Provocation In Patients Research Articles

Study on the diagnosis of idiopathic rhinitis by cold dry air provocation

Objective:This study aimed to compare the nasal response of cold dry air（CDA） provocation in patients with idiopathic rhinitis（IR） and healthy individuals, and further assess its ability in diagnosing IR. Method:CDA provocation was performed among 15 healthy volunteers and 17 IR patients from Beijing Tongren Hospital Outpatient Department. Nasal symptom scores, total nasal volume（TNV）, total nasal resistance（TNR） and minimal cross-sectional area（MCA） were checked before and after the provocation. Logistic regression analysis and Receiver Operating Characteristic（ROC） curves were used in data evaluation. Result:Subjects in the IR group showed significantly larger changes after CDA provocation in total nasal symptom score（TNSS）, total nasal resistance（TNR）, minimal cross-sectional area（MCA） and total nasal volume（TNV）, compared with healthy volunteers. We built a predictive model for IR, Y=0.394×ΔTNSS-0.061 ×ΔTNV（%）+0.014×ΔTNV（%） -2.318, whose area under curve was 0.919 based on multi-factor logistic regression and ROC curve. According to the Youden index, the cut-off criteria was set to be Y >0.49, when its sensitivity and specificity were 82.4% and 84.6%, respectively. Conclusion:Aggravated nasal symptoms and decreased nasal ventilation could be seen after CDA provocation in the IR population. The CDA provocation provides a possible method for assisting the diagnosis of IR, and we'll expand the sample size in future research to verify its clinical application value.

Response to bronchodilator and clinical, pathophysiological features in patients with nonasthmatic eosinophilic bronchitis.

Whether nonasthmatic eosinophilic bronchitis (NAEB) shows response to bronchodilator (RB) remains unclear. To investigate the RB and its relationship with clinical and pathophysiological features in NAEB. Fifty-one patients with NAEB were assigned in a 2:1 ratio to receive oral bambuterol hydrochloride (n=34, 10mg, once daily, for 3days) or matched placebo (n=17) randomly, of whom 48 patients (32 with bronchodilator and 16 with placebo) completed the study. Sputum induction, spirometry and cough reflex sensitivity were measured. RB was considered when cough Visual analogue scale (VAS) score decreased 30% or more after treatment. Cough reflex sensitivity was defined as the lowest concentration of capsaicin inducing five coughings or more (C5), and presented as Log C5. The responsive rate of patients with bronchodilator was significantly higher than that with placebo (34.4% vs 6.3%, P<0.05). The VAS score decreased significantly in patients with bronchodilator (median: 6.0-3.0, P<0.01). There was a significantly higher median Log C5 (2.7 vs 1.3, P<0.05), and a higher trend of decline in FEV1 % predicted and MMEF% predicted after bronchial provocation in patients with RB as compared with patients without RB. No significant differences in baseline percentages of sputum eosinophil were found between patients with RB and that without RB. One third of patients with NAEB respond well to bronchodilator treatment, which are related with lower cough reflex sensitivity and increased airway responsiveness. The relationship between NAEB and asthma needs to be investigated further.

Cerebral Oximetry in Syncope and Syndromes of Orthostatic Intolerance.

Cerebral autoregulation is crucial for maintaining cerebral blood flow and perfusion. In recent years, the importance of cerebral oxygenation in syncope and orthostatic intolerance (OI) has received increased attention. Cerebral tissue oxygenation can be measured by using near-infrared spectroscopy (NIRS), which determines the ratio of oxygenated hemoglobin to total hemoglobin in cerebral tissue. NIRS is non-invasive technology using near-infrared light, which displays real-time cerebral tissue oxygenation. Normal values of cerebral tissue oxygenation in healthy subjects are 60 to 80%. Head-up tilt test (HUT) offers the opportunity to observe the haemodynamic changes precipitating syncope and is, today, the standard method for the evaluation of syncope and orthostatic intolerance syndromes. In previous studies where NIRS was applied during HUT, a significant decrease in cerebral tissue oxygenation both prior to and during loss-of-consciousness in vasovagal syncope (VVS) has been observed. Interestingly, cerebral tissue oxygenation appears to decrease even before haemodynamic changes can be observed. Apart from VVS, cerebral tissue oxygenation decreases during orthostatic provocation in patients with orthostatic hypotension (OH) and postural orthostatic tachycardia syndrome (POTS), in the latter even in the absence of hypotension. Importantly, decline of cerebral tissue oxygenation in VVS and POTS during HUT may not correlate with hemodynamic changes. In this mini review, we summarize the current knowledge of the application of cerebral oximetry in syncope and orthostatic intolerance syndromes, discuss its likely value as a clinical diagnostic tool and also emphasize its potential in the understanding of the relevant pathophysiology.

