Evaluation of autonomic nervous system in children with spastic cerebral palsy: clinical and electophysiological study

Background Cerebral palsy (CP) is the most prevalent severe motor disability among children. The aim of this work was to assess autonomic dysfunction in children with cerebral palsy clinically and electrophysiologically. Results Age of the studied children ranged from 4 to 12 years. Quadriplegic type of spastic cerebral palsy constituted 82.5% of CP children while diplegic type constituted 17.5%. Based on Gross Motor Function Classification System (GMFCS), the majority of children were in levels 4 and 5. The prevalence of autonomic dysfunction symptoms were 80% for thermoregulatory abnormalities (cold extremities), 65% for chronic constipation, 52.5% for sleep disturbance, 47.5% for loss of appetite, 40% for sweating abnormalities, 25% for recurrent nausea and/or vomiting, 22.5% for increased sensitivity to light or dark and 15% for bloating. As regards sympathetic skin response, 19 CP children had unobtainable response in both upper and lower limbs while 5 children had unobtainable response in lower limbs only. All of them were in levels 4 and 5 of GMFCS. Postural hypotension was present in 20% of CP children. Mean Heart rate of CP children was significantly increased more than healthy children upon head tilt test. Conclusions Autonomic dysfunction has been objectively proven in CP children through absent sympathetic skin response, presence of orthostatic tachycardia and postural hypotension.

Evidence for fludrocortisone in postural hypotension

Overview of: Veazie S, Peterson K, Ansari Y, et al. Fludrocortisone for orthostatic hypotension. Cochrane Database of Syst Revs 2021;5:10.1002/14651858.CD012868.pub2.

Steroids Significantly Decrease Postoperative Postural Hypotension in Total Knee Replacement

Total knee replacement (TKR) is one of the most common orthopaedic procedures performed, and enhanced recovery after surgery (ERAS) has been developed and incorporated into inpatient surgical pathways to improve patient outcomes. Under ERAS recommendations, multimodal prophylaxis has been used to help manage postoperative nausea and vomiting (PONV) following TKR. Dexamethasone is one of the commonly used for this and the anti-inflammatory properties could depress vagal activity, reducing postural hypotension (PH). The hypothesis of this study is that postoperative dexamethasone use is associated with lower rates of early postoperative PH following TKR surgery. In our institution, patients who undergo elective primary TKR are admitted on the day of surgery and follow a standardized ERAS protocol. Data on patients who underwent elective primary TKR under a single adult reconstruction team from September 2017 to March 2020 were reviewed and analyzed. A review of demographic characteristics, surgical data, postoperative medications, and postoperative notes was performed. Binary logistic regression was used to assess the effect of the use of dexamethasone on PH, with an adjusted odds ratio (OR) calculated after accounting for potential confounders. Of the 149 patients were included in the study, 78 had dexamethasone postoperatively, and 71 did not. Patients who had received dexamethasone were statistically less likely to suffer from PH (OR = 0.31, p = 0.03) and less likely to develop PONV (OR = 0.21, p = 0.006). Patients who had received dexamethasone were more likely able to participate in early physiotherapy (OR = 2.42, p = 0.14), and this result was statistically insignificant. The use of postoperative intravenous dexamethasone is significantly associated with lower rates of postoperative PH after TKR. However, more studies are required to assess the optimal dosing amount and frequency, as well as to assess other factors which can enhance early postoperative patient mobilization as part of our goals for ERAS. This therapeutic study reflects level of evidence III.

A Case of Insulin Induced Peripheral Neuropathy

A 24-year-old man with type 1 diabetes, presented with neuropathic pain and severe postural hypotension, was diagnosed with insulin-induced peripheral neuropathy which mimicking diabetic peripheral neuropathy following a rapid improvement in glycaemic control. HbA1c was reduced from 17.5% to 7.4 % within two months. A decrease in insulin dosage with a relaxing glycaemic target improved his condition. In conclusion, clinicians should have a high index of suspicion of this condition in a patient presenting with neuropathic pain and autonomic dysfunction following rigorous glycaemic control.

ASSESSMENT OF COMPARATIVE PATIENT SATISFACTION AND SIDE-EFFECTS ASSOCIATED WITH TAMSULOSIN VERSUS SILODOSIN THERAPY IN BENIGN PROSTATE HYPERPLASIA

Objective: The aim of our study was to assess the comparative patient satisfaction and side-effects of the currently prescribed drugs – tamsulosin and silodosin for benign prostatic hyperplasia (BPH). Methods: A prospective study was conducted in a total of 110 BPH patients from the Department of Urology for a period of 6 months. Fifty-five patients in each group received silodosin 8 mg or tamsulosin 0.4 mg once daily. Data were collected using a suitably designed pro forma and the patient satisfaction was assessed with patient’s perception of study medication (PPSM) scale. International prostate symptom score (IPSS) was used for assessing the severity of symptoms. Results: The current study found that the treatment had a significant effect on improving scores of PPSM and IPSS at which all changes were significant at p<0.01 (paired t-test). An independent t-test showed that silodosin group had a greater improvement in PPSM scores – PPSM total by 40.4%, PPSM global by 43.7%, and PPSM pain by 0.39% which was supported by corresponding decline in IPSS scores. The side effects reported for tamsulosin were headache (5.5%), dizziness (5.5%), dry mouth (3.6%), and postural hypotension (14.4%) and those reported for silodosin were myalgia (5.5%), dizziness (7.3%), diarrhea (1.8%), and postural hypotension (10.9%). Conclusion: Patient satisfaction was improved by both the alpha blockers but silodosin showed a significantly greater increase in patient satisfaction than tamsulosin. Thus, silodosin is the better drug of choice.

