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An inverted U-shape relationship between cognitive performance and indoor temperature with best performance peaking at 21.6 °C was previously described. Little is known on classroom temperature reduction effects on cognitive performances and cardiac autonomic profile, during the cold season. Fifteen students underwent electrocardiogram recording during a lecture in two days in December when classroom temperatures were set as neutral (NEUTRAL, 20-22 °C) and cool (COOL, 16-18 °C). Cognitive performance (memory, verbal ability, reasoning, overall cognitive C-score) was assessed by Cambridge Brain Science cognitive evaluation tool. Cardiac autonomic control was evaluated via the analysis of spontaneous fluctuations of heart period, as the temporal distance between two successive R-wave peaks (RR). Spectral analysis provided the power in the high frequency (HF, 0.15-0.40 Hz) and low frequency (LF, 0.04-0.15 Hz) bands of RR variability. Sympatho-vagal interaction was assessed by LF to HF ratio (LF/HF). Symbolic analysis provided the fraction of RR patterns composed by three heart periods with no variation (0 V%) and two variations (2 V%), taken as markers of cardiac sympathetic and vagal modulations, respectively. The students' thermal comfort was assessed during NEUTRAL and COOL trials. Classroom temperatures were 21.5 ± 0.8 °C and 18.4 ± 0.4 °C during NEUTRAL and COOL. Memory, verbal ability, C-Score were greater during COOL (13.01 ± 3.43, 12.32 ± 2.58, 14.29 ± 2.90) compared to NEUTRAL (9.98 ± 2.26, p = 0.002; 8.57 ± 1.07, p = 0.001 and 10.35 ± 3.20, p = 0.001). LF/HF (2.4 ± 1.7) and 0 V% (23.2 ± 11.1%) were lower during COOL compared to NEUTRAL (3.7 ± 2.8, p = 0.042; 28.1 ± 12.2.1%, p = 0.031). During COOL, 2 V% was greater (30.5 ± 10.9%) compared to NEUTRAL (26.2 ± 11.3, p = 0.047). The students' thermal comfort was slightly reduced during COOL compared to NEUTRAL trial. During cold season, a better cognitive performance was obtained in a cooler indoor setting enabling therefore energy saving too.

Postural orthostatic tachycardia syndrome (POTS) is a multifactorial condition capable of chronically reducing the quality of life and the work ability of patients. The study aim was to assess the burden of autonomic symptoms in a cohort of POTS patients over 2 years. Patients&rsquo, clinical profiles were assessed by the 31-item Composite Autonomic Symptom Score questionnaire (COMPASS 31) and a visual analog scale (VAS). One-way ANOVA for repeated measures followed by Dunnett&rsquo, s post-hoc test were used to compare symptoms at baseline and at 1 and 2 years. Out of 42 enrolled patients, 25 had a 1-year follow-up and 12 had a 2-year follow-up. At baseline, the reported burden of autonomic symptoms was high (overall COMPASS 31 = 49.9 &plusmn, 14.3 /100). Main complaints were related to orthostatic intolerance according to both COMPASS 31 and VAS. Fourteen patients were rendered inactive because of symptoms. At 1-year follow-up, a statistically significant improvement in pupillomotor function and overall score was detected by the COMPASS 31. These findings were confirmed at 2 years, together with a significant reduction in quality of life impairment, assessed by VAS. However, these improvements did not change patients&rsquo, occupational status. Awareness of POTS diagnosis, patient monitoring, and tailored therapies can help to improve patients&rsquo, condition.

The effect of classroom temperature reduction on cognitive performance and cardiac autonomic control were assessed in 12 healthy undergraduate students during a 2-hour lasting lecture. In all subjects ECG was continuously recorded by a portable device when classroom temperature was “neutral” $(22.4\pm 0.1^{\circ}\mathrm{C}$ , Day1) and “cool” $(18.4^{\circ}\mathrm{C}\pm 0.3^{\circ}\mathrm{C}$ , Day2). Symbolic analysis of RR variability provided the percentage of three heart period sequences with no significant change in RR interval (0V%) and with two significant variations (2UV%), reflecting cardiac sympathetic and vagal modulation, respectively. Students' cognitive performance was assessed at the end of each lecture by the Cambridge Brain Sciences cognitive evaluation tool. In Day2 the 0V% was greater and 2UV% was lower compared to Day1. Cognitive performance rated better in Day2 compared to Day1. Students' cognitive performance was improved and their cardiac sympathetic modulation was enhanced when the lecture was performed in a cooler environment.