Immediate Effects of Transcranial Direct Current Stimulation on Obsession-Induced Anxiety in Refractory Obsessive-Compulsive Disorder: A Pilot Study.

Studies have shown that transcranial direct current stimulation (tDCS) has immediate effects on brain activity. The aim of this study was to investigate the potential use of tDCS to regulate obsession-induced anxiety immediately after symptom provocation in patients with refractory obsessive-compulsive disorder (OCD). Twelve patients with refractory OCD received cathode, anode, and sham transcranial direct current stimulation over the medial prefrontal cortex conjugant to pharmacological treatment in a crossover design. Before and after the DC stimulation, patients graded the intensity of their anxiety after a short exposure to a provoking stimulus using the visual analogue scale. Clinical questionnaires assessing symptoms severity were also applied before each stimulation mode. We found a statistically significant decrease in the severity of the obsession-induced anxiety (decreased visual analogue scale) as a result of cathode tDCS in comparison with the anode and sham stimulation. Reduction in obsession-induced anxiety was consistent, yet short lasting, and was independent of symptom severity. Cathode tDCS could be potentially used to regulate obsession-induced anxiety in refractory OCD patients. Further studies are warranted to confirm our results as well as to determine whether tDCS can achieve prolonged benefits in OCD and be of aid in behavioral treatments based on exposure.

The complexity of hemodynamic response to the tilt test with and without nitroglycerine provocation in patients with vasovagal syncope

The paper presents a comparison of vasovagal syndrome occurrence in a head up tilt table test between patients with a positive result of passive tilt test and those with a positive result after pharmacological provocation. The study group consisted of 80 patients: 57 patients who experienced syncope in the passive phase of the test (43 women (aged: 35.6 ± 16.2) and 14 men (aged: 41.7 ± 15.6) and 23 patients who experienced syncope after pharmacological provocation (17 women (age: 32.3 ± 12) and 6 men (age: 43 ± 15). The main investigation was based on the assessment of monitored signals complexity: heart rate, blood pressure and stroke volume. The analysis of complexity in chosen measurement phases was performed with Sample Entropy. The investigation showed that the reactions of autonomic nervous system during tilt test and before syncope are similar for positive result of passive tilt test and positive result of tilt test with provocation. The differences in supine position occurred only in analysis based on impedance measurement (SV: p = 0.01). Significant differences were denoted for all signals just before the syncope (RRI, sBP, dBP: p = 0,00001 and SV: p = 0.01). In analysis of signals complexity the significant differences occurred just before the syncope for Sample Entropy of blood pressure (SampEn (sBP): p = 0.0008, SampEn (dBP): p = 0,0001).

Hyperactivation of the Frontal Control Network Revealed by Symptom Provocation in Obsessive-Compulsive Disorder Using EEG Microstate and sLORETA Analyses

The aim of this study was to investigate the changes of brain electric field induced by symptom provocation in patients with obsessive-compulsive disorder (OCD) in comparison to healthy controls in the resting state. For this purpose, EEG recordings in conditions of initial rest, clean control, symptom provocation by imaginal exposure, and final rest were used for computing spatiotemporal activity characteristics based on microstate segmentation. Within-group comparisons were significant for the symptom provocation condition: OCD showed high global field power (GFP) and transition rates into a medial frontal microstate, whereas healthy controls showed high frequency of occurrence and high percent of dwelling time for a medial occipitoparietal microstate. Between-group comparisons demonstrated significantly lower GFP and dwelling time for the medial occipitoparietal microstate in OCD in several conditions including initial rest and symptom provocation. In addition, OCD compared to healthy controls showed significant instability of the medial occipitoparietal microstate, with high preference for transitions into the medial frontal microstate. In conclusion, during rest and symptom provocation, OCD patients make preferential use of a medial frontal brain network, with concomitant reduction of use of a medial occipitoparietal network, as shown by dwelling times, explained variance, and dynamic transition rates. These findings support the idea of a possible biological marker for OCD, which might correspond to pathological hyperactivation of the frontal control network.

