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Liu L, Li X, Zhao Q, Yang L, Jiang X. Pathogenesis of Port-Wine Stains: Directions for Future Therapies. Int J Mol Sci 2022; 23:ijms232012139. [PMID: 36292993 PMCID: PMC9603382 DOI: 10.3390/ijms232012139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 11/26/2022] Open
Abstract
Port-wine stains (PWSs) are congenital vascular malformations that involve the skin and mucosa. To date, the mechanisms underlying the pathogenesis and progression of PWSs are yet to be clearly elucidated. The potential reasons for dilated vessels are as follows: (1) somatic GNAQ (R183Q) mutations that form enlarged capillary malformation-like vessels through angiopoietin-2, (2) decreased perivascular nerve elements, (3) the coexistence of Eph receptor B1 and ephrin B2, and (4) the deficiency of αSMA expression in pericytes. In addition, ERK, c-JNK, P70S6K, AKT, PI3K, and PKC are assumed to be involved in PWS development. Although pulsed-dye laser (PDL) remains the gold standard for treating PWSs, the recurrence rate is high. Topical drugs, including imiquimod, axitinib, and rapamycin, combined with PDL treatments, are expected to alter the recurrence rate and reduce the number of PDL sessions for PWSs. For the deep vascular plexus, photosensitizers or photothermal transduction agents encapsulated by nanocarriers conjugated to surface markers (CD133/CD166/VEGFR-2) possess a promising therapeutic potential in photodynamic therapy or photothermal therapy for PWSs. The pathogenesis, progression, and treatment of PWSs should be extensively investigated.
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Affiliation(s)
- Lian Liu
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu 610017, China
- Laboratory of Dermatology, Clinical Institute of Inflammation and Immunology (CIII), Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610017, China
| | - Xiaoxue Li
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu 610017, China
- Laboratory of Dermatology, Clinical Institute of Inflammation and Immunology (CIII), Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610017, China
| | - Qian Zhao
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu 610017, China
- Laboratory of Dermatology, Clinical Institute of Inflammation and Immunology (CIII), Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610017, China
- Department of Medical Cosmetology, Chengdu Second People’s Hospital, Chengdu 610056, China
| | - Lihua Yang
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu 610017, China
- Laboratory of Dermatology, Clinical Institute of Inflammation and Immunology (CIII), Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610017, China
| | - Xian Jiang
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu 610017, China
- Laboratory of Dermatology, Clinical Institute of Inflammation and Immunology (CIII), Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610017, China
- Correspondence: ; Tel.: +86-028-8542-3315; Fax: +86-028-8542-2560
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2
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Hovaguimian A. Dysautonomia. Neurol Clin 2022; 41:193-213. [DOI: 10.1016/j.ncl.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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3
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Characterization of Patients With and Without Painful Peripheral Neuropathy After Receiving Neurotoxic Chemotherapy: Traditional Quantitative Sensory Testing vs C-Fiber and Aδ-Fiber Selective Diode Laser Stimulation. THE JOURNAL OF PAIN 2022; 23:796-809. [PMID: 34896646 PMCID: PMC9086082 DOI: 10.1016/j.jpain.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 11/09/2021] [Accepted: 11/12/2021] [Indexed: 11/21/2022]
Abstract
Painful chemotherapy induced peripheral neuropathy (CIPN) is a common complication of chemotherapy with drugs such as taxanes and platinum compounds. Currently, no methods are available for early detection of sensory changes that are associated with painful CIPN, nor are there biomarkers that are specific to painful CIPN. This study aimed to compare Diode Laser fiber type-selective stimulator (DLss), a method to selectively stimulate cutaneous C and Aδ fibers, to traditional quantitative sensory testing (QST) in determining psychophysical differences between patients with painful CIPN and a control group. Sensory testing was performed on the dorsal mid-foot of 20 patients with painful neuropathy after taxane- or platinum-based chemotherapy, and 20 patients who received similar neurotoxic chemotherapy, without painful CIPN. In a multivariable analysis, C-fiber to Aδ fiber detection threshold ratio, measured by DLss, was significantly different between the groups (P <.05). While QST parameters such as warmth detection threshold were different between the groups in univariate analyses, these findings were likely attributable to group differences in patient age and cumulative chemotherapy dose. PERSPECTIVE: In this study, fiber-specific DLss test showed potential in identifying sensory changes that are specific for painful neuropathy, encouraging future testing of this approach as a biomarker for early detection of painful CIPN. TRIAL REGISTRATION: The study was approved by the Washington University Institutional Review Board (#201807162) and registered at ClinicalTrials.gov (NCT03687970).
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4
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Bailleux S, Collins P, Nikkels AF. The Relevance of Skin Biopsies in General Internal Medicine: Facts and Myths. Dermatol Ther (Heidelb) 2022; 12:1103-1119. [PMID: 35430724 PMCID: PMC9110592 DOI: 10.1007/s13555-022-00717-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Non-dermatology medical specialties may refer patients for skin biopsies, searching for a particular diagnosis. However, the diagnostic impact of the skin biopsy is not clearly established. This article aims to assess the indications for, and evaluate the clinical relevance of, skin biopsies in non-dermatology medical specialties. Methods A questionnaire was sent to 23 non-dermatology specialty departments in a university medical center, requesting a list of indications for skin biopsies, as well as to 10 staff dermatologists to collect the indications of skin biopsies requested by non-dermatology specialties. Once the indications were collected, a literature search was performed to evaluate their clinical value and relevance. Results Eleven non-dermatology specialties provided a list of skin biopsy indications, to which staff dermatologists added seven more indications. A literature search revealed evidence-based medicine data for six diseases, that is, amyloidosis, peripheral autonomic neuropathy, Sneddon’s syndrome, intravascular lymphoma, sarcoidosis, and chronic graft-versus-host disease. Results were questionable concerning infectious endocarditis, acute graft-versus-host-disease, and the lupus band test. Skin biopsy were not evidenced as useful for the diagnosis of calciphylaxis, systemic scleroderma, Behçet’s disease, or hypermobile Ehlers–Danlos syndrome. For the diagnosis of Alport’s syndrome, pseudoxanthoma elasticum, and vascular Ehlers–Danlos syndrome, skin biopsy is currently outperformed by genetic analyses. For diagnoses such as Henoch–Schönlein purpura and Sjögren’s syndrome, skin biopsy represents an additional item among other diagnostic criteria. Conclusion The usefulness of skin biopsy as requested by non-dermatology specialties is only evidenced for amyloidosis, peripheral autonomic neuropathy, Sneddon’s syndrome, intravascular lymphoma, sarcoidosis, chronic graft-versus-host-disease, Henoch–Schönlein purpura, and Sjögren’s syndrome.
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Affiliation(s)
- Sophie Bailleux
- Department of Dermatology, University Hospital Centre, CHU du Sart Tilman, University of Liège, 4000, Liège, Belgium
| | - Patrick Collins
- Department of Dermatopathology, University Hospital Centre, CHU du Sart Tilman, Liège, Belgium
| | - Arjen F Nikkels
- Department of Dermatology, University Hospital Centre, CHU du Sart Tilman, University of Liège, 4000, Liège, Belgium.
