1
|
Adler BL, Chung T, Rowe PC, Aucott J. Dysautonomia following Lyme disease: a key component of post-treatment Lyme disease syndrome? Front Neurol 2024; 15:1344862. [PMID: 38390594 PMCID: PMC10883079 DOI: 10.3389/fneur.2024.1344862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Dysautonomia, or dysfunction of the autonomic nervous system (ANS), may occur following an infectious insult and can result in a variety of debilitating, widespread, and often poorly recognized symptoms. Dysautonomia is now widely accepted as a complication of COVID-19 and is an important component of Post-Acute Sequelae of COVID-19 (PASC or long COVID). PASC shares many overlapping clinical features with other infection-associated chronic illnesses including Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) and Post-Treatment Lyme Disease Syndrome (PTLDS), suggesting that they may share common underlying mechanisms including autonomic dysfunction. Despite the recognition of this complication of Lyme disease in the care of patients with PTLD, there has been a scarcity of research in this field and dysautonomia has not yet been established as a complication of Lyme disease in the medical literature. In this review, we discuss the evidence implicating Borrelia burgdorferi as a cause of dysautonomia and the related symptoms, propose potential pathogenic mechanisms given our knowledge of Lyme disease and mechanisms of PASC and ME/CFS, and discuss the diagnostic evaluation and treatments of dysautonomia. We also outline gaps in the literature and priorities for future research.
Collapse
Affiliation(s)
- Brittany L Adler
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, United States
| | - Tae Chung
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, United States
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, United States
| | - John Aucott
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, United States
| |
Collapse
|
2
|
Novak P, Systrom DM, Marciano SP, Knief A, Felsenstein D, Giannetti MP, Hamilton MJ, Nicoloro-SantaBarbara J, Saco TV, Castells M, Farhad K, Pilgrim DM, Mullally WJ. Mismatch between subjective and objective dysautonomia. Sci Rep 2024; 14:2513. [PMID: 38291116 PMCID: PMC10828385 DOI: 10.1038/s41598-024-52368-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024] Open
Abstract
Autonomic symptom questionnaires are frequently used to assess dysautonomia. It is unknown whether subjective dysautonomia obtained from autonomic questionnaires correlates with objective dysautonomia measured by quantitative autonomic testing. The objective of our study was to determine correlations between subjective and objective measures of dysautonomia. This was a retrospective cross-sectional study conducted at Brigham and Women's Faulkner Hospital Autonomic Laboratory between 2017 and 2023 evaluating the patients who completed autonomic testing. Analyses included validated autonomic questionnaires [Survey of Autonomic Symptoms (SAS), Composite Autonomic Symptom Score 31 (Compass-31)] and standardized autonomic tests (Valsalva maneuver, deep breathing, sudomotor, and tilt test). The autonomic testing results were graded by a Quantitative scale for grading of cardiovascular reflexes, sudomotor tests and skin biopsies (QASAT), and Composite Autonomic Severity Score (CASS). Autonomic testing, QASAT, CASS, and SAS were obtained in 2627 patients, and Compass-31 in 564 patients. The correlation was strong between subjective instruments (SAS vs. Compass-31, r = 0.74, p < 0.001) and between objective instruments (QASAT vs. CASS, r = 0.81, p < 0.001). There were no correlations between SAS and QASAT nor between Compass-31 and CASS. There continued to be no correlations between subjective and objective instruments for selected diagnoses (post-acute sequelae of COVID-19, n = 61; postural tachycardia syndrome, 211; peripheral autonomic neuropathy, 463; myalgic encephalomyelitis/chronic fatigue syndrome, 95; preload failure, 120; post-treatment Lyme disease syndrome, 163; hypermobile Ehlers-Danlos syndrome, 213; neurogenic orthostatic hypotension, 86; diabetes type II, 71, mast cell activation syndrome, 172; hereditary alpha tryptasemia, 45). The lack of correlation between subjective and objective instruments highlights the limitations of the commonly used questionnaires with some patients overestimating and some underestimating true autonomic deficit. The diagnosis-independent subjective-objective mismatch further signifies the unmet need for reliable screening surveys. Patients who overestimate the symptom burden may represent a population with idiosyncratic autonomic-like symptomatology, which needs further study. At this time, the use of autonomic questionnaires as a replacement of autonomic testing cannot be recommended.
Collapse
Affiliation(s)
- Peter Novak
- Autonomic Laboratory, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Neurology, Brigham and Women's Faulkner Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - David M Systrom
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Sadie P Marciano
- Department of Neurology, Brigham and Women's Faulkner Hospital, Boston, MA, USA
| | - Alexandra Knief
- Department of Neurology, Brigham and Women's Faulkner Hospital, Boston, MA, USA
| | - Donna Felsenstein
- Harvard Medical School, Boston, MA, USA
- Department of Infectious Disease and Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew P Giannetti
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Mastocytosis Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew J Hamilton
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Mastocytosis Center, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Tara V Saco
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Mastocytosis Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Mariana Castells
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Mastocytosis Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Khosro Farhad
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - David M Pilgrim
- Department of Neurology, Brigham and Women's Faulkner Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - William J Mullally
- Department of Neurology, Brigham and Women's Faulkner Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| |
Collapse
|
3
|
Kotb MA, Bedewi MA, Almalki DM, AlAseeri AA, Alhariqi BA, Soliman SB, Aldossary NM, Aboulela WH. The vagus nerve cross-sectional area on ultrasound in patients with type 2 diabetes. Medicine (Baltimore) 2023; 102:e36768. [PMID: 38134052 PMCID: PMC10735154 DOI: 10.1097/md.0000000000036768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023] Open
Abstract
Diabetic neuropathy, including autonomic neuropathy is a serious complication related to type 2 diabetes mellitus (T2D). The vagus nerve (VN) is the longest nerve in the autonomic nervous system, and since diabetic neuropathy manifests first in longer nerves, the VN is commonly affected in early diabetic autonomic neuropathy. The use of high-resolution ultrasound for peripheral and cranial nerve imaging has significantly increased over the past 2 decades. The aim of the study is to compare the cross-sectional area of the VN in patients with T2D to that of a control cohort without T2D. A total of 52 VN cross-sectional areas were recorded from patients with T2D. A total of 56 VN cross-sectional areas were also recorded from asymptomatic subjects without T2D. In each subject, high-resolution ultrasound imaging of the bilateral VNs was performed in the short-axis between the common carotid artery and the internal jugular vein. The VN cross-sectional areas were recorded and compared. In the patients with T2D, HbA1c and fasting blood glucose levels were obtained as well as the duration of T2D in years and correlated with the cross-sectional areas. The bilateral VN cross-sectional areas were similar in both cohorts. Additionally, no correlation was seen between the VN cross-sectional areas, demographics, or clinical data of T2D. Our study demonstrated normal VN cross-sectional areas in patients with T2D without any significant relation with the patients' demographic or clinical data.