The capability of hypnosis to act on the Autonomic Nervous System under a controlled breath condition (12 breaths/min) was assessed in 11 healthy volunteers. Subjects were split into high and low susceptibility to hypnosis groups, using the Stanford hypnotic susceptibility scale form $\mathrm{C}$ (SHSS). Autoregressive power spectrum analysis of RR interval and SAP variabilities provided the markers of cardiac sympatho-vagal interaction (LF/HF) and vascular sympathetic vasomotor control $(\mathrm{LF}_{\mathrm{SAP}})$ . Under controlled respiration, no significant changes in LF/HF ratio were observed between the two groups. Hypnosis induced a significant increase of $\mathrm{LF}_{\mathrm{SAP}}$ in high susceptible subjects. These preliminary results highlight how the state of hypnotic trance acts directly on the cardiovascular autonomic profile by increasing the sympathetic vascular activity only in high susceptible subjects. These effects become evident when the role of potential changes in respiration rate are excluded by the controlled breathing condition.

Postural Tachycardia Syndrome (POTS) is a chronic disorder characterized by symptoms of orthostatic intolerance such as fatigue, lightheadedness, dizziness, palpitations, dyspnea, chest discomfort and remarkable tachycardia upon standing. Non-invasive transdermal vagal stimulators have been applied for the treatment of epilepsy, anxiety, depression, headache, and chronic pain syndromes. Anti-inflammatory and immunomodulating effects after transdermal vagal stimulation raised interest for applications in other diseases. Patients with sympathetic overactivity, reduced cardiac vagal drive and presence of systemic inflammation like POTS may benefit from tVNS. This article will address crucial methodological aspects of tVNS and provide preliminary results of its acute and chronic use in POTS, with regards to its potential effectiveness on autonomic symptoms reduction and heart rate modulation.

Background: Enrollment of large cohorts of syncope patients from administrative data is crucial for proper risk stratification but is limited by the enormous amount of time required for manual revision of medical records. Aim: To develop a Natural Language Processing (NLP) algorithm to automatically identify syncope from Emergency Department (ED) electronic medical records (EMRs). Methods: De-identified EMRs of all consecutive patients evaluated at Humanitas Research Hospital ED from 1 December 2013 to 31 March 2014 and from 1 December 2015 to 31 March 2016 were manually annotated to identify syncope. Records were combined in a single dataset and classified. The performance of combined multiple NLP feature selectors and classifiers was tested. Primary Outcomes: NLP algorithms&rsquo, accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and F3 score. Results: 15,098 and 15,222 records from 2013 and 2015 datasets were analyzed. Syncope was present in 571 records. Normalized Gini Index feature selector combined with Support Vector Machines classifier obtained the best F3 value (84.0%), with 92.2% sensitivity and 47.4% positive predictive value. A 96% analysis time reduction was computed, compared with EMRs manual review. Conclusions: This artificial intelligence algorithm enabled the automatic identification of a large population of syncope patients using EMRs.

We hypothesized that sympathetic baroreflex mediated uncoupling between neural sympathetic discharge pattern and arterial pressure (AP) fluctuations at 0.1 Hz during baroreceptor unloading might promote orthostatic pre-syncope. Ten volunteers (32 &plusmn, 6 years) underwent electrocardiogram, beat-to-beat AP, respiratory activity and muscle sympathetic nerve activity (MSNA) recordings while supine (REST) and during 80&deg, head-up tilt (HUT) followed by &minus, 10 mmHg stepwise increase of lower body negative pressure until pre-syncope. Cardiac and sympathetic baroreflex sensitivity were quantified. Spectrum analysis of systolic and diastolic AP (SAP and DAP) and calibrated MSNA (cMSNA) variability assessed the low frequency fluctuations (LF, ~0.1 Hz) of SAP, DAP and cMSNA variability. The squared coherence function (K2) quantified the coupling between cMSNA and DAP in the LF band. Analyses were performed while supine, during asymptomatic HUT (T1) and at pre-syncope onset (T2). During T2 we found that: (1) sympathetic baroreceptor modulation was virtually abolished compared to T1, (2) a progressive decrease in AP was accompanied by a persistent but chaotic sympathetic firing, (3) coupling between cMSNA and AP series at 0.1 Hz was reduced compared to T1. A negligible sympathetic baroreceptor modulation during pre-syncope might disrupt sympathetic discharge pattern impairing the capability of vessels to constrict and promote pre-syncope.

