Research in Review

Abstracts obtained from PubMed

Salt supplementation improves orthostatic cerebral and peripheral vascular control in patients with syncope.

Hypertension. 2004 Apr;43(4):809-13. Epub 2004 Feb 23.

Claydon VE, Hainsworth R.

Institute for Cardiovascular Research, University of Leeds, Leeds, UK. v.e.claydon@leeds.ac.uk

Salt supplementation improves orthostatic tolerance in many patients with posturally related syncope (PRS). This study aimed to examine whether in those patients who responded to salt loading there was also evidence of improved cerebral autoregulation and more powerful peripheral vasoconstriction during orthostasis.

Eleven PRS patients were studied before and after ingestion of 100 mmol/d slow sodium for 2 months. Subjects underwent an orthostatic stress test of combined head-up tilting and lower body suction. We continuously monitored heart rate (ECG), blood pressure (Finapres), forearm and cerebral blood flow velocities (Doppler ultrasound), and end-tidal carbon dioxide (CO2). Forearm vascular resistance was calculated from pressure divided by velocity. Cerebral autoregulation was assessed from the correlation coefficient of the relationship between cerebral blood pressure and velocity.

Salt loading had no effect on resting heart rate or blood pressure. Symptoms and orthostatic tolerance significantly improved in 10 of the patients. This was associated with a significant increase in the maximal forearm vasoconstriction from 64.4%+/-13.7% (SEM) to 135.2%+/-23.9% (P<0.005). The relationship between cerebral velocity and pressure was less strong (before salt: r=0.74+/-0.8; after salt: r=0.41+/-0.1; P<0.02), indicating improved autoregulation. End-tidal CO2 levels were not different between the 2 tests.

Salt loading in PRS patients increases orthostatic tolerance and improves cerebrovascular and peripheral vascular control without affecting blood pressures. These changes are likely to contribute to the beneficial effects of salt loading in these patients.

PMID: 14981050

New approaches to the treatment and prevention of neurally mediated reflex (neurocardiogenic) syncope.

Curr Cardiol Rep. 2004 Sep;6(5):385-90.

Melby DP, Cytron JA, Benditt DG.

Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, MMC 508, 420 Delaware Street SE, Minneapolis, MN 55455, USA. E-mail bendi001@umn.edu

Neurally mediated reflex syncope (sometimes referred to as neurocardiogenic syncope), encompasses a group of disorders of which the best known and most frequently occurring forms are the vasovagal (or common) faint, and carotid sinus syndrome. Postmicturition syncope, defecation syncope, cough syncope, and other situational reflex faints are also included among these conditions. With the exception of carotid sinus syndrome in which cardiac pacing is effective, treatment of most neurally mediated reflex faints is shifting from reliance on various drugs to greater emphasis on education and nonpharmacologic therapy.

Initial management should include counseling of patients regarding recognition of early warning symptoms, and avoidance of precipitating factors. Volume expansion with salt tablets or electrolyte-containing beverages and patient education on how to perform isometric arm contractions and/or leg crossing in order to abort impending syncope are also important. Thereafter, tilt-training has demonstrated benefit in several clinical studies. When symptoms remain despite the above-noted interventions, pharmacologic therapy with midodrine or a nonselective b-blocker can be considered. In the case of most neurally mediated reflex faints, permanent cardiac pacing should be reserved only for those older patients with significant bradycardia or asystole at time of syncope when all other interventions have failed.

PMID: 15306096

Is joint hypermobility related to anxiety in a nonclinical population also?

Psychosomatics. 2004 Sep-Oct;45(5):432-7.

Bulbena A, Agullo A, Pailhez G, Martin-Santos R, Porta M, Guitart J, Gago J.

Department of Psychiatry, Hospital del Mar, Barcelona, Spain. abulbena@acmcb.es

This study examines the association between joint hypermobility syndrome and anxiety in a nonclinical sample. Subjects (N = 526) receiving a medical check-up were assessed with the Hospital del Mar hypermobility criteria and the State-Trait Anxiety Inventory. Scores for trait anxiety, and to a lesser extent state anxiety, were significantly higher among subjects with joint hypermobility syndrome than among subjects without this syndrome (median trait anxiety scores for women: 17 versus 11; median scores for men: 13 versus 1). These findings indicate that the association of joint hypermobility syndrome and anxiety holds even for subjects with no psychiatric diagnosis. Therefore, it seems that this benign connective tissue disorder is a predisposing factor for trait anxiety. However, it is necessary to further explore and define the biological basis of this syndrome, as well as its associations and clinical expressions, which interact with great complexity.