Collapse
Affiliation(s)
- Mamdouh Ali Kotb
- Department of Internal Medicine, Prince Sattam Bin Abdulaziz University, College of Medicine, Al-Kharj, Kingdom of Saudi Arabia
- Neurology Department, Faculty of Medicine, Minia University, Minia, Egypt
| | - Mohamed A. Bedewi
- Department of Internal Medicine, Prince Sattam Bin Abdulaziz University, College of Medicine, Al-Kharj, Kingdom of Saudi Arabia
| | - Daifallah Mohamed Almalki
- Department of Internal Medicine, Prince Sattam Bin Abdulaziz University, College of Medicine, Al-Kharj, Kingdom of Saudi Arabia
| | - Ali Abdullah AlAseeri
- Department of Internal Medicine, Prince Sattam Bin Abdulaziz University, College of Medicine, Al-Kharj, Kingdom of Saudi Arabia
| | - Bader A. Alhariqi
- Medical Imaging Administration, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Steven B. Soliman
- Division of Musculoskeletal Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI
| | - Nasser M. Aldossary
- Department of Internal Medicine, Prince Sattam Bin Abdulaziz University, College of Medicine, Al-Kharj, Kingdom of Saudi Arabia
| | - Wael Hamed Aboulela
- Neurosurgery Department, Faculty of Medicine, Minia University, Minia, Egypt
| |
Collapse
|
4
|
Weber JE, Ahmadi M, Boldt LH, Eckardt KU, Edelmann F, Gerhardt H, Grittner U, Haubold K, Hübner N, Kollmus-Heege J, Landmesser U, Leistner DM, Mai K, Müller DN, Nolte CH, Pieske B, Piper SK, Rattan S, Rauch G, Schmidt S, Schmidt-Ott KM, Schönrath K, Schulz-Menger J, Schweizerhof O, Siegerink B, Spranger J, Ramachandran VS, Witzenrath M, Endres M, Pischon T. Protocol of the Berlin Long-term Observation of Vascular Events (BeLOVE): a prospective cohort study with deep phenotyping and long-term follow up of cardiovascular high-risk patients. BMJ Open 2023; 13:e076415. [PMID: 37907297 PMCID: PMC10618970 DOI: 10.1136/bmjopen-2023-076415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/22/2023] [Indexed: 11/02/2023] Open
Abstract
INTRODUCTION The Berlin Long-term Observation of Vascular Events is a prospective cohort study that aims to improve prediction and disease-overarching mechanistic understanding of cardiovascular (CV) disease progression by comprehensively investigating a high-risk patient population with different organ manifestations. METHODS AND ANALYSIS A total of 8000 adult patients will be recruited who have either suffered an acute CV event (CVE) requiring hospitalisation or who have not experienced a recent acute CVE but are at high CV risk. An initial study examination is performed during the acute treatment phase of the index CVE or after inclusion into the chronic high risk arm. Deep phenotyping is then performed after ~90 days and includes assessments of the patient's medical history, health status and behaviour, cardiovascular, nutritional, metabolic, and anthropometric parameters, and patient-related outcome measures. Biospecimens are collected for analyses including 'OMICs' technologies (e.g., genomics, metabolomics, proteomics). Subcohorts undergo MRI of the brain, heart, lung and kidney, as well as more comprehensive metabolic, neurological and CV examinations. All participants are followed up for up to 10 years to assess clinical outcomes, primarily major adverse CVEs and patient-reported (value-based) outcomes. State-of-the-art clinical research methods, as well as emerging techniques from systems medicine and artificial intelligence, will be used to identify associations between patient characteristics, longitudinal changes and outcomes. ETHICS AND DISSEMINATION The study was approved by the Charité-Universitätsmedizin Berlin ethics committee (EA1/066/17). The results of the study will be disseminated through international peer-reviewed publications and congress presentations. STUDY REGISTRATION First study phase: Approved WHO primary register: German Clinical Trials Register: https://drks.de/search/de/trial/DRKS00016852; WHO International Clinical Registry Platform: http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00016852. Recruitment started on July 18, 2017.Second study phase: Approved WHO primary register: German Clinical Trials Register DRKS00023323, date of registration: November 4, 2020, URL: http://www.drks.de/ DRKS00023323. Recruitment started on January 1, 2021.
