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Background Postural tachycardia syndrome (POTS) manifests as marked tachycardia while standing. We noticed two forms of circulatory response to orthostatic stress in POTS. We investigated cardiovascular and autonomic nervous response to orthostatic stress in the two forms. Methods We studied 79 patients with POTS and 38 healthy control subjects (Ct). Beat-to-beat blood pressure (BP) and heart rate (HR) were non-invasively and continuously measured in the supine and standing positions. Autonomic nervous function was evaluated on power spectral analysis of HR variability and diastolic BP variability. We divided the subjects into two groups: standing-induced tachycardia (SI group; increase in HR ≥35 beats/min) and supine tachycardia (Su group; standing HR ≥115 beats/min with standing-induced HR increase

Aim Postural tachycardia syndrome (POTS) is one of the most frequent forms of chronic orthostatic intolerance in children and adolescents. The aim of the present study was to examine the influence of a genetic background on POTS. Methods A total of 96 children and adolescents with orthostatic dysregulation were studied. The polymorphism of the G protein β3 subunit (GNB3) C825T and G protein α subunit (GNAS1) T131C of genes encoding components of the autonomic nervous system were determined and compared with circulatory responses to active standing. Results In the GNB3 gene C825T polymorphism, the CT and TT genotype had a significant lower supine heart rate and a larger increase of heart rate by standing than the CC, associated with evaluated power of the high-frequency component of heart rate variability. According to the criteria of the Japanese clinical guidelines, 48 children were diagnosed as POTS and 30 were as normal responder with somatoform disorder (SD). In GNB3 C825T polymorphism, the TT genotype was more frequently found in the POTS group (45.8%) than in the SD group (25.0%; P = 0.036). In the GNAS1 T393C, the genotype frequencies for the T393C polymorphisms of GNA1 did not differ significantly between the groups. Conclusion The gene polymorphisms GNB3 C825T might be a risk factor for POTS through the enhanced vagal withdrawal of the heart in children and adolescents.

Chronic pain is a common problem in pediatric practice. The prevalence of chronic pain in children is >30%. Because pain indicates emotional expression as well as the physiological reaction toward infection, injury, and inflammation, both physiological and psychological assessments are essential to determine primary interventions for chronic pain. The Japanese Society of Psychosomatic Pediatrics Task Force of clinical practice guidelines for chronic pain in children and adolescents compiled clinical evidence and opinions of specialists associated with the primary care of pediatric chronic pain in the Japanese 'clinical guidelines for chronic pain in children and adolescents' in 2009, which are presented herein. The guidelines consist of three domains: general introduction to chronic pain; chronic abdominal pain; and chronic headache. Each section contains information on the physiological mechanism, psychological aspects, assessment methods, and primary interventions for pediatric chronic pain. These guidelines are expected to help disseminate knowledge on primary interventions for chronic pain in children and adolescents.

AIM: To investigate changes in cerebral blood volume during standing in healthy children with or without abnormal cardiovascular responses. METHODS: We studied 53 children (age, 10-15 years). Cerebral oxygenated haemoglobin (oxy-Hb) and deoxygenated Hb (deoxy-Hb) were non-invasively and continuously measured using near-infrared spectroscopy (NIRS) (NIRO 300, Hamamatsu Photomedics, Shizuoka, Japan) during active standing. Beat-to-beat arterial pressure was monitored by Portapres. RESULTS: Of 49 children with complete data acquisition, 33 had a normal cardiovascular response to the test (Group I) and 16 showed an abnormal response (Group II); nine with instantaneous orthostatic hypotension, three with postural tachycardia syndrome, three with neutrally mediated syncope and one with delayed orthostatic hypotension. At the onset of standing, Group II showed a significantly larger fall of oxy-Hb than Group I did (-2.9 +/- 2.8 micromol/L vs. -6.4 +/- 7.2 micromol/L, respectively, p < 0.05). During min 1 to 7 of standing, with one exception, changes in oxy-Hb were normally distributed over the level of -4 micromol/L in Group I. Group II also showed a significantly marked decrease in oxy-Hb compared to Group I. Decreases in oxy-Hb were not correlated with blood pressure changes. CONCLUSION: This study shows that precise change in cerebral blood volume caused by orthostatic stress can be determined by NIRS in children in a quantitative manner of NIRS. Children with abnormal circulatory responses to standing showed a significant reduction of oxy-Hb compared with normal counterparts, suggesting impairment of cerebral autoregulation in these children.

This clinical practice guideline provides recommendations for the assessment, diagnosis and treatment of school-aged children and juveniles with orthostatic dysregulation (OD), usually named orthostatic intolerance in USA and Europe. This guideline is intended for use by primary care clinicians working in primary care settings. The guideline contains the following recommendations for diagnosis of OD: (i) initial evaluation composed of including and excluding criteria, the assessment of no evidence of other disease including cardiac disease and so on; (ii) a new orthostatic test to determine four different subsets: instantaneous orthostatic hypotension, postural tachycardia syndrome, neurally mediated syncope and delayed orthostatic hypotension; (iii) evaluation of severity; and (iv) judgment of psychosocial background with the use of rating scales. The guideline also contains the following recommendations for treatment of OD on the basis of the result of an orthostatic test in addition to psychosocial assessment: (i) guidance and education for parents and children; (ii) non-pharmacological treatments; (iii) contact with school personnel; (iv) use of adrenoceptor stimulants and other medications; (v) strategies of psychosocial intervention; and (vi) psychotherapy. This clinical practice guideline is not intended as a sole source of guidance in the evaluation of children with OD. Rather, it is designed to assist primary care clinicians by providing a framework for decision making of diagnosis and treatments.