Loss of Peristaltic Reserve, Determined by Multiple Rapid Swallows, Is the Most Frequent Esophageal Motility Abnormality in Patients With Systemic Sclerosis.

We assessed peristaltic reserve using multiple rapid swallows (MRS) during esophageal high-resolution manometry (HRM) of 111 patients with systemic sclerosis (89 women; ages, 42-64 y). We performed a retrospective analysis of HRM studies that included MRS in patients with systemic sclerosis, performed at 2 tertiary referral centers, and compared data with those from 18 healthy volunteers (controls). HRM findings were analyzed according to the Chicago Classification to provide an esophageal motility diagnosis. Response to MRS was evaluated for the presence of contraction and for augmentation, defined as the distal contractile integral after MRS greater than the median distal contractile integral of 10 supine swallows. Esophageal motility diagnoses included 41% with absent contractility, 31% with normal motility, 23% with ineffective esophageal motility, and 5% that met the criteria for other esophageal motility disorders. Contraction (37%) and peristaltic augmentation (18%) after MRS were observed less frequently in patients with systemic sclerosis than in controls (83% and 100%, respectively). Impaired peristaltic reserve, as assessed with MRS during HRM, is therefore the most common esophageal motility finding among patients with systemic sclerosis.

Allergen-Induced Asthmatic Responses Modified by a GATA3-Specific DNAzyme

BackgroundThe most prevalent phenotype of asthma is characterized by eosinophil-dominated inflammation that is driven by a type 2 helper T cell (Th2). Therapeutic targeting of GATA3, an important transcription factor of the Th2 pathway, may be beneficial. We evaluated the safety and efficacy of SB010, a novel DNA enzyme (DNAzyme) that is able to cleave and inactivate GATA3 messenger RNA (mRNA).MethodsWe conducted a randomized, double-blind, placebo-controlled, multicenter clinical trial of SB010 involving patients who had allergic asthma with sputum eosinophilia and who also had biphasic early and late asthmatic responses after laboratory-based allergen provocation. A total of 40 patients could be evaluated; 21 were assigned to receive 10 mg of SB010, and 19 were assigned to receive placebo, with each study drug administered by means of inhalation once daily for 28 days. An allergen challenge was performed before and after the 28-day period. The primary end point was the late asthmatic response as quantified by the change in the area under the curve (AUC) for forced expiratory volume in 1 second (FEV1).ResultsAfter 28 days, SB010 attenuated the mean late asthmatic response by 34%, as compared with the baseline response, according to the AUC for FEV1, whereas placebo was associated with a 1% increase in the AUC for FEV1 (P=0.02). The early asthmatic response with SB010 was attenuated by 11% as measured by the AUC for FEV1, whereas the early response with placebo was increased by 10% (P=0.03). Inhibition of the late asthmatic response by SB010 was associated with attenuation of allergen-induced sputum eosinophilia and with lower levels of tryptase in sputum and lower plasma levels of interleukin-5. Allergen-induced levels of fractional exhaled nitric oxide and airway hyperresponsiveness to methacholine were not affected by either SB010 or placebo.ConclusionsTreatment with SB010 significantly attenuated both late and early asthmatic responses after allergen provocation in patients with allergic asthma. Biomarker analysis showed an attenuation of Th2-regulated inflammatory responses. (Funded by Sterna Biologicals and the German Federal Ministry of Education and Research; ClinicalTrials.gov number, NCT01743768.)

Reduced Responsiveness to Social Provocation in Autism Spectrum Disorder.