Collapse
Affiliation(s)
- Joachim E Weber
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- Center for Stroke Research (CSB), Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Michael Ahmadi
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Leif-Hendrik Boldt
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Department of Internal Medicine and Cardiology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
| | - Kai-Uwe Eckardt
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- Department of Nephrology and Medical Intensive Care, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Frank Edelmann
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Department of Internal Medicine and Cardiology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Holger Gerhardt
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Ulrike Grittner
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Kathrin Haubold
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Norbert Hübner
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Experimental and Clinical Research Center (ECRC), a cooperation of Charité - Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine (MDC), Berlin, Germany
- Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Jil Kollmus-Heege
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Ulf Landmesser
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Department of Cardiology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- Department for Cardiology, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
| | - David M Leistner
- Department of Cardiology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Knut Mai
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Department of Endocrinology and Metabolism, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- Center for Cardiovascular Research (CCR), Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- German Center for Diabetes Research, München-Neuherberg, Germany
| | - Dominik N Müller
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Experimental and Clinical Research Center (ECRC), a cooperation of Charité - Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine (MDC), Berlin, Germany
- Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Christian H Nolte
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- Center for Stroke Research (CSB), Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Burkert Pieske
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Department of Internal Medicine and Cardiology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Sophie K Piper
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- Institute of Medical Informatics, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Simrit Rattan
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Geraldine Rauch
- Institute of Biometry and Clinical Epidemiology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Sein Schmidt
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- Center for Stroke Research (CSB), Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Kai M Schmidt-Ott
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- Department of Nephrology and Medical Intensive Care, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- Experimental and Clinical Research Center (ECRC), a cooperation of Charité - Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine (MDC), Berlin, Germany
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Katharina Schönrath
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Jeanette Schulz-Menger
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Experimental and Clinical Research Center (ECRC), a cooperation of Charité - Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine (MDC), Berlin, Germany
| | - Oliver Schweizerhof
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Bob Siegerink
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joachim Spranger
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Department of Endocrinology and Metabolism, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- Center for Cardiovascular Research (CCR), Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- German Center for Diabetes Research, München-Neuherberg, Germany
| | - Vasan S Ramachandran
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- Sections of Preventive Medicine and Epidemiology, and Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Martin Witzenrath
- Division of Pulmonary Inflammation, and Department of Infectious Diseases and Respiratory Medicine, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- German Center for Lung Research (DZL), Germany
| | - Matthias Endres
- Department of Neurology, Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- Center for Stroke Research (CSB), Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany
- ExellenceCluster NeuroCure, Berlin, Germany
| | - Tobias Pischon
- Berlin Institute of Health (BIH) at Charité- Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Charité- Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
- Molecular Epidemiology Research Group, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Biobank Technology Platform, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| |
Collapse
|
5
|
Karabacak A, İnan R, Şen N. Evaluation of peripheral nerve involvements in patients with familial Mediterranean fever. Arch Rheumatol 2023; 38:441-450. [PMID: 38046242 PMCID: PMC10689019 DOI: 10.46497/archrheumatol.2023.9695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 11/21/2022] [Indexed: 12/05/2023] Open
Abstract
Objectives The aim of this study was to evaluate possible peripheral and autonomic nerve involvement in familial Mediterranean fever (FMF) patients with nerve conduction studies, sympathetic skin response (SSR) and RR interval variability (RRIV). Patients and methods The comparative case series was conducted with 76 participants between November 2017 and December 2018. Forty-six FMF patients, [12 with amyloidosis (5 males, 7 females; mean age: 44.7±13.9 years) and 34 without amyloidosis (14 males, 20 females; mean age: 35.9±8.7 years)], and 30 healthy volunteers (11 males, 19 females; mean age: 38.4±10 years) were included in this study. Nerve conduction parameters, SSR latency and amplitude from palmar and plantar responses, and RRIV at rest and deep breathing were studied in all the subjects. Neuropathic symptoms of the patient group were evaluated using the survey of autonomic symptoms scale and the neuropathy disability score. Results Nerve conduction studies of the patient group revealed polyneuropathy in seven (15.21%) patients and carpal tunnel syndrome in six (13.04%) patients. The mean amplitudes of SSR measured from the soles were significantly lower than the control group (p=0.041). The mean values of RRIV during rest and hyperventilation were lower in the patient group compared to the control group, but no statistically significant difference was found (p=0.484, p=0.341). Conclusion We detected that the prevalence of carpal tunnel syndrome in our patient population (13.04%) was higher than in the general population. Most of the changes in the range of parameters of SSR and RRIV determined in the patient group did not reach statistical significance, suggesting subclinical dysautonomia in FMF patients.
Collapse
Affiliation(s)
- Atak Karabacak
- Department of Neurology, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| | - Rahşan İnan
- Department of Neurology, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| | - Nesrin Şen
- Department of Rheumatology, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| |
Collapse
|
6
|
Meling S, Tjora E, Eichele H, Ejskjaer N, Carlsen S, Njølstad PR, Brock C, Søfteland E. The Composite Autonomic Symptom Score 31 Questionnaire: A Sensitive Test to Detect Risk for Autonomic Neuropathy. J Diabetes Res 2023; 2023:4441115. [PMID: 37593120 PMCID: PMC10432092 DOI: 10.1155/2023/4441115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/21/2023] [Accepted: 07/18/2023] [Indexed: 08/19/2023] Open
Abstract
Background and Aims Autonomic neuropathy is a common but often neglected complication of diabetes, prediabetes, and even in individuals with an elevated risk of diabetes. The Composite Autonomic Symptom Score (COMPASS) 31 is a validated and easy-to-use questionnaire regarding autonomic symptoms. We aimed to use a digitally, Norwegian version of the COMPASS 31 in people with different durations of diabetes and healthy controls to consider feasibility and to investigate if scores could discriminate between positive and negative outcomes for established tests for diabetic neuropathy, including cardiovascular autonomic neuropathy (CAN) and a novel method of examining the gastrointestinal visceral sensitivity. Method We included 21 participants with longstanding type 2 diabetes, 15 with early type 2 diabetes, and 30 matched controls. The mean age for all groups was 69 years. Participants were phenotyped by cardiovascular autonomic reflex tests, electrical skin conductance, sural nerve electrophysiology, and the monofilament test. As a proxy for gastrointestinal visceral and autonomic nerve function, evoked potentials were measured following rapid rectal balloon distention. Results Participants with longstanding diabetes scored a median (IQR) of 14.9 (10.8-28.7) points, early diabetes of 7.3 (1.6-15.2), and matched controls of 8.6 (4.1-21.6), p = 0.04. Women and men scored 14.4 (5.5-28.7) and 7.8 (3.6-14.6) points, respectively, p = 0.01. Participants with definite or borderline CAN scored 14.3 (10.4-31.9) points, compared to participants with no CAN, 8.3 (3.2-21.5), p = 0.04. Lowering the diagnostic cut-off from 16 to 10 points increased the sensitivity from 0.33 to 0.83, with a decreased specificity from 0.68 to 0.55. Conclusion We successfully used COMPASS 31 in Norwegian. Thus, following the guidelines, we suggest clinical implementation for the assessment of autonomic neuropathy. Participants with longstanding diabetes had an increased likelihood of symptoms and signs of autonomic neuropathy. For screening purposes, the sensitivity was improved by lowering the cut-off to 10 points, with a lower score nearly excluding the diagnosis.