Tanaka H, Thulesius O, Yamaguchi H, Mino M, Konishi K. Continuous non-invasive finger blood pressure monitoring in children. Acta Padiatr 1994;83:646–52. Stockholm. ISSN 0803–5253 We evaluated the performance of continuous non-invasive finger arterial pressure measurement using the volume-clamp technique (Finapres). The study was designed to compare finger arterial pressure with brachial blood pressure estimated by the auscultatory method in 217 children (90 boys and 127 girls) aged 4–16 years and in 38 adults (aged 18–45 years). Finger and brachial artery pressure readings were obtained consecutively from the ipsilateral side in the supine position. Fingcr arterial pressure waveforms were recorded in all children except 4 with small and thin fingers. There was good agreement for systolic pressure with only a slight underestimation of 1.9 mmHg and 5.1 mmHg lower for diastolic pressure. This difference most probably reflects inaccuracy of the auscultatory cuff method rather than an error in the Finapres. There was large inter-individual variability in Finapres recordings which might be due to diffcrences in vasomotor tone, as demonstrated by systolic amplification in 5 patients with anorexia. However, Finapres showed a small within-subject variability (3.8 mmHg for systolic and 4.1 mmHg for diastolic pressure) dctermined in 5 patients during phenylephrine infusion, and as good reproducibility as the auscultatory method. These results suggest that finger arterial pressure measurement in children older than 6 years of age has similar accuracy as that in adults, and that this method is useful for clinical applications in children, especially for the non-invasive evaluation of autonomic control and cardiovascular reflexes involving transient and rapid blood pressure changes.

Background: Physical symptoms are an increasing problem among Japanese children and adolescents, and the symptoms seem to be related to their school situation. These symptoms are prevalent in Sweden, and a comparison with Japan is of interest due to the differences in the educational system and school climate. Objective and methods: To compare physical symptoms and psychiatric complaints in school pupils from Japan and Sweden, using a questionnaire that also addressed life satisfaction and stressful life events. The study population comprised 742 Japanese children and 1120 Swedish children attending public compulsory schools, grades 4–9 (10–15 y). Physical symptom and psychiatric complaint scores were calculated for each pupil. Results: The Japanese children had significantly higher physical symptom and psychiatric complaint scores than did the Swedish children. Both the physical symptom and psychiatric complaint scores were significantly higher in adolescents than in preadolescents in Japan; this trend was less apparent in Swedish children. In addition, Japanese children were found to have considerably lower life satisfaction. Loss of appetite was the only physical symptom more prevalent in the Swedish population compared to the Japanese population. Conclusion: We conclude that Japanese schoolchildren have more physical symptoms and psychiatric complaints and less life satisfaction than Swedish schoolchildren of corresponding ages.

Cardiovascular responses on active standing in children with unexplained syncope were investigated with continuous non-invasive finger artery pressure monitoring (Finapres). We examined 34 symptomatic patients (13 boys and 21 girls), aged 8-16 years, and 24 age-matched controls. Finger blood pressure and heart rate were monitored continuously for 5 min in the supine position and for 10 min while standing. Ten of 34 patients developed fainting symptoms with hypotension during upright posture (fainters). In the initial standing phase (0-30 s), two prominent abnormal blood pressure responses were found in patients: a marked decrease 45 +/- 18/23 +/- 8 mmHg and a prolonged recovery time (16.5 +/- 2.9 versus 27.7 +/- 13.6 s), which appeared to be based on impaired vasoconstriction. Either or both abnormalities were observed in 21 (62%) of the 34 patients and in 2 (8%) of the controls. In addition, fainters also had a more marked increase in heart rate during standing compared with non-fainters. Our findings suggested that more than half of children with syncope had abnormal cardiovascular reflexes in the initial phase which appeared to be associated with vasodepressor syncope. The active standing test with a continuous beat-to-beat blood pressure recording has a high sensitivity in detecting abnormalities of autonomic function in patients with unexplained syncope.

The purpose of the present study was to determine the levels of osteocalcin, a bone specific matrix protein, in gingival crevicular fluid (GCF) from periodontal disease patients and to investigate the relationship between GCF osteocalcin levels and clinical parameters. Nineteen initial visit patients, 5 patients with gingivitis and 14 patients with adult periodontitis, participated in this study. The clinical parameters including probing depth, attachment level, gingival index, and tooth mobility were recorded following careful sampling of GCF with a filter paper strip harvested for 3 minutes. Osteocalcin adsorbed on a strip was extracted in a plastic tube containing 150 microliters of 10 mM sodium phosphate buffer (pH 6.5). GCF osteocalcin was determined by a newly-developed, high sensitive enzyme immunoassay which could recognize the N-terminal 20 residue peptide. In gingivitis patients, no significant amounts of osteocalcin were detected. In periodontitis patients, on the other hand, osteocalcin levels were detected, ranging between 0 and 540 pg/tube and positively correlated with these clinical parameters (P < 0.01). Moreover, in several sites in GI = 3 group, extremely higher levels of GCF osteocalcin were detected. These results strongly suggest that in addition to the presence of GCF osteocalcin the levels of osteocalcin may reflect the degree of the periodontal inflammation at the sampled sites.