Deficits in emotion processing and social interaction are prominent symptoms of autism spectrum disorder (ASD). ASD has also been associated with aggressive tendencies towards self and others. The prevalence of aggressive behavior in this disorder, its etiology and its impact on social life are still unclear. This study investigated behavioral and physiological effects of social provocation in patients with ASD and healthy controls. We used a modified Taylor Aggression Paradigm in 24 high-functioning patients with ASD and 24 healthy controls. Participants were instructed to play against a fictitious human opponent. Money withdrawals toward the participant represented provocation and money deduction by the participant denoted aggressive behavior. Throughout the measurement, electrodermal activity (EDA) was recorded. Healthy controls showed higher aggressive responses to high provocation compared to low provocation, which demonstrated the effectiveness of the used procedure in eliciting aggression. Patients' responses were not influenced by the level of social provocation, although in both groups aggression was higher after lost compared to won trials. Physiologically, controls showed fewer but higher EDA amplitudes when responding aggressively, whereas patients displayed the opposite pattern of more but lower EDA amplitudes. The modified Taylor Aggression Paradigm successfully elicited aggression and revealed different behavioral and neurophysiological responses in patients and healthy controls. Patients' aggressive behavior as well as their physiological responses were less modulated by level of provocation compared to controls. Therapeutic attempts for patients might concentrate on improving empathic abilities and the understanding of social situations, including provocation and aggressive behavior.

Nickel sensitization and dietary nickel are a substantial cause of symptoms provocation in patients with chronic allergic-like dermatitis syndromes.

Data in literature seem to show that, in patients with contact allergic dermatitis, dietary nickel might be a cause of systemic dermatitis, but little information exists in literature about the role of nickel sensitization and dietary nickel in patients with allergic-like chronic dermatitis syndromes. The prevalence of nickel sensitization in patients with chronic allergic-like, non-IgE-mediated skin diseases, and the possible impact of dietary nickel on symptom provocation and persistence has been assessed in the present retrospective study on a case series of 1726 patients referred to our allergy unit for chronic allergic-like skin diseases. IgE-mediated pathogenesis and other differential diagnoses excluded, patients were patch tested. Nickel-positive patients underwent an elimination diet and double-blind placebo-controlled nickel challenge (DBPCNC) test. A total of 339 (20%) tested nickel-positive. Fifty-two patients (15%) recovered by avoiding sources of nickel contact and 29 (10%) dropped out. Out of the remaining nickel-sensitized patients, 277 (80%) achieved complete or near complete recovery with low-nickel content diet, and 185 of them (89%) were positive to DBPCNC. We conclude that nickel sensitization and dietary nickel seem to be the chief trigger for provocation and persistence of symptoms in an important part (∼11%) of patients with chronic allergic-like dermatitis syndromes.

More symptoms but similar blood glucose curve after oral carbohydrate provocation in patients with a history of hypoglycemia-like symptoms compared to asymptomatic patients after Roux-en-Y gastric bypass

BackgroundLaparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective treatment for obesity through altering several physiologic mechanisms. Some patients experience symptoms suggestive of hypglycemia after LRYGB, but whether these symptoms always are associated with low blood glucose are unclear. The objective of this study was to investigate the correlation between symptoms suggestive of hypglycemia, plasma glucose levels and gut hormones involved in glycemic control. MethodsEight LRYGB patients with hypglycemia-like symptoms (SY) and 8 patients with no hypglycemia-like symptoms (ASY) ingested a liquid carbohydrate meal. Insulin, plasma-glucose, glucagon-like peptide 1 (GLP-1) and glucagon were measured intermittently 180 minutes postprandially. In addition, pulse rate, blood pressure and symptoms were assessed. ResultsPlasma glucose at 120 min was lower in the ASY mean (95% CI) 2.4 (1.6,3.3) mmol/L (43.2 mg/dL) compared to the SY group 3.0 (3.1,4.6) mmol/L (54.6 mg/dL), (P = .050). The ASY group had larger reduction in plasma glucose than the SY group from pre- to 120 min postmeal -2.2 (-2.8,-1.7) mmol/L (-39.6 mg/dL) versus -1.1 (-1.7,-0.4) mmol/L (-19.8 mg/dL), (P = .011). The concentrations of insulin, GLP-1 and glucagon did not differ significantly between groups. Blood pressure was similar between groups, but the AUC for pulse rate was higher in the SY than ASY group 13009 (11148,14870) versus 11569 (10837,12300) beats/180 minutes, (P = .038). The SY group reported more symptoms than the ASY group, AUC for Sigstad scale 60 to 180 minutes was 970 (-274,1667) for SY versus 170 for ASY (-39,379), (P = .028). ConclusionPatients with a history of symptoms suggestive of hypglycemia after LRYGB neither demonstrated lower plasma glucose nor greater insulin response compared to asymptomatic patients in response to a liquid carbohydrate meal, but perceived more symptoms.