Collapse
Affiliation(s)
- Sondre Meling
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Erling Tjora
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Children and Youth Clinic, Haukeland University Hospital, Bergen, Norway
| | - Heike Eichele
- Department of Biological and Medical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway
- Regional Resource Centre for Autism, ADHD and Tourette Syndrome Western Norway, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Niels Ejskjaer
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Siri Carlsen
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Pål Rasmus Njølstad
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Children and Youth Clinic, Haukeland University Hospital, Bergen, Norway
- Mohn Center for Diabetes Precision Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Christina Brock
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Eirik Søfteland
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Hormone Laboratory, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
7
|
Reynolds EL, Watanabe M, Banerjee M, Chant E, Villegas-Umana E, Elafros MA, Gardner TW, Pop-Busui R, Pennathur S, Feldman EL, Callaghan BC. The effect of surgical weight loss on diabetes complications in individuals with class II/III obesity. Diabetologia 2023; 66:1192-1207. [PMID: 36917280 PMCID: PMC10011764 DOI: 10.1007/s00125-023-05899-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/25/2023] [Indexed: 03/16/2023]
Abstract
AIMS/HYPOTHESIS The aim of this study was to determine the effect of bariatric surgery on diabetes complications in individuals with class II/III obesity (BMI > 35 kg/m2). METHODS We performed a prospective cohort study of participants with obesity who underwent bariatric surgery. At baseline and 2 years following surgery, participants underwent metabolic phenotyping and diabetes complication assessments. The primary outcomes for peripheral neuropathy (PN) were a change in intra-epidermal nerve fibre density (IENFD, units = fibres/mm) at the distal leg and proximal thigh, the primary outcome for cardiovascular autonomic neuropathy (CAN) was a change in the expiration/inspiration (E/I) ratio, and the primary outcome for retinopathy was a change in the mean deviation on frequency doubling technology testing. RESULTS Among 127 baseline participants, 79 completed in-person follow-up (age 46.0 ± 11.3 years [mean ± SD], 73.4% female). Participants lost a mean of 31.0 kg (SD 18.4), and all metabolic risk factors improved except for BP and total cholesterol. Following bariatric surgery, one of the primary PN outcomes improved (IENFD proximal thigh, +3.4 ± 7.8, p<0.01), and CAN (E/I ratio -0.01 ± 0.1, p=0.89) and retinopathy (deviation -0.2 ± 3.0, p=0.52) were stable. Linear regression revealed that a greater reduction in fasting glucose was associated with improvements in retinopathy (mean deviation point estimate -0.7, 95% CI -1.3, -0.1). CONCLUSIONS/INTERPRETATION Bariatric surgery may be an effective approach to reverse PN in individuals with obesity. The observed stability of CAN and retinopathy may be an improvement compared with the natural progression of these conditions; however, controlled trials are needed.
Collapse
Affiliation(s)
- Evan L Reynolds
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Maya Watanabe
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Ericka Chant
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Thomas W Gardner
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, USA
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Subramaniam Pennathur
- Division of Nephrology, Department of Internal Medicine and Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, USA
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Brian C Callaghan
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
8
|
de Azevedo Vieira ARS, Porto-Dantas LB, do Prado Romani FA, Carvalho PS, Pop-Busui R, Pedrosa HC. Autonomic neuropathic symptoms in patients with diabetes: practical tools for screening in daily routine. Diabetol Metab Syndr 2023; 15:83. [PMID: 37101234 PMCID: PMC10130803 DOI: 10.1186/s13098-023-01036-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/22/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Diabetic autonomic neuropathy (DAN) is a frequent complication in people with diabetes whose screening is often neglected. This study aimed to evaluate DAN through practical tools in people with diabetes in a referral center for diabetes treatment. METHODS DAN symptoms and severity were assessed using the Survey of Autonomic Symptoms (SAS) via digital application (app) in patients attended from June 1, 2021, to November 12, 2021. SAS scoring for DAN was performed using established validated cutoffs. The adhesive with cobalt salt color indicator (Neuropad™) was used as a measure of sudomotor dysfunction. Demographical and clinical data were also collected. RESULTS Data from 109 participants, 66.9% T2DM, 73.4% female, with a median age of 54.00 (± 20.00) years, were analyzed. Symptomatic DAN was present in 69.7% of participants and was associated with older age (p = 0.002), higher HbA1c (p = 0.043), higher abdominal circumference (p = 0.019), higher BMI (p = 0.013), more likely to have metabolic syndrome (MS) with a 10-fold increased risk, and more frequent association with diabetic peripheral neuropathy (p = 0.005). Sudomotor dysfunction was found in 65 participants with positive Neuropad™ detected in 63.1% of them. CONCLUSION The use of SAS through an app proved to be a practical and easy-to-use instrument to document symptoms of DAN in busy clinical practice. The high frequency of symptoms draws attention to the importance of screening this underdiagnosed diabetes complication. The risk factors and comorbidities associated with symptomatic DAN highlight the patients' phenotypes linked to MS that should be targeted for DAN evaluations in larger samples in the community.
Collapse
Affiliation(s)
- Ana Raquel Souza de Azevedo Vieira
- Unit of Endocrinology of the Regional Hospital of Taguatinga and Research Center of the Foundation for Education and Research in Health Sciences, Secretariat of Health of the Federal District, Brasilia, Brazil
| | - Lara Benigno Porto-Dantas
- Unit of Endocrinology of the Regional Hospital of Taguatinga and Research Center of the Foundation for Education and Research in Health Sciences, Secretariat of Health of the Federal District, Brasilia, Brazil.
| | - Flaviene Alves do Prado Romani
- Unit of Endocrinology of the Regional Hospital of Taguatinga and Research Center of the Foundation for Education and Research in Health Sciences, Secretariat of Health of the Federal District, Brasilia, Brazil
| | - Patrícia Souza Carvalho
- Unit of Endocrinology of the Regional Hospital of Taguatinga and Research Center of the Foundation for Education and Research in Health Sciences, Secretariat of Health of the Federal District, Brasilia, Brazil
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Hermelinda Cordeiro Pedrosa
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
9
|
Affiliation(s)
- Dan Ziegler
- Institute for Clinical Diabetology, German Diabetes Center (DDZ) at Heinrich Heine University; Leibniz Center for Diabetes Research, Düsseldorf, Germany
| | - Jutta Keller
- Department of Internal Medicine, Israelite Hospital, Hamburg, Germany
| | - Christoph Maier
- Department of Pediatric and Adolescent Medicine, University Hospital Bochum, Ruhr University Bochum, Bochum, Germany
| | - Jürgen Pannek
- Neuro-Urology, Swiss Paraplegic Center Nottwil, Nottwil, Switzerland
| |
Collapse
|
10
|
Kwon S, Jeong WK, Park JH, Kim J, Cho EB, Seok JM, Kim SJ, Kim K, Jeon ES, Min JH, Kim BJ. Generalised autonomic failure as a prognostic factor in systemic light-chain (AL) amyloidosis. Amyloid 2022; 29:263-269. [PMID: 35652834 DOI: 10.1080/13506129.2022.2082866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND In the present study, it was investigated whether autonomic dysfunction could predict prognosis in light-chain (AL) amyloidosis patients. PATIENTS AND METHODS Seventy-two patients with biopsy-proven AL amyloidosis were included and underwent an autonomic function test (AFT) between January 2016 and June 2019. Autonomic failure was evaluated using the Composite Autonomic Severity Score (CASS). Survival curves and the three-year overall survival (OS) rate were estimated using the Kaplan-Meier curve, and the Cox proportional hazards regression method was used to evaluate the variables that influenced survival. RESULTS Autonomic dysfunction was observed in 69 (96%) patients with AL amyloidosis, and the three-year OS rate was 67%. Generalised autonomic failure (GAF) was observed in 31 (43%) patients. In the Kaplan-Meier curve, the three-year OS rates in patients with sudomotor dysfunction or GAF were lower than that in control patients (35 vs. 84%, and 33 vs. 81%, respectively). In Cox proportional hazards regression model, female, bone marrow plasma cell percentage, left ventricular systolic dysfunction, and GAF were significant independent variables associated with survival. CONCLUSION The results of this study indicate that GAF on the AFT is an independent adverse prognostic factor for survival in AL amyloidosis patients.
