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finally, uh, certainly not least a Professor IDG professor of autonomic neurology Queen Square. So she's traveled a vast distance to get to us. Who's going to give us an idea about current research in the area, which equals will be vital. I'm going so good afternoon. Everyone think you need continue toe puts you pay, so it's really good pressure to be here. So I would try my best to be brief. I know that it said a very long day, but actually it's been a fantastic opportunity. So we will discuss the autonomic dysfunction, long coverage and the overlap. I mean, you ever heard quite a lot regarding any of a lot of spots and which are the current research? So much on the autonomic dysfunction and webzine inpatient covet syndrome. Our experience from a tertiary center with pilots data and what we're planning for the future. So you have had a few times today then. The most frequent atomic presentation in post covet syndrome is a cardiovascular autonomic dysfunction. We are at the moment not really sure that actually that is the case is also them. Actually, this feature the one thing that easily recognize in our clinic. And this is why is the most prominent referral to either a secondary tertiary care. So when it comes to cardiovascular make dysfunction, you have seen in quite a few pills and especially present with the collapse with the lightheadedness dizziness court on the same. So it's been in neck and shoulder than it doesn't prove when the patient is lying down, exercise intolerance with fatigue than it's triggered by other steamers, like post mi in particle with a large me. So what is important to recognize that this is where the confusion, I suppose start and the way we don't know the full story when it comes to a comet and longer been single is that Orthostatic intolerance is a label for very, very different resort. So you have from one spectrum something that extremely severe so neurogenic wages. Nick was mentioning this morning, which is a severe is disabling, is persistent, so you wouldn't expect the patient to be well one day and I'm well the second day, and they require long term treatment. So usually there is an underlying lesion off the atomic nervous system. In one of the pathways off either the the central, the spinal cord or the benefit. And then on the other side you have a patient that, actually, they might present to you with also started in dollar, but in fact that it's not in order of conditions. So it wouldn't surprise anyone if somebody after a problem that dress my head off the statin intolerance. If there is a very low fluid intake, or maybe drunks, then they can cause you're too static. Intolerance, which know necessary means, you know, don't result in the middle is the most, uh, what we class that is it benign, but actually the most difficult past of your toe. Sudden intolerance physiology where you have a patient with pots and frequently early like syncope. So why so thinking about your to starting intolerance? Why autonomic dysfunction my occur in long coat syndrome? And I don't think again. We have the final answer, But there are three for maybe seen on So eater, we are looking at a note immune inflammatory disorder, and this is why you would see the mention here regarding memory. For that, this was the point of it is working regarding autoimmune pathology, so autonomic ganglion. Nobody. So one patient has been described by the case serious. And when you're cleaning cans, we have seen one patient with genital to start to get attention. The reason why can't you know? But he's mentioned here is because actually does offer us a brilliant modern to understand a little bit more regarding Long, Kobe. Because in this patient, we know exactly where the pathologies so potentially mother than we can a plan to study this patient. So in my big in autonomic neuropathy, and we would see if your example the the wrong or as you have seen all this morning, you know, prevent Sinus tachycardia prostrate talking about the symptoms. So is it the transcends problem of the autonomic nervous system? Actually, investigation were observing a lesion off the Zomig nasal system. Uh, so they've been wife. You Case reports. So this is the case series from Mayo Clinic that I was referring to. And you can see one patient at the definitely onset of the no team. You know, Tommy can blow up, but it is a severe but treatable bottom of failure. These older and the rest of the patient had a 4 ft. The criteria still think you got the scenes. Oh my God, the static in Collins, however, even when it comes here to pots and my daughter started intolerance, we still we need to do a quite a lot to understand what we manage with that. So the reason why you have had today from brilliant public and many other colleague s what we would expect the patient pots they do recover or the patients do respond all the patient to the same medication. What is the natural east of the disorder? The tricky part is, then we are looking at label to describe a very a terror genius group of patients. So it's very possible that actually we're looking at several different disorder. So this is another study, more recent study using a compass 51 which is a very well validated a question and which looks at age autonomic domain. And as you can see, this actually confirmed than the patient did not say just cardiovascular autonomic dysfunction without stopping intolerance. But actually there is a wide spread the environment off the stomach nervous system involving the gun to blood on down another stupid motorcycle, it a motor donate, which it does resembling what we do see in our patient with lots of similarity Eso maybe understanding