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Eldridge SA, Mortazavi F, Rice FL, Ketten DR, Wiley DN, Lyman E, Reidenberg JS, Hanke FD, DeVreese S, Strobel SM, Rosene DL. Specializations of somatosensory innervation in the skin of humpback whales (Megaptera novaeangliae). Anat Rec (Hoboken) 2022; 305:514-534. [PMID: 35023618 DOI: 10.1002/ar.24856] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 11/12/2022]
Abstract
Cetacean behavior and life history imply a role for somatosensory detection of critical signals unique to their marine environment. As the sensory anatomy of cetacean glabrous skin has not been fully explored, skin biopsy samples of the flank skin of humpback whales were prepared for general histological and immunohistochemical (IHC) analyses of innervation in this study. Histology revealed an exceptionally thick epidermis interdigitated by numerous, closely spaced long, thin diameter penicillate dermal papillae (PDP). The dermis had a stratified organization including a deep neural plexus (DNP) stratum intermingled with small arteries that was the source of intermingled nerves and arterioles forming a more superficial subepidermal neural plexus (SNP) stratum. The patterns of nerves branching through the DNP and SNP that distribute extensive innervation to arteries and arterioles and to the upper dermis and PDP provide a dense innervation associated through the whole epidermis. Some NF-H+ fibers terminated at the base of the epidermis and as encapsulated endings in dermal papillae similar to Merkel innervation and encapsulated endings seen in terrestrial mammals. However, unlike in all mammalian species assessed to date, an unusual acellular gap was present between the perineural sheaths and the central core of axons in all the cutaneous nerves perhaps as mechanism to prevent high hydrostatic pressure from compressing and interfering with axonal conductance. Altogether the whale skin has an exceptionally dense low-threshold mechanosensory system innervation most likely adapted for sensing hydrodynamic stimuli, as well as nerves that can likely withstand high pressure experienced during deep dives.
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Affiliation(s)
- Sherri A Eldridge
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts, USA.,Biology Department, University of Massachusetts Dartmouth, Dartmouth, Massachusetts, USA
| | - Farzad Mortazavi
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Frank L Rice
- Integrated Tissue Dynamics, Rensselaer, New York, USA
| | - Darlene R Ketten
- Woods Hole Oceanographic Institution, Woods Hole, Massachusetts, USA
| | - David N Wiley
- National Oceanic and Atmospheric Administration/ National Ocean Service/Stellwagen Bank National Marine Sanctuary, Scituate, Massachusetts, USA
| | - Ed Lyman
- Hawaiian Islands Humpback Whale National Marine Sanctuary, Kihei, Hawaii, USA
| | - Joy S Reidenberg
- Center for Anatomy and Functional Morphology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Frederike D Hanke
- University of Rostock, Institute for Biosciences, Neuroethology, Rostock, Germany
| | - Steffen DeVreese
- Department of Comparative Biomedicine and Food Science, University of Padova, Padova, Italy.,Laboratory of Applied Bioacoustics, Technical University of Catalonia, BarcelonaTech, Barcelona, Spain
| | - Sarah McKay Strobel
- Department of Ecology and Evolutionary Biology, University of California Santa Cruz, Santa Cruz, California, USA
| | - Douglas L Rosene
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts, USA
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Motataianu A, Barcutean L, Bajko Z, Stoian A, Maier S, Voidazan S, Balasa R. Autonomic and Somatic Nerve Functions in Type 2 Diabetes Mellitus Patients: Electrophysiological Aspects. Diagnostics (Basel) 2021; 11:diagnostics11112005. [PMID: 34829352 PMCID: PMC8621884 DOI: 10.3390/diagnostics11112005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/25/2021] [Accepted: 10/25/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives: To investigate the relationship between neurophysiological sensory and motor nerve function parameters, assessed by nerve conduction studies (NCS) with parasympathetic autonomic function and by heart rate variability (HRV) tests in patients with type 2 diabetes mellitus (T2DM). Material and Methods: A total of 161 T2DM patients underwent NCS. Cardiac autonomic response was assessed by HRV tests to deep breathing (HRV DB), to Valsalva manoeuvre, and during postural change from lying to standing. Results: The amplitude of motor response in the median nerve, tibial nerve, and peroneal nerve was associated with reduced HRV DB (p = 0.0001). The amplitude of motor response in the median nerve, tibial nerve, and peroneal nerve was associated with reduced HRV Valsalva (p = 0.0001). The correlation between the amplitude of response in all sensory nerves (sural, median, and ulnar) and HRV DB was statistically significant (p = 0.0001). Conclusion: The results indicate that there is a correlation in T2DM patients between the damage of small myelinated and unmyelinated nerve fibres from cardiac autonomic nerves, assessed by HRV tests and damage of large motor and sensory fibres, assessed by NCS. Based on the above results, a combination of NCS and HRV tests should be considered in the neurophysiological approach to diabetic neuropathy.
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Affiliation(s)
- Anca Motataianu
- Neurology 1 Clinic, Emergency Clinical County Hospital Mureș, Gh. Marinescu Str., No. 50, 540136 Târgu Mureș, Romania; (A.M.); (Z.B.); (A.S.); (S.M.); (R.B.)
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, Gh. Marinescu Str., No. 38, 540139 Târgu Mureș, Romania
| | - Laura Barcutean
- Neurology 1 Clinic, Emergency Clinical County Hospital Mureș, Gh. Marinescu Str., No. 50, 540136 Târgu Mureș, Romania; (A.M.); (Z.B.); (A.S.); (S.M.); (R.B.)
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, Gh. Marinescu Str., No. 38, 540139 Târgu Mureș, Romania
- Correspondence: ; Tel.: +40-7453-73947
| | - Zoltan Bajko
- Neurology 1 Clinic, Emergency Clinical County Hospital Mureș, Gh. Marinescu Str., No. 50, 540136 Târgu Mureș, Romania; (A.M.); (Z.B.); (A.S.); (S.M.); (R.B.)
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, Gh. Marinescu Str., No. 38, 540139 Târgu Mureș, Romania
| | - Adina Stoian
- Neurology 1 Clinic, Emergency Clinical County Hospital Mureș, Gh. Marinescu Str., No. 50, 540136 Târgu Mureș, Romania; (A.M.); (Z.B.); (A.S.); (S.M.); (R.B.)
- Department of Pathophysiology, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, Gh. Marinescu Str., No. 38, 540139 Târgu Mureș, Romania
| | - Smaranda Maier
- Neurology 1 Clinic, Emergency Clinical County Hospital Mureș, Gh. Marinescu Str., No. 50, 540136 Târgu Mureș, Romania; (A.M.); (Z.B.); (A.S.); (S.M.); (R.B.)
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, Gh. Marinescu Str., No. 38, 540139 Târgu Mureș, Romania
| | - Septimiu Voidazan
- Department of Epidemiology, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, Gh. Marinescu Str., No. 38, 540139 Târgu Mureș, Romania;
| | - Rodica Balasa
- Neurology 1 Clinic, Emergency Clinical County Hospital Mureș, Gh. Marinescu Str., No. 50, 540136 Târgu Mureș, Romania; (A.M.); (Z.B.); (A.S.); (S.M.); (R.B.)