Collapse
Affiliation(s)
- Soonwook Kwon
- Department of Neurology, Inha University Hospital, Incheon, Korea
| | - Woo Kyo Jeong
- Department of Neurology, Hana General Hospital, Cheongju, Korea
| | - Ji-Hyung Park
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Neuroscience Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Juhyun Kim
- Department of Neurology, Gyeongsang Institute of Health Science, Gyeongsang National University, College of Medicine, Jinju, Korea.,Department of Neurology, Gyeongsang National University Hospital, Jinju, Korea
| | - Eun Bin Cho
- Department of Neurology, Gyeongsang Institute of Health Science, Gyeongsang National University, College of Medicine, Jinju, Korea.,Department of Neurology, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Jin Myoung Seok
- Department of Neurology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Seok Jin Kim
- Department of Medicine, Division of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kihyun Kim
- Department of Medicine, Division of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Seok Jeon
- Department of Medicine, Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ju-Hong Min
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Neuroscience Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Korea
| | - Byoung Joon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Neuroscience Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
11
|
Angeles-Zurita G, Narro-Fuentes M, Bernabe-Ortiz A. Association between blood glucose levels and autonomic symptoms in Peru. Prim Care Diabetes 2022; 16:709-713. [PMID: 36041979 DOI: 10.1016/j.pcd.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 07/19/2022] [Accepted: 08/15/2022] [Indexed: 11/28/2022]
Abstract
AIMS To determine whether there is an association between high blood glucose levels and having autonomic symptoms among adults aged 30-69 years. MATERIAL AND METHODS A population-based cross-sectional study was conducted. The presence of autonomic symptoms was defined as the positive response to any item of the Survey of Autonomic Symptoms (SAS). Blood glucose levels were defined as euglycemia, prediabetes, and type 2 diabetes (T2D), based on oral glucose tolerance test. Poisson regression, with link log and robust variance, and linear regression were conducted to evaluate the association of interest. RESULTS A total of 1607 subjects, mean age 48.2 (SD: 10.6) and 810 (49.7 %) women, were included. T2D was associated with higher prevalence of erectile dysfunction (PR = 3.00; 95 % CI: 1.78-5.02) and dryness of mouth and eyes (PR = 1.29; 95 % CI: 1.02-1.61) compared with those with euglycemia. Those with T2D had 0.32 (95 % CI: 0.04-0.62) and 1.03 (95 % CI: 0.03-2.03) more points in the SAS score and severity scale, respectively. CONCLUSIONS Erectile dysfunction and dry mouth and eyes are the more common autonomic symptoms associated with T2D. Our results suggest a periodic evaluation of sexual function and eye humidity among T2D patients.
Collapse
Affiliation(s)
| | | | - Antonio Bernabe-Ortiz
- Universidad Científica del Sur, Lima, Peru; CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.
| |
Collapse
|
12
|
Network autonomic analysis of post-acute sequelae of COVID-19 and postural tachycardia syndrome. Neurol Sci 2022; 43:6627-6638. [PMID: 36169757 PMCID: PMC9517969 DOI: 10.1007/s10072-022-06423-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/21/2022] [Indexed: 11/30/2022]
Abstract
Background The autonomic nervous system (ANS) is a complex network where sympathetic and parasympathetic domains interact inside and outside of the network. Correlation-based network analysis (NA) is a novel approach enabling the quantification of these interactions. The aim of this study is to assess the applicability of NA to assess relationships between autonomic, sensory, respiratory, cerebrovascular, and inflammatory markers on post-acute sequela of COVID-19 (PASC) and postural tachycardia syndrome (POTS). Methods In this retrospective study, datasets from PASC (n = 15), POTS (n = 15), and matched controls (n = 11) were analyzed. Networks were constructed from surveys (autonomic and sensory), autonomic tests (deep breathing, Valsalva maneuver, tilt, and sudomotor test) results using heart rate, blood pressure, cerebral blood flow velocity (CBFv), capnography, skin biopsies for assessment of small fiber neuropathy (SFN), and various inflammatory markers. Networks were characterized by clusters and centrality metrics. Results Standard analysis showed widespread abnormalities including reduced orthostatic CBFv in 100%/88% (PASC/POTS), SFN 77%/88%, mild-to-moderate dysautonomia 100%/100%, hypocapnia 87%/100%, and elevated inflammatory markers. NA showed different signatures for both disorders with centrality metrics of vascular and inflammatory variables playing prominent roles in differentiating PASC from POTS. Conclusions NA is suitable for a relationship analysis between autonomic and nonautonomic components. Our preliminary analyses indicate that NA can expand the value of autonomic testing and provide new insight into the functioning of the ANS and related systems in complex disease processes such as PASC and POTS. Supplementary Information The online version contains supplementary material available at 10.1007/s10072-022-06423-y.