Prevalence of postural hypotension in primary, community and institutional care: a systematic review and meta-analysis

Background Postural hypotension (PH), the reduction in blood pressure when rising from sitting or lying 0to standing, is a risk factor for falls, cognitive decline and mortality. However, it is not often tested for in primary care. PH prevalence varies according to definition, population, care setting and measurement method. The aim of this study was to determine the prevalence of PH across different care settings and disease subgroups. Methods Systematic review, meta-analyses and meta-regression. We searched Medline and Embase to October 2019 for studies based in primary, community or institutional care settings reporting PH prevalence. Data and study level demographics were extracted independently by two reviewers. Pooled estimates for mean PH prevalence were compared between care settings and disease subgroups using random effects meta-analyses. Predictors of PH were explored using meta-regression. Quality assessment was undertaken using an adapted Newcastle-Ottawa Scale. Results One thousand eight hundred sixteen studies were identified; 61 contributed to analyses. Pooled prevalences for PH using the consensus definition were 17% (95% CI, 14–20%; I2 = 99%) for 34 community cohorts, 19% (15–25%; I2 = 98%) for 23 primary care cohorts and 31% (15–50%; I2 = 0%) for 3 residential care or nursing homes cohorts (P = 0.16 between groups). By condition, prevalences were 20% (16–23%; I2 = 98%) with hypertension (20 cohorts), 21% (16–26%; I2 = 92%) with diabetes (4 cohorts), 25% (18–33%; I2 = 88%) with Parkinson’s disease (7 cohorts) and 29% (25–33%, I2 = 0%) with dementia (3 cohorts), compared to 14% (12–17%, I2 = 99%) without these conditions (P < 0.01 between groups). Multivariable meta-regression modelling identified increasing age and diabetes as predictors of PH (P < 0.01, P = 0.13, respectively; R2 = 36%). PH prevalence was not affected by blood pressure measurement device (P = 0.65) or sitting or supine resting position (P = 0.24), however, when the definition of PH did not fulfil the consensus description, but fell within its parameters, prevalence was underestimated (P = 0.01) irrespective of study quality (P = 0.04). Conclusions PH prevalence in populations relevant to primary care is substantial and the definition of PH used is important. Our findings emphasise the importance of considering checking for PH, particularly in vulnerable populations, to enable interventions to manage it. These data should contribute to future guidelines relevant to the detection and treatment of PH. PROSPERO:CRD42017075423.

Internal Bleaching of a Non vital Anterior Tooth in Patient with Postural Hypotension

Postural hypotension is a form of low blood pressure, characterized a 20 mmHg decrease in systolic blood pressure or a 10 mmHg drop in diastolic blood pressure when rising from a sitting or lying position. This can cause syncope. A patient who comes to a dentist with postural hypotension may be a tough case. A 48-year-old woman arrived with postural hypotension and felt dissatisfied with the discolored and unsightly condition of her upper central incisor. This clinical case shows a management of postural hypotension patient in internal bleaching technique on non-vital teeth using 35% hydrogen peroxide. This therapy is simple, safety and adequate for patients who has postural hypotension with satisfactory results.

Prevalence of postural hypotension in primary, community and institutional care: A systematic review and meta-analysis

Background: Postural hypotension (PH), the reduction in blood pressure when rising from sitting or lying to standing, is a risk factor for falls, cognitive decline and mortality. However, it is not often tested for in primary care. PH prevalence varies according to definition, population, care setting and measurement method. The aim of this study was to determine the prevalence of PH across different care settings and disease subgroups. Methods: Systematic review, meta-analyses and meta-regression. We searched Medline and Embase to October 2019 for studies based in primary, community or institutional care settings reporting PH prevalence. Data and study level demographics were extracted independently by two reviewers. Pooled estimates for mean PH prevalence were compared between care settings and disease subgroups using random effects meta-analyses. Predictors of PH were explored using meta-regression. Quality assessment was undertaken using an adapted Newcastle-Ottawa Scale. Results: 1816 studies were identified; 61 contributed to analyses. Pooled prevalences for PH using the consensus definition were 17% (95% CI, 14-20%; I2=99%) for community cohorts, 19% (15-25%; I2=98%) for 23 primary care cohorts and 31% (15-50%; I2=0%) for 3 residential care or nursing homes cohorts (P=0.16 between groups). By condition, prevalences were 20% (16-23%; I2=98%) with hypertension (20 cohorts), 21% (16-26%; I2=92%) with diabetes (4 cohorts), 25% (18-33%; I2=88%) with Parkinson’s disease (7 cohorts) and 29% (25-33%; I2=0%) with dementia (3 cohorts), compared to 14% (12-17%; I2=99%) without these conditions (P<0.01 between groups). Multivariable meta-regression modelling identified increasing age and diabetes as predictors of PH (P<0.01, P=0.13, respectively; R2=36%). PH prevalence was not affected by blood pressure measurement device (P=0.65) or sitting or supine resting position (P=0.24), however, when the definition of PH did not fulfil the consensus description, but fell within its parameters, prevalence was underestimated (P=0.01) irrespective of study quality (P=0.04). Conclusions: PH prevalence in populations relevant to primary care is substantial and the definition of PH used is important. Our findings emphasise the importance of considering checking for PH, particularly in vulnerable populations, to enable interventions to manage it. These data should contribute to future guidelines relevant to the detection and treatment of PH. PROSPERO:CRD42017075423.