- Department of Neurology, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, Gh. Marinescu Str., No. 38, 540139 Târgu Mureș, Romania
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Drechsel TJ, Monteiro RL, Zippenfennig C, Ferreira JSSP, Milani TL, Sacco ICN. Low and High Frequency Vibration Perception Thresholds Can Improve the Diagnosis of Diabetic Neuropathy. J Clin Med 2021; 10:3073. [PMID: 34300239 PMCID: PMC8304943 DOI: 10.3390/jcm10143073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 12/20/2022] Open
Abstract
Recent studies demonstrate neuropathic changes with respect to vibration sensitivity for different measurement frequencies. This study investigates the relationship between vibration perception thresholds (VPTs) at low and high frequencies at two plantar locations and diabetic peripheral neuropathy (DPN) severity in diabetes mellitus (DM) subjects with DPN. We examine differences of VPTs between participants with DM, with DPN, as well as healthy controls. The influence of anthropometric, demographic parameters, and DM duration on VPTs is studied. Thirty-three healthy control group subjects (CG: 56.3 ± 9.9 years) and 33 with DM are studied. DM participants are subdivided into DM group (DM without DPN, n = 20, 53.3 ± 15.1 years), and DPN group (DM with DPN, n = 13, 61.0 ± 14.5 years). VPTs are measured at the first metatarsal head (MTH1) and heel (30 Hz, 200 Hz), using a customized vibration exciter. Spearman and Pearson correlations are used to identify relationships between VPTs and clinical parameters. ANOVAs are calculated to compare VPTs among groups. Significant correlations are observed between DPN severity (by fuzzy scores) and VPTs at both locations and frequencies (MTH1_30 Hz vs. fuzzy: r = 0.68, p = 0.011; Heel_30 Hz vs. fuzzy: r = 0.66, p = 0.014; MTH1_200 Hz vs. fuzzy: r = 0.73, p = 0.005; Heel_200 Hz vs. fuzzy: r = 0.60, p = 0.032). VPTs in CG and DM groups are significantly smaller than the DPN group, showing higher contrasts for the 30 Hz compared to the 200 Hz measurement. The correlations between fuzzy scores and VPTs confirm the relevance of using low and high frequencies to assess a comprehensive foot sensitivity status in people with DM.
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Affiliation(s)
- Tina J. Drechsel
- Department of Human Locomotion, Faculty of Behavioral and Social Sciences, Institute of Human Movement Science and Health, Chemnitz University of Technology, 09107 Chemnitz, Germany; (C.Z.); (T.L.M.)
| | - Renan L. Monteiro
- Department of Physical Therapy, Speech, and Occupational Therapy, Faculdade de Medicina, Universdade de São Paulo, São Paulo 05360-160, Brazil; (R.L.M.); (J.S.S.P.F.); (I.C.N.S.)
| | - Claudio Zippenfennig
- Department of Human Locomotion, Faculty of Behavioral and Social Sciences, Institute of Human Movement Science and Health, Chemnitz University of Technology, 09107 Chemnitz, Germany; (C.Z.); (T.L.M.)
| | - Jane S. S. P. Ferreira
- Department of Physical Therapy, Speech, and Occupational Therapy, Faculdade de Medicina, Universdade de São Paulo, São Paulo 05360-160, Brazil; (R.L.M.); (J.S.S.P.F.); (I.C.N.S.)
| | - Thomas L. Milani
- Department of Human Locomotion, Faculty of Behavioral and Social Sciences, Institute of Human Movement Science and Health, Chemnitz University of Technology, 09107 Chemnitz, Germany; (C.Z.); (T.L.M.)
| | - Isabel C. N. Sacco
- Department of Physical Therapy, Speech, and Occupational Therapy, Faculdade de Medicina, Universdade de São Paulo, São Paulo 05360-160, Brazil; (R.L.M.); (J.S.S.P.F.); (I.C.N.S.)
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Peng Y, Liu YS, Wu MY, Chen CN, Li CQ, Jiang AQ, Li CX, Wang Y, Tian G, Pan SY, Xu LL. Evaluation of the Degree of Agreement of Four Methods for Diagnosing Diabetic Autonomic Neuropathy. Front Neurol 2021; 12:637099. [PMID: 34113304 PMCID: PMC8185195 DOI: 10.3389/fneur.2021.637099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/07/2021] [Indexed: 11/17/2022] Open
Abstract
Background: There are many methods to diagnose diabetic autonomic neuropathy (DAN); however, often, the various methods do not provide consistent results. Even the two methods recommended by the American Diabetes Association (ADA) guidelines, Ewing's test and heart rate variability (HRV), sometimes give conflicting results. The purpose of this study was to evaluate the degree of agreement of the results of the Composite Autonomic Symptom Score 31 (COMPASS-31), skin sympathetic reaction (SSR) test, Ewing's test, and HRV in diagnosing DAN. Methods: Patients with type 2 diabetes were recruited and each received the COMPASS-31, SSR, Ewing's test, and HRV for the diagnosis of DAN. Patients were categorized as DAN(+) and DAN(–) by each of the tests. Kappa consistency tests were used to evaluate the agreement of diagnosing DAN between any two methods. Spearman's correlation test was used to evaluate the correlations of the severity of DAN between any two methods. Receiver operating characteristic (ROC) analyses were used to evaluate the diagnostic value and the cutoff value of each method. Results: A total of 126 type 2 diabetic patients were included in the study. The percentages of DAN(+) results by HRV, Ewing's test, COMPASS-31, and SSR were 61, 40, 35, and 33%, respectively. COMPASS-31 and Ewing's test had the best agreement for diagnosing DAN (κ = 0.512, p < 0.001). COMPASS-31 and Ewing's test also had the best correlation with respect to the severity of DAN (r = 0.587, p < 0.001). Ewing's test and COMPASS-31 had relatively good diagnostic values (AUC = 0.703 and 0.630, respectively) in the ROC analyses. Conclusions: COMPASS-31 and Ewing's test exhibit good diagnostic consistency and severity correlation for the diagnosis of DAN. Either test is suitable for the diagnosis of DAN and treatment follow-up.
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Affiliation(s)
- Yu Peng
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ying-Shan Liu
- Department of Endocrinology, Shenzhen Hospital, Southern Medical University, Guangzhou, China.,The Third School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Min-Yi Wu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chu-Na Chen
- Department of Endocrinology, Shenzhen Hospital, Southern Medical University, Guangzhou, China.,The Third School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Chu-Qiao Li
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - An-Qi Jiang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chong-Xin Li
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yao Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ge Tian
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Su-Yue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ling-Ling Xu
- Department of Endocrinology, Shenzhen Hospital, Southern Medical University, Guangzhou, China.,The Third School of Clinical Medicine, Southern Medical University, Guangzhou, China
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9
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Marcinkevics Z, Aglinska A, Rubins U, Grabovskis A. Remote Photoplethysmography for Evaluation of Cutaneous Sensory Nerve Fiber Function. SENSORS 2021; 21:s21041272. [PMID: 33670087 PMCID: PMC7916836 DOI: 10.3390/s21041272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/06/2021] [Accepted: 02/08/2021] [Indexed: 11/23/2022]
Abstract
About 2% of the world’s population suffers from small nerve fiber dysfunction, neuropathy, which can result in severe pain. This condition is caused by damage to the small nerve fibers and its assessment is challenging, due to the lack of simple and objective diagnostic techniques. The present study aimed to develop a contactless photoplethysmography system using simple instrumentation, for objective and non-invasive assessment of small cutaneous sensory nerve fiber function. The approach is based on the use of contactless photoplethysmography for the characterization of skin flowmotions and topical heating evoked vasomotor responses. The feasibility of the technique was evaluated on volunteers (n = 14) using skin topical anesthesia, which is able to produce temporary alterations of cutaneous nerve fibers function. In the treated skin region in comparison to intact skin: neurogenic and endothelial component of flowmotions decreased by ~61% and 41%, the local heating evoked flare area decreased by ~44%, vasomotor response trend peak and nadir were substantially reduced. The results indicate for the potential of the remote photoplethysmography in the assessment of the cutaneous nerve fiber function. It is believed that in the future this technique could be used in the clinics as an affordable alternative to laser Doppler imaging technique.
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Affiliation(s)
- Zbignevs Marcinkevics
- Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, Jelgavas St.1, LV-1004 Riga, Latvia
- Biophotonics Laboratory, Institute of Atomic Physics and Spectroscopy, University of Latvia, Jelgavas St. 3, LV-1004 Riga, Latvia; (A.A.); (U.R.); (A.G.)