Collapse
|
13
|
Špiljak B, Lisak M, Pašić H, Trkanjec Z, Lovrenčić Huzjan A, Bašić Kes V. SIALORRHEA AND XEROSTOMIA IN PARKINSON'S DISEASE PATIENTS. Acta Clin Croat 2022; 61:320-326. [PMID: 36818932 PMCID: PMC9934048 DOI: 10.20471/acc.2022.61.02.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
Parkinson's disease (PD) is generally considered as a primary movement disorder, but the majority of patients also suffer from non-motor oral, salivary symptoms. The most common salivary symptoms, sialorrhea and xerostomia, have a considerable negative impact on the quality of life. Although these symptoms are completely opposite ones, both significantly impair oral health of patients. Sialorrhea is defined as an increased amount of the retaining saliva. It is related to salivary overproduction, or it may be associated with impaired clearance of saliva. Opposed to sialorrhea, xerostomia is subjectively defined as dryness of mouth and it is related to insufficient salivary secretion. Xerostomia promotes imbalance of oral microflora and oral pathology that often leads to malnutrition in PD patients. It is mostly related to autonomic dysfunction, or it might be considered as a side effect of dopaminergic or anticholinergic medication. In PD, different assessments are used for evaluation of sialorrhea and xerostomia, including validated scales for non-motor symptoms and standardized questionnaires on oral health. Consequently, treatment of salivary symptoms includes pharmacological and nonpharmacological approach, and surgical interventions. A multidisciplinary approach in clinical neurology and dental medicine, which includes accurate evaluation of salivary symptoms and effective treatment, indicates successful management of PD patients.
Collapse
Affiliation(s)
- Bruno Špiljak
- School of Dental Medicine, University of Zagreb, Zagreb, Croatia
| | - Marijana Lisak
- Department of Neurology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Hanna Pašić
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Zlatko Trkanjec
- School of Dental Medicine, University of Zagreb, Zagreb, Croatia;,Department of Neurology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Arijana Lovrenčić Huzjan
- School of Dental Medicine, University of Zagreb, Zagreb, Croatia;,Department of Neurology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Vanja Bašić Kes
- School of Dental Medicine, University of Zagreb, Zagreb, Croatia;,Department of Neurology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| |
Collapse
|
14
|
Mizokami-Stout K, Bailey R, Ang L, Aleppo G, Levy CJ, Rickels MR, Shah VN, Polsky S, Nelson B, Carlson AL, Vendrame F, Pop-Busui R. Symptomatic diabetic autonomic neuropathy in type 1 diabetes (T1D): Findings from the T1D exchange. J Diabetes Complications 2022; 36:108148. [PMID: 35279403 DOI: 10.1016/j.jdiacomp.2022.108148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 10/19/2022]
Abstract
AIMS We aimed to evaluate the contemporary prevalence of and risk factors for symptomatic diabetic autonomic neuropathy (DAN) in participants with type 1 diabetes (T1D) enrolled in the T1D Exchange Clinic Registry. METHODS DAN symptoms and severity were assessed with the Survey of Autonomic Symptoms (SAS) in adults with ≥5 years of T1D participating in the T1D Exchange from years 2010-2017. Associations of demographic, clinical, and laboratory factors with symptomatic DAN were assessed. RESULTS Of the 4919 eligible T1D participants, 965 (20%) individuals completed the SAS questionnaire [mean age 40 ± 17 years, median diabetes duration 20 years (IQR: 13,34), 64% female, 90% non-Hispanic White, and 82% with private insurance]. DAN symptoms were present in 166 (17%) of responders with 72% experiencing moderate severity symptoms or worse. Symptomatic DAN participants had higher hemoglobin A1c (p = 0.03), longer duration (p = 0.004), were more likely to be female (p = 0.03), and more likely to have lower income (p = 0.03) versus no DAN symptoms. Symptomatic DAN was associated with diabetic peripheral neuropathy (p < 0.0001), smoking (p = 0.002), cardiovascular disease (p = 0.02), depression (p < 0.001), and opioid use (p = 0.004). CONCLUSIONS DAN symptoms are common in T1D. Socioeconomic factors and psychological comorbidities may contribute to DAN symptoms and should be explored further.
Collapse
Affiliation(s)
| | - Ryan Bailey
- Jaeb Center for Health Research, Tampa, FL, United States of America
| | - Lynn Ang
- University of Michigan, Ann Arbor, MI, United States of America
| | - Grazia Aleppo
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Carol J Levy
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Michael R Rickels
- Rodebaugh Diabetes Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Sarit Polsky
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Bryce Nelson
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Anders L Carlson
- International Diabetes Center, Minneapolis, MN, United States of America
| | | | | |
Collapse
|
15
|
Buckert M, Hartmann M, Monzer N, Wolff K, Nawroth P, Fleming T, Streibel C, Henningsen N, Wild B. Pronounced cortisol response to acute psychosocial stress in type 2 diabetes patients with and without complications. Horm Behav 2022; 141:105120. [PMID: 35220091 DOI: 10.1016/j.yhbeh.2022.105120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 12/23/2021] [Accepted: 01/13/2022] [Indexed: 11/04/2022]
Abstract
It is increasingly recognized that psychological stress is linked with type 2 diabetes mellitus and its late complications. Thus, the aim of the current study was to investigate the psychophysiological response to acute psychosocial stress in patients with type 2 diabetes. In total, 53 type 2 diabetes patients with complications, 16 type 2 diabetes patients without complications, and 47 age and gender matched non-diabetic participants underwent the Trier Social Stress Test. Subjective as well as biological parameters (i.e., blood levels of cortisol, adrenocorticotropic hormone (ACTH), norepinephrine, methylglyoxal) were assessed repeatedly before and after stress induction. Data were analyzed by means of multilevel regression. Patients with type 2 diabetes showed an exaggerated cortisol response to acute stress as compared to age matched control participants (diabetes*T2 est. = 1.23, p < .001), while stress-induced alterations of ACTH and subjective parameters did not differ. Norepinephrine levels were lower among patients (diabetes est. = -4.36, p = .044) and tended to decrease earlier than in controls. The subjective reaction of type 2 diabetes patients with complications was stronger than that of patients without complications (complication*T2 est. = -1.83, p = .032), while their endocrine response to stress was similar. Stress had no effect on methylglyoxal level, and there were no group differences regarding methylglyoxal response. These results show that the cortisol reactivity of patients with type 2 diabetes to acute psychosocial stress is increased compared to a control group. Thus, alterations of the hypothalamus-pituitary-adrenal axis - especially regarding its dynamic regulation - are a plausible link between psychological stress and type 2 diabetes and its complications.