belong cause they will give us inside into wanted us up in in patient with you about it. So this is our pilots a study which has been presented with the European Academy of Neurology this week and we're grateful to the collaboration off many Colligan, UCLA judge So we did look at our court of patients with with the long term it seem from and this is just to give you a contest. So in the old range of patient, we do see it's our, uh that should referral center will see motor less more than 5000 in on station for here When we started or getting six months after the start of the pandemic, you can see that we were receiving more or less if i the new referral off long coat syndrome for a week. And now we're doubling the number which obviously, uh, is a little bit concerning for overall for the so the the provision the service more than 40 station, But they might hit, and also people they organize Long Corbett syndrome much more than it is the start. This is Why the so I won't go into much of the days you ever had locked regarding what's Proscar syndrome remained fully understood. That is substantially long term patient else and economic implication it does. It seems, to occur independently off the severity of the Children. Infection is was point out just a tad a previous question. Uh, and the tricky part of the study looking at autonomic function in this special court on Leaf You study patient. They were assessed with formula comic. Best thing. So we did look at our court. So the cold what was the patient's already for with the suspected confirmed the story of Cove it 19 majority of the station. Actually, they were federal from respiratory medicine, the usual age. You can see the mean number of days between the two of the infection. The testing was 374 and angel between 30 and 579 days. Um, so 62 patients female 42 maybe 20. It's a racial to one, the mean age of 41.3 in a range between 18 and 82. And this is again I should raise some some alarm. How it Regina sections the patient cold so mild that very covered symptoms in 12 patients in our court, obviously you a quiz where we have any interest enjoying type of mobility. So every patient and it comes to the unit. So it's a screen for that was possible, comma Billy, that that was something very interesting to answer. So we were looking at Is it possible that maybe there are predisposition packed? Or so this is a patient than yes, that's developing copy infection, longer bit syndrome. But there is anything in there medical history that is unfortunate poster patient risk off developing a long coughing syndrome. So this is the range of symptoms. So no difference what you're seeing this morning. So majority of the patients palpitations definitely prominence, lightheadedness and dizziness. The chest pain. So all the constellation of symptoms you would expect in a patient we got to start it. Intolerance. So this is that that when it comes to the outcome from, you know, the the formal autonomic best thing. So what is that? If you're short? Uh, well, yes and no, actually. So, so much. Under the patients they present within the week that is old. That's always the way got sick of impersonal tachycardia Single. We've seen a patient with, um a neurogenic Ohh! And a patient with initial Oh, to starting a ball. That and the reason why I'm saying yes and no, it's because we need to understand a little bit more. What is the underlying pathology reports and I will show you one case. So when it comes to what we see the lab. So these are all the final type of that you have seen this morning? This is what we would expect the vision with boats until on this is that this is a patient with so they don't syncope off interest. I mean, this is a patient with initial orthostatic hypertension. So in the autonomic neurology, we would have assumed that actually, these patients who have been in the meat there is also something benign. So it drop in blood pressure. Then you can only capture if you're measuring the BP continuously. Only standing test and you can see that when it does generate important chronotropic of its phones with increasing our trade and then every cover over time. Yeah, so something that usually doesn't assure us, but actually wasn't not the case in this patient called. So we we did look at the patient with initial which and actually medication with initial, which they do ever other dysfunction off the the the autonomic nervous system So they do ever use after it. But I've been breathing, which means parasympathetic important. So this is just to make it a point, Then I guess we should not assume. Then we know the full story where it comes to autonomic dysfunction in long covered. So the reason why I'm presenting this case is again toe challenge a little bit. The concept of what will 92 weeks dot So this is a patient 58 woman developed the dyspenea addressed short of breath with minimal exertion. For example, working upstairs at home was speaking on the on on the telephone fever, dizziness, just a light, headiness and palpitations. So patient was tested. So same straight forwards. For cardia, this is a 24 hour pressure profile than the patient it does before with the diary. They were the typical trigger, so strangle exercise. Then they need extensively the tachycardia and the patient also presents with a post exercise malaise, an exacerbation of the booster of tachycardia after it's supine existence. What is the concern Us is that in the recovery things the patient was still presenting with these temperature and and with prominent eating tolerance? So the question was, Are we missing anything? So is it the station actually said a more broad impairment off the autonomic nervous system. So these are