- Correspondence:
| | - Alise Aglinska
- Biophotonics Laboratory, Institute of Atomic Physics and Spectroscopy, University of Latvia, Jelgavas St. 3, LV-1004 Riga, Latvia; (A.A.); (U.R.); (A.G.)
| | - Uldis Rubins
- Biophotonics Laboratory, Institute of Atomic Physics and Spectroscopy, University of Latvia, Jelgavas St. 3, LV-1004 Riga, Latvia; (A.A.); (U.R.); (A.G.)
| | - Andris Grabovskis
- Biophotonics Laboratory, Institute of Atomic Physics and Spectroscopy, University of Latvia, Jelgavas St. 3, LV-1004 Riga, Latvia; (A.A.); (U.R.); (A.G.)
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10
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Early Detection of Diabetic Peripheral Neuropathy: A Focus on Small Nerve Fibres. Diagnostics (Basel) 2021; 11:diagnostics11020165. [PMID: 33498918 PMCID: PMC7911433 DOI: 10.3390/diagnostics11020165] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/14/2021] [Accepted: 01/20/2021] [Indexed: 02/07/2023] Open
Abstract
Diabetic peripheral neuropathy (DPN) is the most common complication of both type 1 and 2 diabetes. As a result, neuropathic pain, diabetic foot ulcers and lower-limb amputations impact drastically on quality of life, contributing to the individual, societal, financial and healthcare burden of diabetes. DPN is diagnosed at a late, often pre-ulcerative stage due to a lack of early systematic screening and the endorsement of monofilament testing which identifies advanced neuropathy only. Compared to the success of the diabetic eye and kidney screening programmes there is clearly an unmet need for an objective reliable biomarker for the detection of early DPN. This article critically appraises research and clinical methods for the diagnosis or screening of early DPN. In brief, functional measures are subjective and are difficult to implement due to technical complexity. Moreover, skin biopsy is invasive, expensive and lacks diagnostic laboratory capacity. Indeed, point-of-care nerve conduction tests are convenient and easy to implement however questions are raised regarding their suitability for use in screening due to the lack of small nerve fibre evaluation. Corneal confocal microscopy (CCM) is a rapid, non-invasive, and reproducible technique to quantify small nerve fibre damage and repair which can be conducted alongside retinopathy screening. CCM identifies early sub-clinical DPN, predicts the development and allows staging of DPN severity. Automated quantification of CCM with AI has enabled enhanced unbiased quantification of small nerve fibres and potentially early diagnosis of DPN. Improved screening tools will prevent and reduce the burden of foot ulceration and amputations with the primary aim of reducing the prevalence of this common microvascular complication.
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Abstract
PURPOSE OF REVIEW This article reviews disorders of sweating, including hyperhidrosis and anhidrosis due to central or peripheral autonomic nervous system causes. RECENT FINDINGS Disorders of thermoregulation and sweating may manifest with hyperhidrosis or hypohidrosis/anhidrosis. Primary disorders of hyperhidrosis may significantly impact quality of life yet tend to be benign. Many sweating disorders present with compensatory hyperhidrosis due to areas of anhidrosis. Anhidrosis may occur due to either central or peripheral damage to the autonomic nervous system. The thermoregulatory control of sweating involves central pathways from the hypothalamus to the brainstem and then spinal cord as well as projections to peripheral structures, including the sympathetic chain ganglia, peripheral nerves, and eccrine sweat glands. Disruption at any point of this pathway may lead to impaired sweating. Characterization of sweating dysfunction helps localize different autonomic disorders to guide diagnosis and may allow for evaluation of treatment effect. SUMMARY Sweating dysfunction manifests in myriad ways, including essential hyperhidrosis, complete anhidrosis with heat intolerance, and compensatory hyperhidrosis due to anhidrosis, and often indicates involvement of underlying central or peripheral autonomic dysfunction.
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Hu A, Koh B, Teo MR. A review of the current evidence on the sensitivity and specificity of the Ipswich touch test for the screening of loss of protective sensation in patients with diabetes mellitus. Diabetol Int 2020; 12:145-150. [PMID: 33786269 DOI: 10.1007/s13340-020-00451-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/25/2020] [Indexed: 10/24/2022]
Abstract
Aims To evaluate the sensitivity and specificity of the Ipswich touch test for the screening of loss of protective sensation in patients with diabetes mellitus based on the current literature. Methods Three electronic databases were searched for eligible studies that investigated the sensitivity and specificity of the Ipswich touch test. Methodological quality was assessed using the QUADAS-2 tool. Results Five studies that reported the sensitivity and specificity of the Ipswich touch test were included. When compared to the 10 g monofilament, the sensitivity ranges from 51 to 83.3% and the specificity ranges from 96.4 to 98%. When compared to the vibration perception test ≥25 V, Ipswich touch test sensitivity ranges from 76 to 100% and specificity ranges from 90 to 96.6%. Conclusions The Ipswich touch test has a high specificity in screening for loss of protective sensation in the feet of patients with diabetes mellitus. It is a useful test to be included in diabetic foot screenings, especially when other sensory tools are not available. However, more rigorous studies need to be conducted as there is currently only a limited pool of research evidence to substantiate it as a screening tool for loss of protective sensation in the diabetic foot.
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Affiliation(s)
- Arnold Hu
- Podiatry Department, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606 Singapore
| | - Beatrice Koh
- Podiatry Department, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606 Singapore
| | - Melissa-Raye Teo
- Podiatry Department, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606 Singapore
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Is postural tachycardia syndrome an autoimmune disorder? And other updates on recent autonomic research. Clin Auton Res 2020; 30:3-5. [PMID: 31938977 DOI: 10.1007/s10286-019-00661-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 12/26/2019] [Indexed: 10/25/2022]
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Intraepidermal Nerve Fiber Density in Postmortem Skin: A Novel Approach. J Clin Neuromuscul Dis 2019; 21:69-76. [PMID: 31743249 DOI: 10.1097/cnd.0000000000000264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the feasibility of examining intraepidermal nerve fiber density (IENFD) in postmortem skin. METHODS From 12 subjects, 3-mm skin punch biopsies were collected 1-4 days postmortem from the proximal leg and distal leg, with a mean (range) interval from the death of 37 (15-91) hours. Causes of death varied broadly, including hepatocellular carcinoma, chronic lymphocytic leukemia, generalized atherosclerosis, progressive supranuclear palsy, Parkinson disease, emphysema, and obesity. The mean (range) number of sections evaluated from each biopsy was 5.08 (2-6) from the proximal leg and 5.92 (5-6) from the distal leg. Sections were stained with PGP 9.5 for blinded counting using bright field microscopy. Qualitative and quantitative assessment of feasibility included a comparison of fiber staining with that in healthy subjects and mean IENFD in postmortem samples. Interobserver reliability was assessed among 3 blinded raters by calculating intraclass correlation coefficients and percentage variability of IENFD in at least 4 sections from biopsies in 5 healthy subjects. RESULTS Intraobserver and interobserver correlation coefficients of blinded IENFD counts undertaken by 4 authors were consistently >0.80, and the coefficient of variation was ≤10%. The quality of staining in postmortem samples was comparable with that in healthy subjects and was not substantially affected by time from death to specimen collection of up to nearly 4 days. Mean (range) IENFD from postmortem samples in the proximal and distal leg was 2.73 (0-7.65) and 1.93 (0-4.91) fibers/mm of skin, respectively. Two of 3 patients who had received chemotherapy during life showed a nearly complete absence of intraepidermal nerve fibers. CONCLUSIONS IENFD measurement in postmortem skin is feasible and may be used to study the epidemiology of SFN.