Collapse
Affiliation(s)
- M Buckert
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany.
| | - M Hartmann
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - N Monzer
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - K Wolff
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - P Nawroth
- Department of Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany; German Center for Diabetes Research (DZD), Heidelberg, Germany
| | - T Fleming
- Department of Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany
| | - C Streibel
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - N Henningsen
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - B Wild
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany.
| |
Collapse
|
16
|
Diabetische Neuropathie. DIABETOLOGE 2022. [DOI: 10.1007/s11428-022-00880-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
17
|
Potockova V, Mala S, Hoskovcova L, Capek V, Nedelka T, Riedlbauchova L, Baumgartner D, Mensova L, Mazanec R. Thermal quantitative sensory testing as a screening tool for cardiac autonomic neuropathy in patients with diabetes mellitus. Brain Behav 2022; 12:e2506. [PMID: 35212197 PMCID: PMC8933758 DOI: 10.1002/brb3.2506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/14/2021] [Accepted: 01/02/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Electrophysiological diagnosis of cardiac autonomic neuropathy (CAN) is based on the evaluation of cardiovascular autonomic reflex tests (CARTs). CARTs are relatively time consuming and must be performed under standardized conditions. This study aimed to determine whether thermal quantitative sensory testing (TQST) can be used as a screening tool to identify patients with diabetes at a higher risk of CAN. METHODS Eighty-five patients with diabetes and 49 healthy controls were included in the study. Neurological examination, CARTs, TQST, biochemical analyses, and neuropathy symptom questionnaires were performed. RESULTS CAN was diagnosed in 46 patients with diabetes (54%). CAN-positive patients with diabetes had significantly higher warm detection thresholds (WDT) and significantly lower cold detection thresholds (CDT) in all tested regions (thenar, tibia, and the dorsum of the foot). CDT on the dorsum < 21.8°C in combination with CDT on the tibia < 23.15°C showed the best diagnostic ability in CAN prediction, with 97.4 % specificity, 60.9% sensitivity, 96.6% positive predictive value, and 67.3% negative predictive value. CONCLUSION TQST can be used as a screening tool for CAN before CART.
Collapse
Affiliation(s)
- Veronika Potockova
- Second Faculty of Medicine, Department of Neurology, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Sarka Mala
- Second Faculty of Medicine, Department of Internal Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Lucie Hoskovcova
- Second Faculty of Medicine, Department of Internal Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Vaclav Capek
- Second Faculty of Medicine, Department of Neurology, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Tomas Nedelka
- Second Faculty of Medicine, Department of Neurology, Motol University Hospital, Charles University, Prague, Czech Republic.,Faculty of Biomedical Engineering, Czech Technical University in Prague, Prague, Czech Republic
| | - Lucie Riedlbauchova
- Second Faculty of Medicine, Department of Cardiology, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Daniel Baumgartner
- Second Faculty of Medicine, Department of Neurology, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Livie Mensova
- Second Faculty of Medicine, Department of Neurology, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Radim Mazanec
- Second Faculty of Medicine, Department of Neurology, Motol University Hospital, Charles University, Prague, Czech Republic
| |
Collapse
|
18
|
Mahfouz FM, Park SB, Li T, Timmins HC, Horvath LG, Harrison M, Grimison P, King T, Goldstein D, Mizrahi D. Association of electrochemical skin conductance with neuropathy in chemotherapy-treated patients. Clin Auton Res 2022; 32:497-506. [PMID: 36129622 PMCID: PMC9719444 DOI: 10.1007/s10286-022-00895-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/06/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE Chemotherapy-induced peripheral neuropathy (CIPN) is an adverse event of cancer treatment that can affect sensory, motor, or autonomic nerves. Assessment of autonomic neuropathy is challenging, with limited available tools. Accordingly, it is not routinely assessed in chemotherapy-treated patients. In this study, we aimed to examine whether electrochemical skin conductance (ESC) via Sudoscan, a potential measure of autonomic function, associates with subjective and objective measures of CIPN severity and autonomic neuropathy. METHODS A cross-sectional assessment of patients who completed neurotoxic chemotherapy 3-24 months prior was undertaken using CIPN patient-reported outcomes (EORTC-QLQ-CIPN20), clinically graded scale (NCI-CTCAE), neurological examination score (TNSc), autonomic outcome measure (SAS), and Sudoscan. Differences in CIPN severity between participants with or without ESC dysfunction were investigated. Linear regression analyses were used to identify whether ESC values could predict CIPN severity. RESULTS A total of 130 participants were assessed, with 93 participants classified with CIPN according to the clinically graded scale (NCI-CTCAE/grade ≥ 1), while 49% demonstrated hands or feet ESC dysfunction (n = 46). Participants with ESC dysfunction did not significantly differ from those with no dysfunction on multiple CIPN severity measures (clinical-grade, patient-report, neurological examination), and no differences on the autonomic outcome measure (SAS) (all p > 0.0063). Linear regression analyses showed that CIPN could not be predicted by ESC values. CONCLUSIONS The inability of ESC values via Sudoscan to predict clinically-graded and patient-reported CIPN or autonomic dysfunction questions its clinical utility for chemotherapy-treated patients. The understanding of autonomic neuropathy with chemotherapy treatment remains limited and must be addressed to improve quality of life in cancer survivors.