sudomotor assessment of pseudomonas off. So this is the same patient was evaluated with the postganglionic assessment off the never than the Innovate the sweat glands. So this is a normal control. Each of this dot is one sweat glands activated, so you can see that there is a significant difference in the patient. So that test is telling me that there's a post of them below negative provision. So this patient that's a potentially is more fiber neuropathy. Now, if we were stopping here, it would have been a final time. Then we can see in the fetus in patient without belief in on your opening vision with the burning pain so in in the patient, then you would Plaster is a small father neuropathy. However, this very profound eating tolerance is not justified by a lung dependent process. So in neuropathy innovation, they only does affect the distal part. So we didn't perform it. A term regular dose where tests which you see you back in use. Yes, So this is a chamber where we can control the humidity and temperature. We have a 16 channel where we can measure the skin temperature and the draft. You see here the purple at the area where the patient is able to sweat from the young, though at the area where the vision is not able to sweat from. We use a powder than it does change color. When the patient starts sweating, so you can see, then the pattern is that thing, Not what we would expect in a small fiber neuropathy is very profound. A large area beneath roses. So he's obviously, you know, the Y further study, and this is what we are planning now. But this is just to make the point. I don't think we know the full story when it comes to autonomic dysfunction. Long Cove it It might be very benign. In some patients. It might be moderate, another or maybe even more more city at the end of the spectrum and then it's It's very well with the started and we know regarding postural tachycardia syndrome. So we called Taltz something that is extremely rare urgency. So some patient on your party, some patients because of the conditioning. Artificially, you have hypoglycemia. Splanchnic a very maybe some patients, whoever to three of the underlying pathology at the same time. And then we have the very strong association with joint type of mobility. So maybe one of the reason why we cannot predict naturally story. We cannot predict response to treatment because we are looking at one label, but actually several different results. So in conclusion, you know what pilots? They definitely majority of the patients they had Internet, the disorder. We did look at weight, follow up. All these patients in clinic and majority of the patients did improve again. This is very limited to the small group pilot, so I don't think we can draw lots of conclusion what we are planning for the future and anyone of any centrists. And we would love and be delighted to collaborate. But we would apply a model than we know that it works extremely well. So I guess it by now we are all familiar with the concept that actually this is a disorder that is monthly system. So when it comes to those army, we can't use one outcome measure to capture ophthalmology. So we will use a model than we're using the country and over this again, since this paper looking at several outcome measure and with you, then we will be able to finally like these patients. And by final typing this patient, we may be able to answer some of this this question. So this study would start in September. So it's a set. We would welcome a collaboration. Thank you so much for your So we don't have time to some questions, which is I was okay. You know, I told my gosh, I feel like the big bad time Wilfert. So we do have We do have any questions here before I am flick back tonight. Screen people might be questioned out. Um, that's otherwise I'll go with the back yet. Left knee. Let's see. Thank you. It's been brilliant meeting you. It was over a year ago, I think on teams, or maybe two years ago. But we've learned so much that we we didn't even know we didn't know. One of the things that Patricia McNamara's in teaching us in the usual age clinic is house to take her. The better autonomic history on deeper ticulitis issue about the sweating is something that actually bony really got scripts within the last month on, one of our patients did have that abnormality that you described. So do you think there's a need for us to train postcode clinicians in this autonomic history taking because we've kind of got fixated on the palpitations and the postural sentence, But there is actually more to it. Isn't that yes, when I will say absolutely. Yes, so I guess. And in the clinically story, there are many red flag, and then you can use from the legal history to basically different shapes, which kind of also fantasize we're looking at sense. So I definitely there is a blank of school. For me, the potential is the longest neurology. I would say your is the gold standard, the first step before any your autonomic testing. So absolutely yes. And the super model sidemen is very interesting because some patient eventually will not perceived that the Negro sister is very unusual for a patient, Even with the larger need roses, so not lack of ability to sweat, to be able to recognize, actually occasionally will tell you the opposite. It would say, Oh, I have developed hyperhidrosis off the chest. And then you just the patient in reality, the problem, obviously. Then they tried to convince it just the body. So the story when it comes to sudomotor domain is very, very difficult, because the perception of the patient is very difficult to capture. Yeah, So we might need your help with these training resources that really developing it would be Thank you.