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C-Fiber Assays in the Cornea vs. Skin. Brain Sci 2019; 9:brainsci9110320. [PMID: 31718074 PMCID: PMC6896162 DOI: 10.3390/brainsci9110320] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/07/2019] [Accepted: 11/08/2019] [Indexed: 12/11/2022] Open
Abstract
C-fibers are unmyelinated nerve fibers that transmit high threshold mechanical, thermal, and chemical signals that are associated with pain sensations. This review examines current literature on measuring altered peripheral nerve morphology and discusses the most relevant aspects of corneal microscopy, especially whether corneal imaging presents significant method advantages over skin biopsy. Given its relative merits, corneal confocal microscopy would seem to be a more practical and patient-centric approach than utilizing skin biopsies.
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Bolon B, Krinke GJ, Pardo ID. Essential References for Structural Analysis of the Peripheral Nervous System for Pathologists and Toxicologists. Toxicol Pathol 2019; 48:87-95. [DOI: 10.1177/0192623319868160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Toxicologic neuropathology for the peripheral nervous system (PNS) is a vital but often underappreciated element of basic translational research and safety assessment. Evaluation of the PNS may be complicated by unfamiliarity with normal nerve and ganglion biology, which differs to some degree among species; the presence of confounding artifacts related to suboptimal sampling and processing; and limited experience with differentiating such artifacts from genuine disease manifestations and incidental background changes. This compilation of key PNS neurobiology, neuropathology, and neurotoxicology references is designed to allow pathologists and toxicologists to readily access essential information that is needed to enhance their proficiency in evaluating and interpreting toxic changes in PNS tissues from many species.
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Mangus LM, Rao DB, Ebenezer GJ. Intraepidermal Nerve Fiber Analysis in Human Patients and Animal Models of Peripheral Neuropathy: A Comparative Review. Toxicol Pathol 2019; 48:59-70. [PMID: 31221022 DOI: 10.1177/0192623319855969] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Analysis of intraepidermal nerve fibers (IENFs) in skin biopsy samples has become a standard clinical tool for diagnosing peripheral neuropathies in human patients. Compared to sural nerve biopsy, skin biopsy is safer, less invasive, and can be performed repeatedly to facilitate longitudinal assessment. Intraepidermal nerve fiber analysis is also more sensitive than conventional nerve histology or electrophysiological tests for detecting damage to small-diameter sensory nerve fibers. The techniques used for IENF analysis in humans have been adapted for large and small animal models and successfully used in studies of diabetic neuropathy, chemotherapy-induced peripheral neuropathy, HIV-associated sensory neuropathy, among others. Although IENF analysis has yet to become a routine end point in nonclinical safety testing, it has the potential to serve as a highly relevant indicator of sensory nerve fiber status in neurotoxicity studies, as well as development of neuroprotective and neuroregenerative therapies. Recently, there is also interest in the evaluation of IENF via skin biopsy as a biomarker of small fiber neuropathy in the regulatory setting. This article provides an overview of the anatomic and pathophysiologic principles behind IENF analysis, its use as a diagnostic tool in humans, and applications in animal models with focus on comparative methodology and considerations for study design.
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Affiliation(s)
- Lisa M Mangus
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University, Baltimore, MD, USA.,Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Deepa B Rao
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, MD, USA
| | - Gigi J Ebenezer
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
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Kaewjiaranai T, Srisatjaluk RL, Sakdajeyont W, Pairuchvej V, Wongsirichat N. The efficiency of topical anesthetics as antimicrobial agents: A review of use in dentistry. J Dent Anesth Pain Med 2018; 18:223-233. [PMID: 30186969 PMCID: PMC6115368 DOI: 10.17245/jdapm.2018.18.4.223] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/18/2018] [Accepted: 08/22/2018] [Indexed: 01/04/2023] Open
Abstract
Topical anesthetics are commonly used in oral & maxillofacial surgery to control pain in the oral cavity mucosa before local anesthetic injection. These anesthetic agents come in many forms, developed for different usages, to minimize adverse reactions, and for optimal anesthetic efficiency. Earlier studies have revealed that these agents may also limit the growth of microorganisms in the area of anesthetic application. Many topical anesthetic agents show different levels of antimicrobial activity against various bacterial strains and Candida. The dosage of local anesthetic agent used in some clinical preparations is too low to show a significant effect on microbial activity. Efficiency of antimicrobial activity depends on the local anesthetic agent's properties of diffusion within the bloodstream and binding efficiency with cytoplasmic membrane, which is followed by disruption of the bacterial cell membrane. The antimicrobial properties of these agents may extend their usage in patients to both control pain and infection. To develop the topical local anesthetic optimal usage and antimicrobial effect, a collaborating antiseptic agent may be used to benefit the local anesthetic. However, more research is required regarding minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of topical local anesthetic agents with drug interaction between anesthetics and antiseptic agents.
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Affiliation(s)
- Thanawat Kaewjiaranai
- Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | | | - Watus Sakdajeyont
- Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | - Verasak Pairuchvej
- Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | - Natthamet Wongsirichat
- Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
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Mawuntu AH, Mahama CN, Khosama H, Estiasari R, Imran D. Early detection of peripheral neuropathy using stimulated skin wrinkling test in human immunodeficiency virus infected patients: A cross-sectional study. Medicine (Baltimore) 2018; 97:e11526. [PMID: 30045275 PMCID: PMC6078746 DOI: 10.1097/md.0000000000011526] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Peripheral neuropathy is a common condition of human immunodeficiency virus (HIV)-infected patients, which often remains undetected. We assessed the performance of stimulated skin wrinkling-eutectic mixture of local anesthetic (SSW-EMLA) test compared with brief peripheral neuropathy screening (BPNS) to detect HIV neuropathy.This is a cross-sectional study conducted in HIV-positive patients. A modified skin wrinkling grading was used to assess SSW-EMLA effect. BPNS-detectable neuropathy was assessed by a combination of neuropathy severity scoring scale (subjective) and objective method of sensory and tendon reflex examination. The SSW-EMLA test accuracy with reference to BPNS was assessed using sensitivity and specificity and predictive values.In a total of 99 HIV patients, 61.6% were males and the majority age group were between 30 and 40 years (52%). The neuropathy detection was SSW-EMLA test 36.4% versus BPNS 15.2% (P = .04). The sensitivity of SSW-EMLA test was 60.0% [95% confidence interval (95% CI) 34.5-81.7], specificity 67% (95% CI 63.3-3-71.7), and overall accuracy of 66.7% (95% CI 58.9-73.2).The SSW-EMLA test detected many more peripheral neuropathy cases than BPNS in HIV patients and has potential as an alternative test for screening for HIV neuropathy in resource-constraint hospitals in Indonesia.
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Affiliation(s)
- Arthur H.P. Mawuntu
- Neurology Department Faculty of Medicine Sam Ratulangi University/R.D. Kandou Hospital, North Sulawesi
| | - Corry N. Mahama
- Neurology Department Faculty of Medicine Sam Ratulangi University/R.D. Kandou Hospital, North Sulawesi
| | - Herlyani Khosama
- Neurology Department Faculty of Medicine Sam Ratulangi University/R.D. Kandou Hospital, North Sulawesi
| | - Riwanti Estiasari
- Neurology Department, Faculty of Medicine, Universitas Indonesia/Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Darma Imran
- Neurology Department, Faculty of Medicine, Universitas Indonesia/Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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Histologic and Clinical Changes in Vulvovaginal Tissue After Treatment With a Transcutaneous Temperature-Controlled Radiofrequency Device. Dermatol Surg 2018; 44:705-713. [PMID: 29701623 DOI: 10.1097/dss.0000000000001453] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although transcutaneous temperature-controlled radiofrequency (TTCRF) may effectively treat vulvovaginal laxity (VVL), atrophic vaginitis (AV), orgasmic dysfunction (OD), and stress urinary incontinence (SUI), there is a lack of histopathologic evidence to validate its use. OBJECTIVE Evaluate clinical and histological changes induced by vulvovaginal TTCRF. MATERIALS AND METHODS This was a prospective, nonrandomized trial. Ten female subjects with mild-to-moderate VVL, with or without AV, OD, and/or SUI underwent 3 TTCRFs at 4-week intervals. Five subjects underwent pre- and post-treatment biopsies of the labia majora and vaginal canal for histology. Assessments were performed at baseline and Days 10, 30, 60, and 120. RESULTS Investigator-rated VVL improved significantly from baseline to Day 10, with improvement maintained through Day 120 (p = .001 and .001, respectively). Sexual satisfaction improved significantly by Day 60 (p = .001). Improvement in AV reached significance at Day 120 (p = .048). Although OD and SUI improved steadily, the difference in improvement did not reach statistical significance. Histology revealed that post-treatment increases in collagen, elastin, vascularity, and small nerve fibers. CONCLUSION Transcutaneous temperature-controlled RF resulted in significant improvements in AV, VVL, and sexual satisfaction with milder improvements in OD and SUI. Post-treatment histology demonstrated neocollagenesis, neoelastogenesis, neoangiogenesis, and the first reported finding of TTCRF-related neurogenesis.
