclosed the dynamics of distinct whole-brain motor network states, including frequency of occurrence, state duration, fractional coverage and their transition probabilities. Notably, the data-driven decoding of whole-brain intrinsic motor network states revealed that subthalamic stimulation reshaped functional network expression and stabilized state transitions. Moreover, subthalamic stimulation improved motor symptoms by modulating key trajectories of state transition within whole-brain intrinsic motor network states. This modulation mechanism of subthalamic stimulation was manifested in three significant effects: recovery, relieving and remodelling effects. Significantly, recovery effects correlated with improvements in tremor and posture symptoms induced by subthalamic stimulation (P < 0.05). Furthermore, subthalamic stimulation was found to restore a relatively low level of fluctuation of functional connectivity in all motor regions to a level closer to that of healthy participants. Also, changes in the fluctuation of functional connectivity between motor regions were associated with improvements in tremor and gait symptoms (P < 0.05). These findings fill a gap in our knowledge of the role of subthalamic stimulation at the level of neural activity, revealing the regulatory effects of subthalamic stimulation on whole-brain inherent motor network states in Parkinson's disease. Our results provide mechanistic insight and explanation for how subthalamic stimulation modulates motor symptoms in Parkinson's disease.

Correlation between Work Duration and Work Posture with Musculosceletal Disorders Symptoms in Interior Design Students at Campus Biru Surakarta

The activities of interior design students, namely drawing objects and drawing techniques, require a high level of accuracy and concentration, these activities have an impact on health problems such as muscle injury. Musculoskeletal disorders are one of the symptom often felt by interior design students. This study is to determine the relationship between work duration and student work posture with MSDs symptoms. Methods: This study used observational analytics with a cross sectional design. The research respondents were 66 of 2nd semester interior design students used random sampling technique. The research instrument used the REBA method to assess work posture, and the NBM questionnaire to assess musculoskeletal disorder symptom. Data analysis with Pearson Product Moment test and Multiple Linear Regression. Results: The results showed a significant relationship between work duration and MSDs symptoms (p-value 0.000), positive correlation direction and moderate level (0.509). while the significant relationship between work posture and MSDs symptoms (0.000), positive correlation direction and strong level (0.638). Multivariate test results stated significant (0.000) with a positive correlation direction. Work posture has the highest correlation with MSDs symptoms with a proportion of 62%. Conclusion: There was correlation between work duration and work posture with MSDs sysmptoms of interior design students at Campus Biru Surakarta.

Autoimmune polyendocrine syndrome II presenting paradoxically as Takotsubo cardiomyopathy: a case report and reappraisal of pathophysiology

BackgroundTakotsubo cardiomyopathy (TCM) is a rare disease entity characterized by acute, non-ischemic, reversible myocardial dysfunction that mimics acute myocardial infarction. Activation and excessive outflow of sympathetic nervous system are believed to be central to the figure in the disease pathogenesis. Adrenocortical hormones potentiate the systemic actions of sympathetic nervous system and accordingly are essential for regulation of myocardial function. We present an unusual case of a middle-aged woman with primary adrenal insufficiency who presented paradoxically with TCM.Case presentationA 50-year-old woman with past history of hypothyroidism presented to emergency department with history of acute chest pain and syncope. There was no significant drug history or history of an emotional or physical stimulus prior to admission. Prominent pigmentation over the tongue and skin creases of hands were noted. On presentation, she was in shock and had ventricular tachycardia which required electrical cardioversion. The subsequent electrocardiogram demonstrated diffuse T-wave inversions with prolonged QTC. There was apical hypokinesia on echocardiogram, and cardiac biomarkers were elevated. There was persistent inotropic requirement. She had marked postural symptoms, and a postural blood pressure drop of 50 mm Hg was present. Initial laboratory parameters were significant for hyperkalemia (7.8 mEq/L) and hyponatremia (128 mEq/L). These findings prompted evaluation for adrenal insufficiency which was confirmed with appropriate tests. Autoimmune polyendocrine syndrome II was thus diagnosed based on the above findings. Coronary angiography revealed normal coronaries. The diagnoses of TCM was established in accordance with the International Takotsubo Diagnostic Criteria. She was started on stress dose steroid replacement therapy and improved dramatically. At one month of follow-up, the patient is asymptomatic, and there was normalization of her left ventricular function.ConclusionsIntricate relationship and interplay exist between the steroid hormones and catecholamines in the pathogenesis of TCM. Steroid hormones not only potentiate the actions of catecholamines, but they also regulate and channelize catecholaminergic actions preventing their deleterious effects on the cardiac tissue. Hence, both steroid deficiency and exogenous steroid replacement may precipitate TCM. Evidence from more such cases and larger perspective studies in future will further improve our understanding of this complex disease process and its myriad associations.