PMID: 15345789

Functional ability and physical and psychosocial well-being of hypermobile schoolchildren.

Clin Exp Rheumatol. 2004 Jul-Aug;22(4):495-8.

Ruperto N, Malattia C, Bartoli M, Trail L, Pistorio A, Martini A, Ravelli A.

Dipartimento di Pediatria, Universita di Genova, Unita Operativa Pediatria II, Istituto di Ricovero e Cura a Carattere Scientifico G Gaslini, Genova, Italy.

OBJECTIVE: To compare the functional ability and the physical and psychosocial well-being of children with joint hypermobility to those of age- and sex-matched non-hypermobile subjects.

METHODS: 311 healthy Italian schoolchildren aged 6.3 to 19.3 years were examined for hypermobility of the joints. Functional ability was assessed through the Childhood Health Assessment Questionnaire (CHAQ) and the physical and psychosocial well-being through the Childhood Health Questionnaire (CHQ). The parent's assessment of the child's overall well-being and of the child's pain was measured on a visual analogue scale.

RESULTS: The overall prevalence of articular hypermobility was 34% (106/311), with the median hypermobility score being 3 (interquartile range 1, 5). Although the hypermobility score of girls (median 3: interquartile range 2, 5) exceeded that of boys (median 2.5; interquartile range 0, 5), this difference was not statistically significant (p = 0.16). The level of hypermobile children's pain in the preceding weeks, as assessed by the parents, was comparable to that recorded in the non-hypermobile peers. There was a weak negative correlation between the hypermobility score and the age of the child (r = -0.14, p=0.01). All instrument scores were comparable between hypermobile and non-hypermobile subjects, with the sole exception of a borderline significant greater impairment of the Role/social limitations-physical subscale of the CHQ in the hypermobile group. The hypermobility score was not correlated with any instrument score.

CONCLUSIONS: The presence of joint hypermobility does not affect the functional ability and the physical and psychosocial well being of otherwise healthy children. These results suggest that the physical functioning in everyday life and the general health status of hypermobile children are not impaired.

PMID: 15301252

Association between joint hypermobility syndrome and panic disorder.

Am J Psychiatry. 1998 Nov;155(11):1578-83.

Martin-Santos R, Bulbena A, Porta M, Gago J, Molina L, Duro JC.

Department of Psychiatry, Hospital del Mar, Barcelona, Spain.

OBJECTIVE: The purpose of this study was to assess whether joint hypermobility syndrome is more frequent in patients with panic disorder, agoraphobia, or both than in control subjects and, if so, to determine whether mitral valve prolapse modifies or accounts in part for the association.

METHOD: A case-control study was conducted in a general teaching hospital outpatient clinic. Subjects were 99 patients, newly diagnosed and untreated, with panic disorder, agoraphobia, or both and two groups of age- and sex-matched control subjects: 99 psychiatric patients and 64 medical patients who had never suffered from any anxiety disorder. Measures consisted of the Structured Clinical Interview for DSM-III-R, Beighton's criteria for joint hypermobility syndrome, and two-dimensional and M-mode echocardiogram. The presence of mitral valve prolapse and joint hypermobility syndrome was explored by raters who were blind to subjects' psychiatric status.

RESULTS: Joint hypermobility syndrome was found in 67.7% of patients with anxiety disorder but in only 10.1% of psychiatric and 12.5% of medical control subjects. On the basis of statistical analysis, patients with anxiety disorder were over 16 times more likely than control subjects to have joint laxity. These findings were not altered after the presence of mitral valve prolapse was taken into account. Of the patients with anxiety disorder, those who had joint hypermobility syndrome were younger and more often women and had an earlier onset of the disorder than those without joint hypermobility syndrome.

CONCLUSIONS: Joint laxity is highly prevalent in patients with panic disorder, agoraphobia, or both and may reflect a constitutional disposition to suffer from anxiety. Mitral valve prolapse plays a secondary role in the association between joint hypermobility and anxiety.

PMID: 9812121

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