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Bolon B, Krinke G, Butt MT, Rao DB, Pardo ID, Jortner BS, Garman RH, Jensen K, Andrews-Jones L, Morrison JP, Sharma AK, Thibodeau MS. STP Position Paper: Recommended Best Practices for Sampling, Processing, and Analysis of the Peripheral Nervous System (Nerves and Somatic and Autonomic Ganglia) during Nonclinical Toxicity Studies. Toxicol Pathol 2018; 46:372-402. [DOI: 10.1177/0192623318772484] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Peripheral nervous system (PNS) toxicity is surveyed inconsistently in nonclinical general toxicity studies. These Society of Toxicologic Pathology “best practice” recommendations are designed to ensure consistent, efficient, and effective sampling, processing, and evaluation of PNS tissues for four different situations encountered during nonclinical general toxicity (screening) and dedicated neurotoxicity studies. For toxicity studies where neurotoxicity is unknown or not anticipated (situation 1), PNS evaluation may be limited to one sensorimotor spinal nerve. If somatic PNS neurotoxicity is suspected (situation 2), analysis minimally should include three spinal nerves, multiple dorsal root ganglia, and a trigeminal ganglion. If autonomic PNS neuropathy is suspected (situation 3), parasympathetic and sympathetic ganglia should be assessed. For dedicated neurotoxicity studies where a neurotoxic effect is expected (situation 4), PNS sampling follows the strategy for situations 2 and/or 3, as dictated by functional or other compound/target-specific data. For all situations, bilateral sampling with unilateral processing is acceptable. For situations 1–3, PNS is processed conventionally (immersion in buffered formalin, paraffin embedding, and hematoxylin and eosin staining). For situation 4 (and situations 2 and 3 if resources and timing permit), perfusion fixation with methanol-free fixative is recommended. Where PNS neurotoxicity is suspected or likely, at least one (situations 2 and 3) or two (situation 4) nerve cross sections should be postfixed with glutaraldehyde and osmium before hard plastic resin embedding; soft plastic embedding is not a suitable substitute for hard plastic. Special methods may be used if warranted to further characterize PNS findings. Initial PNS analysis should be informed, not masked (“blinded”). Institutions may adapt these recommendations to fit their specific programmatic requirements but may need to explain in project documentation the rationale for their chosen PNS sampling, processing, and evaluation strategy.
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Affiliation(s)
| | | | - Mark T. Butt
- Tox Path Specialists, LLC, Frederick, Maryland, USA
| | - Deepa B. Rao
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
| | | | - Bernard S. Jortner
- Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - Robert H. Garman
- Consultants in Veterinary Pathology, Inc., Murrysville, Pennsylvania, USA
| | - Karl Jensen
- US Environmental Protection Agency, Research Triangle Park, North Carolina, USA
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Evaluation of the Itchy Patient. CURRENT DERMATOLOGY REPORTS 2018. [DOI: 10.1007/s13671-018-0208-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Al-Kofahi K, Korsten P, Ascoli C, Virupannavar S, Mirsaeidi M, Chang I, Qaqish N, Saketkoo LA, Baughman RP, Sweiss NJ. Management of extrapulmonary sarcoidosis: challenges and solutions. Ther Clin Risk Manag 2016; 12:1623-1634. [PMID: 27853374 PMCID: PMC5106225 DOI: 10.2147/tcrm.s74476] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Sarcoidosis is a chronic multisystem disease of unknown etiology characterized by noncaseating granulomas that most often involves the lungs, but frequently has extrapulmonary manifestations, which might be difficult to treat in individual patients. Objective To review different disease manifestations, focusing on extrapulmonary organ systems, and to provide treatment options for refractory cases. Materials and methods We performed a literature search using Medline and Google Scholar for individual or combined keywords of “sarcoidosis, extrapulmonary, treatment, kidney, neurosarcoidosis, cardiovascular, gastrointestinal, transplantation, musculoskeletal, rheumatology, arthritis, and skin”. Peer-reviewed articles, including review articles, clinical trials, observational trials, and case reports that were published in English were included. References from retrieved articles were also manually searched for relevant articles. Results and conclusion Isolated involvement of a single organ or organ system is rare in sarcoidosis, and thus all patients must be thoroughly evaluated for additional disease manifestations. Cardiac sarcoidosis and neurosarcoidosis may be life-threatening. Clinicians need to assess patients comprehensively using clinical, laboratory, imaging, and histopathological data to recommend competently the best and least toxic treatment option for the individual patient.
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Affiliation(s)
- Khalid Al-Kofahi
- Department of Molecular Biosciences, University of Kansas, Lawrence, KS, USA
| | - Peter Korsten
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Christian Ascoli
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, IL
| | | | - Mehdi Mirsaeidi
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Ian Chang
- Department of Medicine, Michigan State University College of Osteopathic Medicine, East Lansing, MI
| | - Naim Qaqish
- Department of Gastroenterology, Hepatology and Nutrition, University of Buffalo, Buffalo, NY
| | - Lesley A Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Robert P Baughman
- Department of Medicine, University Medical Center of Cincinnati, Cincinnati, OH, USA
| | - Nadera J Sweiss
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, IL; Division of Rheumatology, University of Illinois at Chicago, Chicago, IL
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Won JC, Park TS. Recent Advances in Diagnostic Strategies for Diabetic Peripheral Neuropathy. Endocrinol Metab (Seoul) 2016; 31:230-8. [PMID: 27246283 PMCID: PMC4923406 DOI: 10.3803/enm.2016.31.2.230] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 05/12/2016] [Accepted: 05/16/2016] [Indexed: 12/17/2022] Open
Abstract
Diabetes is an increasing epidemic in Korea, and associated diabetic peripheral neuropathy (DPN) is its most common and disabling complication. DPN has an insidious onset and heterogeneous clinical manifestations, making it difficult to detect high-risk patients of DPN. Early diagnosis is recommended and is the key factor for a better prognosis and preventing diabetic foot ulcers, amputation, or disability. However, diagnostic tests for DPN are not clearly established because of the various pathophysiology developing from the nerve injury to clinical manifestations, differences in mechanisms according to the type of diabetes, comorbidities, and the unclear natural history of DPN. Therefore, DPN remains a challenge for physicians to screen, diagnose, follow up, and evaluate for treatment response. In this review, diagnosing DPN using various methods to assess clinical symptoms and/or signs, sensorineural impairment, and nerve conduction studies will be discussed. Clinicians should rely on established modalities and utilize current available testing as complementary to specific clinical situations.