Coronary Microvascular Dysfunction Assessed by Intracoronary Acetylcholine Provocation Testing Is a Frequent Cause of Ischemia and Angina in Patients With Exercise‐Induced Electrocardiographic Changes and Unobstructed Coronary Arteries

The exercise electrocardiogram (ECG) is a standard examination in patients with suspected coronary artery disease. However, despite a pathologic result, many patients undergoing diagnostic coronary angiography do not have any significant epicardial stenosis. In this study, we assessed the relation between a pathologic exercise ECG and coronary microvascular dysfunction in response to intracoronary acetylcholine (ACh) provocation in patients without any relevant epicardial stenosis. Coronary microvascular dysfunction is significantly more often in patients with angina, unobstructed coronary arteries and a pathologic exercise stress test compared to those without pathologic stress test. This study recruited 137 consecutive patients with exertional angina pectoris who underwent diagnostic coronary angiography between September 2008 and April 2011 (68% women; mean age, 63 ± 10 years). In none of the patients was there a stenosis of >50%. All patients underwent an exercise ECG before angiography and intracoronary ACh provocation testing for assessment of coronary vasomotor responses directly after angiography. The exercise ECG showed an abnormal result in 69 patients (50%; ST-segment depression ≥0.1 mV and/or reproduction of the patient's usual symptoms). The ACh test revealed a coronary vasomotor abnormality (reproduction of the patient's symptoms, ischemic ECG shifts ± diffuse distal vasoconstriction) in 87 patients (64%). Such a result was significantly more often found in patients with a pathologic exercise ECG (50/69 [72%] vs 19/69 [28%], P = 0.034). There were no other statistically significant differences between patients with and those without pathologic exercise ECG. Coronary microvascular dysfunction is frequently found in patients with exertional angina pectoris and unobstructed coronary arteries. Such a finding is found significantly more often in presence of a pathologic exercise ECG.

Area-dependent time courses of brain activation during video-induced symptom provocation in social anxiety disorder.

BackgroundPrevious functional imaging studies using symptom provocation in patients with social anxiety disorder (SAD) reported inconsistent findings, which might be at least partially related to different time-dependent activation profiles in different brain areas. In the present functional magnetic resonance imaging study, we used a novel video-based symptom provocation design in order to investigate the magnitude and time course of activation in different brain areas in 20 SAD patients and 20 healthy controls.ResultsThe disorder-related videos induced increased anxiety in patients with SAD as compared to healthy controls. Analyses of brain activation to disorder-related versus neutral video clips revealed amygdala activation during the first but not during the second half of the clips in patients as compared to controls. In contrast, the activation in the insula showed a reversed pattern with increased activation during the second but not during the first half of the video clips. Furthermore, a cluster in the anterior dorsal anterior cingulate cortex showed a sustained response for the entire duration of the videos.ConclusionsThe present findings suggest that different regions of the fear network show differential temporal response patterns during video-induced symptom provocation in SAD. While the amygdala is involved during initial threat processing, the insula seems to be more involved during subsequent anxiety responses. In accordance with cognitive models of SAD, a medial prefrontal region engaged in emotional-cognitive interactions is generally hyperactivated.

Response to hypoxic provocation in patients with chronic heart failure and its predictive value for central sleep apnea