OBJECTIVE Indoor microclimate may affect students' wellbeing, cardiac autonomic control and cognitive performance with potential impact on learning capabilities. To assess the effects of classroom temperature variations on the autonomic profile and students' cognitive capabilities. APPROACH Twenty students attending Humanitas University School, (14M, age 21 ± 3 years) underwent a single-lead ECG continuous recording by a portable device during a 2 h lecture when classroom temperature was set 'neutral' (20 °C-22 °C, Day 1) and when classroom temperature was set to 24 °C-26 °C (Day 2). ECGs were sent by telemetry to a server for off-line analysis. Spectral analysis of RR variability provided indices of cardiac sympathetic (LFnu), vagal (HF, HFnu) and cardiac sympatho-vagal modulation (LF/HF). Symbolic analysis of RR variability provided the percentage of sequences of three heart periods with no significant change in RR interval (0V%) and with two significant variations (2V%) reflecting cardiac sympathetic and vagal modulation, respectively. Students' cognitive performance (memory, verbal comprehension and reasoning) was assessed at the end of each lecture using the Cambridge Brain Sciences cognitive evaluation tool. MAIN RESULTS Classroom temperature and CO2 were assessed every 5 min. Classroom temperatures were 22.4 °C ± 0.1 °C (Day 1) and 26.2 °C ± 0.1 °C (Day 2). Student's thermal comfort was lower during Day 2 compared to Day 1. HR, LF/HF and 0V% were greater during Day 2 (79.5 ± 12.1 bpm, 6.9 ± 7.1 and 32.8% ± 10.3%) than during Day 1 (72.6 ± 10.8 bpm, 3.4 ± 3.7, 21.4% ± 9.2%). Conversely, 2V% was lower during Day 2 (23.1% ± 8.1%) than during Day 1 (32.3% ± 11.4%). Short-term memory, verbal ability and the overall cognitive C-score scores were lower during Day 2 (10.3 ± 0.3; 8.1 ± 1.2 and 10.9 ± 2.0) compared to Day 1 (11.7 ± 2.1; 10.7 ± 1.7 and 12.6 ± 1.8). SIGNIFICANCE During Day 2, a shift of the cardiac autonomic control towards a sympathetic predominance was observed compared to Day 1, in the presence of greater thermal discomfort. Furthermore, during Day 2 reduced cognitive performances were found.

Syncope in a worker undertaking risky tasks may result in fatalities for the individual or for third parties. We aimed at assessing the rate of syncope recurrence and the risk factors underlying the likelihood of syncope relapse in a working-age population. A prospective cohort of all patients aged 18&ndash, 65 years consecutively admitted to the Emergency Department for syncope was enrolled. Risk of syncope relapse was assessed at a six-month, 1-year, and 5-year follow-up. Predictors of syncope recurrence have been evaluated at six months and 1 year from the syncope index by a multivariable logistic regression analysis. 348 patients were enrolled. Risk of syncope relapse was 9.2% at 6 months, 11.8% at 1 year, and 23.4% at 5 years. At 6-month follow-up, predictor of syncope recurrence was &ge, 3 prior lifetime syncope episodes. At 1-year, &ge, 3 prior lifetime syncope episodes, diabetes mellitus, and anaemia were risk factors for syncope relapse. There was an exceeding risk of recurrence in the first 6 months and a reduced risk of 3.5% per year after the first year. Anaemia, diabetes mellitus, and prior lifetime syncope burden are of importance when giving advice about the resumption of &ldquo, high risk&rdquo, jobs following a syncope episode.

Objective The current study aimed to assess the effects of five cycles of automated mechanical somatosensory stimulation (AMSS) of the fore-feet on blood pressure (BP) and cardiovascular autonomic control in Parkinson's Disease patients. Methods Out of 23 patients, 16 underwent an AMSS session every 72 h, for a total of five sessions per patient. Electrocardiogram, noninvasive beat-to-beat blood pressure and respiratory activity were recorded for 20 min in supine position at baseline and after the AMSS sessions. Main outcomes were the changes in SBP and DBP, in the spectral indices of cardiac sympathetic (LFRRn.u.) and vagal (HFRR) modulatory activities, cardiac sympathovagal relationship (LF/HF), vascular sympathetic modulation (LFSAP) and arterial baroreflex sensitivity (sequence technique). Symbolic analysis of heart rate variability provided additional indices of cardiac sympathetic (0V%) and vagal (2UV%) modulation to the sinoatrial node. Results After five AMSS trials a reduction in SBP (baseline: 131.2 ± 15.5 mmHg; post-AMSS: 122.4 ± 16.2 mmHg; P = 0.0004) and DBP (baseline: 73.2 ± 6.1 mmHg; post-AMSS: 68.9 ± 6.2 mmHg; P = 0.008) was observed. Post-AMSS, spectral and symbolic indices of cardiovascular sympathetic control decreased and arterial baroreflex sensitivity increased (baseline: 5.7 ± 1.3 ms/mmHg; post-AMSS: 11.27 ± 2.7 ms/mmHg). Conclusion AMSS sessions were effective in reducing BP, increasing baroreflex sensitivity and decreasing cardiovascular sympathetic modulation in Parkinson's disease patients. AMSS might be useful to control supine hypertension in Parkinson's disease.