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Affiliation(s)
- Jong Chul Won
- Department of Internal Medicine, Cardiovascular and Metabolic Disease Center, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea.
| | - Tae Sun Park
- Department of Internal Medicine, Research Institute of Clinical Medicine, Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea
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Morini E, Dietrich P, Salani M, Downs HM, Wojtkiewicz GR, Alli S, Brenner A, Nilbratt M, LeClair JW, Oaklander AL, Slaugenhaupt SA, Dragatsis I. Sensory and autonomic deficits in a new humanized mouse model of familial dysautonomia. Hum Mol Genet 2016; 25:1116-28. [PMID: 26769677 DOI: 10.1093/hmg/ddv634] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 12/30/2015] [Indexed: 01/30/2023] Open
Abstract
Familial dysautonomia (FD) is an autosomal recessive neurodegenerative disease that affects the development and survival of sensory and autonomic neurons. FD is caused by an mRNA splicing mutation in intron 20 of the IKBKAP gene that results in a tissue-specific skipping of exon 20 and a corresponding reduction of the inhibitor of kappaB kinase complex-associated protein (IKAP), also known as Elongator complex protein 1. To date, several promising therapeutic candidates for FD have been identified that target the underlying mRNA splicing defect, and increase functional IKAP protein. Despite these remarkable advances in drug discovery for FD, we lacked a phenotypic mouse model in which we could manipulate IKBKAP mRNA splicing to evaluate potential efficacy. We have, therefore, engineered a new mouse model that, for the first time, will permit to evaluate the phenotypic effects of splicing modulators and provide a crucial platform for preclinical testing of new therapies. This new mouse model, TgFD9; Ikbkap(Δ20/flox) was created by introducing the complete human IKBKAP transgene with the major FD splice mutation (TgFD9) into a mouse that expresses extremely low levels of endogenous Ikbkap (Ikbkap(Δ20/flox)). The TgFD9; Ikbkap(Δ20/flox) mouse recapitulates many phenotypic features of the human disease, including reduced growth rate, reduced number of fungiform papillae, spinal abnormalities, and sensory and sympathetic impairments, and recreates the same tissue-specific mis-splicing defect seen in FD patients. This is the first mouse model that can be used to evaluate in vivo the therapeutic effect of increasing IKAP levels by correcting the underlying FD splicing defect.
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Affiliation(s)
| | - Paula Dietrich
- Department of Physiology, The University of Tennessee, Health Science Center, Memphis, TN 38163, USA
| | | | - Heather M Downs
- Nerve Unit, Departments of Neurology and Pathology (Neuropathology) and
| | - Gregory R Wojtkiewicz
- Center for Systems Biology, Massachusetts General Hospital Research Institute and Harvard Medical School, Boston, MA 02114, USA and
| | - Shanta Alli
- Department of Physiology, The University of Tennessee, Health Science Center, Memphis, TN 38163, USA
| | | | | | | | | | | | - Ioannis Dragatsis
- Department of Physiology, The University of Tennessee, Health Science Center, Memphis, TN 38163, USA
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Jin HY, Baek HS, Park TS. Morphologic Changes in Autonomic Nerves in Diabetic Autonomic Neuropathy. Diabetes Metab J 2015; 39:461-7. [PMID: 26706915 PMCID: PMC4696981 DOI: 10.4093/dmj.2015.39.6.461] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 11/25/2015] [Indexed: 12/21/2022] Open
Abstract
Diabetic neuropathy is one of the major complications of diabetes, and it increases morbidity and mortality in patients with both type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). Because the autonomic nervous system, for example, parasympathetic axons, has a diffuse and wide distribution, we do not know the morphological changes that occur in autonomic neural control and their exact mechanisms in diabetic patients with diabetic autonomic neuropathy (DAN). Although the prevalence of sympathetic and parasympathetic neuropathy is similar in T1DM versus T2DM patients, sympathetic nerve function correlates with parasympathetic neuropathy only in T1DM patients. The explanation for these discrepancies might be that parasympathetic nerve function was more severely affected among T2DM patients. As parasympathetic nerve damage seems to be more advanced than sympathetic nerve damage, it might be that parasympathetic neuropathy precedes sympathetic neuropathy in T2DM, which was Ewing's concept. This could be explained by the intrinsic morphologic difference. Therefore, the morphological changes in the sympathetic and parasympathetic nerves of involved organs in T1DM and T2DM patients who have DAN should be evaluated. In this review, evaluation methods for morphological changes in the epidermal nerves of skin, and the intrinsic nerves of the stomach will be discussed.
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Affiliation(s)
- Heung Yong Jin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Research Institute of Clinical Medicine, Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea
| | - Hong Sun Baek
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Research Institute of Clinical Medicine, Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea
| | - Tae Sun Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Research Institute of Clinical Medicine, Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea.
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14th Annual Meeting of the Safety Pharmacology Society: Threading through peripheral and central nervous system presentations. J Pharmacol Toxicol Methods 2015; 75:143-57. [DOI: 10.1016/j.vascn.2015.08.155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 08/19/2015] [Indexed: 01/29/2023]
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Kopishinskaya SV, Gustov AV, Kolchanova TV. [Immunohistochemical examination of skin biopsy specimens with calculation of C fibers in the diagnosis of polyneuropathy]. Arkh Patol 2015; 77:43-49. [PMID: 26027400 DOI: 10.17116/patol201577243-49] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The paper discusses the anatomy of innervation of the skin, the epidermis and dermis in particular, which are related to pain, the markers of skin nerves and cells. It gives data on the diagnosis of fine unmyelinated fibers, by immunohistochemically examining skin biopsy specimens. The paper also describes the morphometry of skin nerves: intraepidermal nerve fibers, dermal nerve fibers, and autonomic nerve fibers. It discusses whether a skin biopsy specimen may be used to diagnose polyneuropathies of different etiology: diabetic, immune, HIV-related, and hereditary ones.
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Affiliation(s)
- S V Kopishinskaya
- Nizhny Novgorod State Medical Academy, Ministry of Health of the Russian Federation
| | - A V Gustov
- Nizhny Novgorod State Medical Academy, Ministry of Health of the Russian Federation
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30
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Karlsson P, Nyengaard JR, Polydefkis M, Jensen TS. Structural and functional assessment of skin nerve fibres in small-fibre pathology. Eur J Pain 2014; 19:1059-70. [PMID: 25546653 DOI: 10.1002/ejp.645] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2014] [Indexed: 01/19/2023]
Abstract
Damage to nociceptor nerve fibres may give rise to peripheral neuropathies, some of which are pain free and some are painful. A hallmark of many peripheral neuropathies is the loss of small nerve fibres in the epidermis, a condition called small-fibre neuropathy (SFN) when it is predominantly the small nerve fibres that are damaged. Historically, SFN has been very difficult to diagnose as clinical examination and nerve conduction studies mainly detect large nerve fibres, and quantitative sensory testing is not sensitive enough to detect small changes in small nerve fibres. However, taking a 3-mm punch skin biopsy from the distal leg and quantification of the nerve fibre density has proven to be a useful method to diagnose SFN. However, the correlation between the nerve fibre loss and other test results varies greatly. Recent studies have shown that it is possible not only to extract information about the nerve fibre density from the biopsies but also to get an estimation of the nerve fibre length density using stereology, quantify sweat gland innervation and detect morphological changes such as axonal swelling, all of which may be additional parameters indicating diseased small fibres relating to symptoms reported by the patients. In this review, we focus on available tests to assess structure and function of the small nerve fibres, and summarize recent advances that have provided new possibilities to more specifically relate structural findings with symptoms and function in patients with SFN.