Introduction Central apneas are usually clustered in periodic sequences in patients with chronic heart failure (CHF) and central sleep apnea (CSA), triggered by destabilizing events. We hypothesized that a provocation with exogenous hypoxic hypoxia may destabilize a system with abnormal gain (controller and plant) enough to trigger visually recognizable central events during wakefulness in those patients. The aim of the study is to investigate the response to hypoxic provocation in patients with CHF and its capability to predict the presence of CSA. Materials and methods Nineteen patients with CHF (age=65.5±7.3, EF=51.9±6.6) have been recruited and subjected to polysomnography and hypoxic provocation. Central apnea-hypopnea index (cAHI)>5 determined the presence of CSA, dividing the patients in 2 groups – with CSA ( n =13, cAHI=29.2±16.2) and CHF without CSA ( n =6, cAHI=4.0±1.6, p 3% were scored for each period and respective indices for apneas and hypopneas (hAHI) and oxygen desaturations (hODI) have been calculated in the classical manner (count per 1h). Results No differences were present between the 2 groups in the prehypoxic period (hAHIpre=27.6±26.7 vs. 16.3±27.3, NS; hODIpre=18.6±23.5 vs. 12.9±17.6, NS; average desaturation (hAvDespre)=2.5±2.4 vs. 2.3±1.9, NS in patients and controls, respectively). Significantly higher values for these parameters were found after the hypoxic provocation in the CHF+CSA group, compared to CHF controls (hAHIpost=54.5±28.8 vs. 18.8±28.8, p =0.022; hODIpost=37.0±23.2 vs. 2.4±4.5, p p =0.007). Exogenous hypoxia provoked significantly more events in the posthypoxic period, compared to baseline values only in CHF+CSA patients (hAHIpre/hAHIpost, p =0.002; hODIpre/hODIpost, p =0.002; hAvDespre/hAvDespost, p =0.008). Strong significant correlation was found between cAHI and hAHI3 (rho=0.553, p =0.05) and hODI3 (rho=0.564, p =0.05). Patients presenting with positive hypoxic provocation test (empirically chosen if hAHIpost>30) had 11.8 times higher odds (95% CI=1.34–105, p =0.026) to have CSA. Conclusion Hypoxic provocation triggers central events during wakefulness in the majority of CHF+CSA patients and may be used as a predictor of the presence and magnitude of CSA in CHF. Acknowledgement The study was financed by the Bulgarian Ministry of Youth and Science.

Randomized Prospective Comparison of Two Protocols for Head-up Tilt Testing in Patients with Normal Heart and Recurrent Unexplained Syncope

BackgroundThis randomized study was aimed to compare the diagnostic value of two head-up tilt testing protocols using sublingual nitroglycerin for provocation in patients with recurrent unexplained syncope and normal heart. MethodsThe patients with normal findings in physical examination, electrocardiography and echocardiography were randomly submitted to one of upright tilt test protocols. The only difference between two protocols was that nitroglycerin was administered after a five minute resting phase in supine position during protocol B. We also considered eighty normal persons as the control group. ResultsOut of 290 patients that underwent tilt testing, 132 patients were in group A versus 158 patients in group B. Both groups had an identical distribution of clinical characteristics. Tilt test was positive in 79 patients in group A (25 in passive phase, 54 in active phase) versus 96 patients in group B (43 in passive phase, 53 in active phase). There was no significant difference between results in two groups (P value=0.127). Forty cases were tested with protocol A and forty underwent tilt testing with protocol B. Tilt test was positive in 4 cases with protocol A versus 3 cases in protocol B. The positive rates of tilt testing with protocol A was 60% while it was 61% in protocol B. The specificity of testing with protocol A was 90% and it was 92.5% in protocol B. ConclusionsAccording to our data, adding a period of rest and returning to supine position before nitroglycerin administration had no additional diagnostic yield.

Deep brain stimulation restores frontostriatal network activity in obsessive-compulsive disorder

Little is known about the underlying neural mechanism of deep brain stimulation (DBS). We found that DBS targeted at the nucleus accumbens (NAc) normalized NAc activity, reduced excessive connectivity between the NAc and prefrontal cortex, and decreased frontal low-frequency oscillations during symptom provocation in patients with obsessive-compulsive disorder. Our findings suggest that DBS is able to reduce maladaptive activity and connectivity of the stimulated region.