Postural orthostatic tachycardia syndrome (POTS) negatively impacts quality of life. The excessive increase in cardiac sympathetic modulation during standing, which characterizes POTS patients, leads to many symptoms and signs of orthostatic intolerance. Little is known about the consequences of the disease on work performance and its relationship with individual autonomic profiles. Twenty-two POTS patients regularly engaged in working activity (20 females, age 36 &plusmn, 12 years) and 18 gender- and age-matched controls underwent a clinical evaluation and filled out the Work Ability Index (WAI) questionnaire. POTS patients completed the Composite Autonomic Symptom Score (COMPASS31) questionnaire, underwent continuous electrocardiogram, blood pressure and respiratory activity recordings while supine and during a 75&deg, head-up tilt (HUT). A power spectrum analysis provided the index of cardiac sympatho-vagal balance (LF/HF). WAI scores were significantly reduced in POTS patients (29.84 &plusmn, 1.40) compared to controls (45.63 &plusmn, 0.53, p &lt, 0.01). A significant inverse correlation was found between individual WAI and COMPASS31 scores (r = &minus, 0.46, p = 0.03), HUT increase in heart rate (r = &minus, 0.57, p = 0.01) and LF/HF (r = &minus, 0.55, p = 0.01). In POTS patients, the WAI scores were inversely correlated to the intensity of autonomic symptoms and to the excessive cardiac sympathetic activation induced by the gravitational stimulus.

Rotational shift work is associated with sleep disturbances, increased risk of cardiovascular and psychological disorders, and may negatively impact work&ndash, life balance. The direction of shift rotation (Clockwise, CW or counterclockwise, CCW) and its role in these disorders are poorly understood. The aim of the study was to investigate the effect of the shift schedule direction on sleep quantity and quality, alertness and work performance, and on work&ndash, life balance on hospital nurses. One-hundred female nurses, working a continuous rapid shift schedule in hospitals in the north of Italy, participated in this cross-sectional study. Fifty worked on CW rotation schedule (Morning: 6 a.m.&ndash, 2 p.m., Afternoon: 2 p.m.&ndash, 10 p.m., Night: 10 p.m.&ndash, 6 a.m., 2 rest days) and fifty on CCW rotation (Afternoon, Morning, Morning, Night, 3 rest days). Data were collected by ad hoc questionnaire and daily diary. During the shift cycle CW nurses slept longer (7.40 &plusmn, 2.24 h) than CCW (6.09 &plusmn, 1.73, p &lt, 0.001). CW nurses reported less frequently than CCW awakening during sleep (40% vs. 80%, 0.001), attention disturbance during work (20% vs. 64%, 0.001), and interference with social and family life (60% vs. 96% and 20% vs. 70%, respectively, 0.001). CCW rotating shift schedule seems to be characterized by higher sleep disturbances and a worse work&ndash, life balance.

Introduction Rapidly rotating shiftwork schedule, is common in hospital nurses as it provides continuity to the patients’ care. It has been suggested that shift rotation in clockwise (CW) direction produces less disruption of circadian rhythms than counterclockwise (CCW) rotation. Little is known about the effects of different direction of shift rotation on work-life balance, particularly in women characterised by additional commitments and responsibilities in the home and outside of work. Aim To evaluate if CW and CCW shift rotation differently impacts on family and social relationships in female nurses. Methods One hundred healthy hospital nurses (F, 20–50 years) were enrolled. Fifty of them worked in CW (Morning, M; Afternoon, A; Night, N; two rest days) and 50 in CCW (A, M, M, N, three rest days) shift rotation direction. A daily diary filled out by the nurses at the end of each work-shift provided information concerning family and social relationships during a typical working week. Habits on coffee, smoke, time of meal assumption and home management during working days were also collected. Result Nurses working on CCW shift rotation reported more frequently difficulties in keeping adequate family and social relationships compared to nurses working on CW one (96% vs 73%, p=0.002). No differences were reported in coffee (3–4 cups/day), smoking (61%) habits and time of meals assumption (irregular in about 33% of nurses) during working days in the two groups. No differences were reported in the time spent in home management by the two groups. Discussion CCW shift rotation seemed to disrupt quality of family and social relationships of nurses more than CW one. The fact that CCW shift rotation is associated to higher sleep disturbances and more fatigue in the free-time might partially explain these results. These aspects should be taken into account in shift-work schedule organisation, particularly in women.