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Affiliation(s)
- P Karlsson
- Danish Pain Research Center and Stereology & EM Laboratory, Aarhus University Hospital, Denmark.,Stereology and Electron Microscopy Laboratory and Centre for Stochastic Geometry and Advanced Bioimaging, Aarhus University Hospital, Denmark
| | - J R Nyengaard
- Stereology and Electron Microscopy Laboratory and Centre for Stochastic Geometry and Advanced Bioimaging, Aarhus University Hospital, Denmark
| | - M Polydefkis
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - T S Jensen
- Danish Pain Research Center and Stereology & EM Laboratory, Aarhus University Hospital, Denmark.,Department of Neurology, Aarhus University Hospital, Denmark
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31
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Papanas N, Ziegler D. New vistas in the diagnosis of diabetic polyneuropathy. Endocrine 2014; 47:690-8. [PMID: 24839196 DOI: 10.1007/s12020-014-0285-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 05/02/2014] [Indexed: 01/01/2023]
Abstract
New modalities are now available to improve the diagnosis of diabetic polyneuropathy (DPN). The present review discusses the progress achieved in this area. First, the minimal diagnostic criteria have been better clarified. Moreover, there are now new bedside tests available, such as the indicator test Neuropad, NeuroQuick, Ipswich Touch Test (IpTT), Vibratip, NC-stat(®)/DPNCheck™ for automated nerve conduction study (NCS), tactile circumferential discriminator, steel ball-bearing, and SUDOSCAN(®), while more sophisticated modalities include skin biopsy and corneal confocal microscopy (CCM). Some tests can be used as screening tools, including primary care setting (Neuropad, IpTT, Vibratip, automated NCS), while others are more suitable for research, including evaluation of DPN in prospective studies (CCM, skin biopsy). Importantly, there is some evidence of earlier DPN diagnosis with the aid of some tests (Neuropad, skin biopsy, CCM). Further advantages provided by different tests are educational value and self-examination. Thus far, the potential of these tests has not been fully utilised. In particular, they have not been validated against standardised clinical examination scores in terms of predicting foot ulcers and amputations. Hence, it now remains to investigate the potential benefits from the widespread use of these tests for earlier and easier diagnosis of DPN in the everyday clinic.
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Affiliation(s)
- Nikolaos Papanas
- Institute for Clinical Diabetology, German Diabetes Center at Heinrich Heine University, Leibniz Center for Diabetes Research, Auf'm Hennekamp 65, 40225, Düsseldorf, Germany
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Alsunousi S, Marrif HI. Diabetic neuropathy and the sensory apparatus "meissner corpuscle and merkel cells". Front Neuroanat 2014; 8:79. [PMID: 25177276 PMCID: PMC4132297 DOI: 10.3389/fnana.2014.00079] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 07/22/2014] [Indexed: 01/30/2023] Open
Affiliation(s)
- Salma Alsunousi
- Department of Histology, Faculty of Medicine, Benghazi University Benghazi, Libya
| | - Husnia I Marrif
- Department of Pharmaceutical Sciences, Princess Noura University Riyadh, Saudi Arabia
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Kluger N, Fraitag S, Roguedas AM, Misery L. [Normal skin biopsy as a tool for extra-cutaneous disorders]. Ann Dermatol Venereol 2014; 141:192-200. [PMID: 24635953 DOI: 10.1016/j.annder.2014.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 10/28/2013] [Accepted: 01/09/2014] [Indexed: 12/14/2022]
Abstract
Biopsies of apparently healthy skin can contribute to the diagnosis of an internal disorder in a patient or in the detection of a potential disease carrier. Herein, we review those diseases for which dermatologists may be asked to perform a biopsy on normal skin where analysis by optical microscopy, immunofluorescence or electronic microscopy may result in diagnosis of an "internal" disease. Diseases for which biopsies are required for cell cultures (e.g. fibroblasts cultures), clonality testing or chromosomal analysis are not discussed here.
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Affiliation(s)
- N Kluger
- Department of dermatology, venereology and allergology, skin and allergies hospital, Helsinki University Central Hospital, Meilahdentie 2, PO Box 160, 00029 HUS, Finlande.
| | - S Fraitag
- Service d'anatomo-pathologie, hôpital Necker-Enfants-Malades, AP-HP, 149, rue de Sèvres, 75015 Paris, France
| | - A-M Roguedas
- Service de dermatologie, CHU, 2, avenue Foch, 29200 Brest, France
| | - L Misery
- Service de dermatologie, CHU, 2, avenue Foch, 29200 Brest, France
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Buonocore M. Unilateral peripheral neuropathic pain: The role of neurodiagnostic skin biopsy. World J Clin Cases 2014; 2:27-31. [PMID: 24579067 PMCID: PMC3936215 DOI: 10.12998/wjcc.v2.i2.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 12/09/2013] [Accepted: 12/19/2013] [Indexed: 02/05/2023] Open
Abstract
According to the current definition of neuropathic pain (“pain arising as a direct consequence of a lesion or disease affecting the somatosensory system”), the demonstration of a lesion or disease involving the somatosensory system is mandatory for the diagnosis of definite neuropathic pain. Although several methods are currently available for this aim, none is suitable for every type of disease (or lesion). Neurodiagnostic skin biopsy (NSB) is a relatively new technique for the diagnosis of peripheral nerve lesions. It is an objective method, completely independent from the patient’s complaining, based on immunohistochemical staining techniques that allow measurement of the density of the epidermal nerve fibers, currently considered the free nerve endings of small diameter (A-delta and C) afferent fibers. NSB has the important property of being used to investigate the skin, allowing obtaining a diagnosis of small fiber axonal neuropathy of peripheral nerves supplying every body part covered by skin. This feature appears to be very important, particularly in cases of unilateral nerve lesions, because it allows going beyond the possibilities of neurophysiological tests which are available only for a limited number of peripheral nerves. All these characteristics make NSB a precious instrument for the diagnosis of peripheral unilateral neuropathic pain.
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Schmid AB, Nee RJ, Coppieters MW. Reappraising entrapment neuropathies--mechanisms, diagnosis and management. ACTA ACUST UNITED AC 2013; 18:449-57. [PMID: 24008054 DOI: 10.1016/j.math.2013.07.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 07/10/2013] [Accepted: 07/13/2013] [Indexed: 12/13/2022]
Abstract
The diagnosis of entrapment neuropathies can be difficult because symptoms and signs often do not follow textbook descriptions and vary significantly between patients with the same diagnosis. Signs and symptoms which spread outside of the innervation territory of the affected nerve or nerve root are common. This Masterclass provides insight into relevant mechanisms that may account for this extraterritorial spread in patients with entrapment neuropathies, with an emphasis on neuroinflammation at the level of the dorsal root ganglia and spinal cord, as well as changes in subcortical and cortical regions. Furthermore, we describe how clinical tests and technical investigations may identify these mechanisms if interpreted in the context of gain or loss of function. The management of neuropathies also remains challenging. Common treatment strategies such as joint mobilisation, neurodynamic exercises, education, and medications are discussed in terms of their potential to influence certain mechanisms at the site of nerve injury or in the central nervous system. The mechanism-oriented approach for this Masterclass seems warranted given the limitations in the current evidence for the diagnosis and management of entrapment neuropathies.
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Affiliation(s)
- Annina B Schmid
- The University of Queensland, Division of Physiotherapy, School of Health and Rehabilitation Sciences, Brisbane (St Lucia), Australia; University of Oxford, Nuffield Department of Clinical Neurosciences, Oxford, United Kingdom.
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Ton E, Kruize AA. When and how to perform biopsies in a patient with a (suspected) connective tissue disease. Best Pract Res Clin Rheumatol 2013; 27:209-36. [DOI: 10.1016/j.berh.2013.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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