Assessment of prevalence and pathological response to orthostatic provocation in patients with multiple sclerosis

ObjectiveThe aim of this study was to determine the prevalence of pathologic response to orthostatic challenge in patients with relapsing remitting multiple sclerosis (RRMS) and the difference of the response in patients in relapse and remission. Patients and methodsWe included 112 RRMS patients; group 1 included 53 patients in a relapse and group 2, 59 patients in remission. The head up tilt table test was used to provoke an orthostatic reaction. Results71 (63%) patients (60.4% and 66% of relapse and remission subjects respectively) had a pathological response to orthostatic provocation. Syncope was found in 9 (17%) patients in group 1 compared to 22 (37.3%) in group 2 (p=0.014). Postural orthostatic tachycardia syndrome (POTS) was found in 17 (32%) patients in group 1 compared to 4 (6.8%) in group 2 (p=0.001). There was a significantly negative correlation between the Expanded Disability Status Scale (EDSS) and POTS (−0.201; p=0.034) and a positive correlation between the EDSS and syncope (0.190; p=0.044). ConclusionThe prevalence of distinct types of orthostatic autonomic dysfunction in different phases of RRMS seems to be in direct correlation with the EDSS. Furthermore, certain autonomic dysfunctions of orthostasis, more specifically syncope and POTS, tend to be increased in remission and relapse respectively.

Reliability of a seated three-dimensional passive intervertebral motion test for mobility, end-feel, and pain provocation in patients with cervicalgia

Objectives: Neck pain can be evaluated with passive intervertebral motion (PIVM). No study has evaluated the reliability of three-dimensional (3D) segmental PIVM testing of the cervical spine in symptomatic subjects in a functional, seated position. The purpose of this study was to evaluate inter-rater reliability of such 3D PIVM technique for pain provocation, hypomobility, and end-feel detection.Methods: Subjects (n = 63), age 44±15·6 years, neck pain 3·4±1·6 cm with visual analog scale, were evaluated by two of three raters with varied manual therapy education and experience. To perform the test, the rater passively invoked side-bending motion at each cervical joint from C2–C3 to C6–C7, allowing segmental synkinetic rotation and extension to occur. Each joint was assessed for hypomobility, hard end-feel, and pain provocation. Kappa statistics were used to determine the inter-rater reliability for each variable for joints C2–C3 through C6–C7 for both the most painful and least painful sides.Results: Percent agreements for pain provocation, hypomobility, and end-feel ranged 65–83%, 62–84%, and 68–87%, respectively. Kappa values for pain provocation, hypomobility, and end-feel on the most painful side were fair to moderate (0·29–0·53, 0·21–0·48, and 0·25–0·50, respectively), and on the least painful side were fair to substantial (0·43–0·65, 0·33–0·58, and 0·28–0·60, respectively).Discussion: This is the first investigation to assess reliability of 3D cervical segmental testing in sitting and to assess reliability of end-feel. The seated 3D PIVM test has sufficient clinical reliability for use in patients with cervicalgia for the assessment of hypomobility, end-feel, and pain provocation.

Symptoms suggestive of dumping syndrome after provocation in patients after laparoscopic sleeve gastrectomy

Symptoms suggestive of dumping syndrome after provocation in patients after laparoscopic sleeve gastrectomy

The role of adrenomedullin and galanin in recurrent vasovagal syncope: a case control study

Orthostatic stimuli are known to elicit changes in vasoactive peptide levels. The hypothesis of no difference in adrenomedullin and/or galanin levels in patients with recurrent vasovagal syncope and healthy controls was tested in a passive 35-min head-up tilt test (HUTT). Twenty eight persons (14 patients and 14 healthy controls) were tested in a 35-min/60° head-up tilt test with telemetry monitoring. Three blood samples were evaluated for each person during the HUTT. Plasma levels of adrenomedullin and galanin were analysed by the Kruskal-Wallis test for all sampling periods. Vagal influence was indirectly assessed by the break index. There were no significant differences between groups in median values for either adrenomedullin or galanin plasma levels (all 6 p-values were greater than 0.4). For adrenomedullin, no significant difference between groups was found. For galanin, the rate of change between the 1st and 2nd measurement was significantly greater for patients (P=0.04), regardless of HUTT result but between the 2(nd) and 3(rd) measurement it was insignificant (P=0.36). In the group of positive cases, the break index increased significantly (P=0.02). We confirmed that there is a different galanin secretion pattern during orthostatic provocation in patients with recurrent vasovagal syncope than healthy individuals. For adrenomedullin, no significant difference was found. Asignificant increment of the break index confirmed increased vagal influence in the subgroup of positive cases.