Collapse
Affiliation(s)
- Fawaz Mayez Mahfouz
- grid.1013.30000 0004 1936 834XBrain and Mind Centre, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2050 Australia
| | - Susanna B. Park
- grid.1013.30000 0004 1936 834XBrain and Mind Centre, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2050 Australia
| | - Tiffany Li
- grid.1013.30000 0004 1936 834XBrain and Mind Centre, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2050 Australia
| | - Hannah C. Timmins
- grid.1013.30000 0004 1936 834XBrain and Mind Centre, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2050 Australia
| | - Lisa G. Horvath
- grid.419783.0Chris O’Brien Lifehouse, Camperdown, NSW 2050 Australia ,grid.1013.30000 0004 1936 834XSydney Medical School, The University of Sydney, Camperdown, NSW 2050 Australia ,grid.413249.90000 0004 0385 0051Royal Prince Alfred Hospital, Camperdown, NSW 2050 Australia
| | - Michelle Harrison
- grid.419783.0Chris O’Brien Lifehouse, Camperdown, NSW 2050 Australia ,grid.415994.40000 0004 0527 9653Department of Medical Oncology, Liverpool Hospital, Liverpool, NSW 2170 Australia
| | - Peter Grimison
- grid.419783.0Chris O’Brien Lifehouse, Camperdown, NSW 2050 Australia ,grid.1013.30000 0004 1936 834XSydney Medical School, The University of Sydney, Camperdown, NSW 2050 Australia
| | - Tracy King
- grid.1013.30000 0004 1936 834XCancer Nursing Research Unit, The University of Sydney, Camperdown, NSW 2050 Australia ,grid.413249.90000 0004 0385 0051Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, NSW 2050 Australia
| | - David Goldstein
- grid.1005.40000 0004 4902 0432Prince of Wales Clinical School, Faculty of Medicine and Health, UNSW Sydney, Randwick, NSW 2031 Australia ,grid.415193.bDepartment of Medical Oncology, Prince of Wales Hospital, Randwick, NSW 2031 Australia
| | - David Mizrahi
- grid.1005.40000 0004 4902 0432Prince of Wales Clinical School, Faculty of Medicine and Health, UNSW Sydney, Randwick, NSW 2031 Australia ,grid.1013.30000 0004 1936 834XThe Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Camperdown, NSW 2050 Australia
| |
Collapse
|
19
|
Novak P, Mukerji SS, Alabsi HS, Systrom D, Marciano SP, Felsenstein D, Mullally WJ, Pilgrim DM. Multisystem Involvement in Post-acute Sequelae of COVID-19 (PASC). Ann Neurol 2021; 91:367-379. [PMID: 34952975 PMCID: PMC9011495 DOI: 10.1002/ana.26286] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/15/2021] [Accepted: 12/20/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe cerebrovascular, neuropathic and autonomic features of post-acute sequelae of COVID-19 (PASC). METHODS This retrospective study evaluated consecutive patients with chronic fatigue, brain fog and orthostatic intolerance consistent with PASC. Controls included postural tachycardia syndrome patients (POTS) and healthy participants. Analyzed data included surveys and autonomic (Valsalva maneuver, deep breathing, sudomotor and tilt tests), cerebrovascular (cerebral blood flow velocity (CBFv) monitoring in middle cerebral artery), respiratory (capnography monitoring) and neuropathic (skin biopsies for assessment of small fiber neuropathy) testing and inflammatory/autoimmune markers. RESULTS Nine PASC patients were evaluated 0.7±0.3 years after a mild COVID-19 infection, treated as home observations. Autonomic, pain, brain fog, fatigue and dyspnea surveys were abnormal in PASC and POTS (n=10), compared to controls (n=15). Tilt table test reproduced the majority of PASC symptoms. Orthostatic CBFv declined in PASC (-20.0±13.4%) and POTS (-20.3±15.1%), compared to controls (-3.0±7.5%,p=0.001) and was independent of end-tidal carbon dioxide in PASC, but caused by hyperventilation in POTS. Reduced orthostatic CBFv in PASC included both subjects without (n=6) and with (n=3) orthostatic tachycardia. Dysautonomia was frequent (100% in both PASC and POTS) but was milder in PASC (p=0.013). PASC and POTS cohorts diverged in frequency of small fiber neuropathy (89% vs. 60%) but not in inflammatory markers (67% vs. 70%). Supine and orthostatic hypocapnia was observed in PASC. INTERPRETATION PASC following mild COVID-19 infection is associated with multisystem involvement including: 1) cerebrovascular dysregulation with persistent cerebral arteriolar vasoconstriction; 2) small fiber neuropathy and related dysautonomia; 3) respiratory dysregulation; 4) chronic inflammation. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Peter Novak
- Department of Neurology, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Shibani S Mukerji
- Department of Neurology, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Haitham S Alabsi
- Department of Neurology, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - David Systrom
- Department of Medicine, Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Sadie P Marciano
- Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Donna Felsenstein
- Department of Infectious Disease and Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - William J Mullally
- Department of Neurology, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - David M Pilgrim
- Department of Neurology, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| |
Collapse
|
20
|
Postural tachycardia syndrome (POTS) and antiphospholipid syndrome (APS): What do we know so far? Rev Neurol (Paris) 2021; 178:306-314. [PMID: 34895744 DOI: 10.1016/j.neurol.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/05/2021] [Accepted: 10/05/2021] [Indexed: 11/21/2022]
Abstract
As part of the non-criteria clinical manifestations, postural orthostatic tachycardia syndrome (POTS), a multisystem autonomic dysfunction, can co-exist with antiphospholipid syndrome (APS). Several pieces of evidence hint on the autoimmune basis of POTS, and its possible association with several autoimmune diseases, including APS. Indeed, the evidence exists in the etiologies, symptomatology, and treatment options. Although infections, viral ones in particular, stress, and pregnancy are etiologies to both POTS and APS, the exact pathophysiological connection is still to be studied taking into consideration the activity of cytokines in both diseases. Nevertheless, certain immunomodulatory treatments used for the catastrophic or obstetrical forms of APS, such as intravenous immunoglobulins (IVIG) and steroids, have been also used for the treatment of POTS resistant to classical treatments. Therefore, our review aims to highlight the association between POTS and APS, shedding light on the common etiologies explaining the pathophysiology of the two disorders, the diagnostic approach to POTS as a possible clinical criterion of APS, and the treatment of APS in the context of treating POTS.
Collapse
|
21
|
Ziegler D, Keller J, Maier C, Pannek J. Diabetische Neuropathie. DIABETOL STOFFWECHS 2021. [DOI: 10.1055/a-1515-9168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Dan Ziegler
- Institut für Klinische Diabetologie, Deutsches Diabetes-Zentrum an der Heinrich-Heine-Universität, Leibniz-Zentrum für Diabetesforschung; Klinik für Endokrinologie und Diabetologie, Universitätsklinikum Düsseldorf
| | - Jutta Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg
| | - Christoph Maier
- Universitätsklinik für Kinder- und Jugendmedizin, Ruhr-Universität Bochum
| | - Jürgen Pannek
- Neuro-Urologie, Schweizer Paraplegiker-Zentrum Nottwil, Schweiz
| |
Collapse
|
22
|
Novak P, Giannetti MP, Weller E, Hamilton MJ, Castells M. Mast cell disorders are associated with decreased cerebral blood flow and small fiber neuropathy. Ann Allergy Asthma Immunol 2021; 128:299-306.e1. [PMID: 34648976 DOI: 10.1016/j.anai.2021.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/01/2021] [Accepted: 10/08/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Mast cell disorders including hereditary alpha tryptasemia (HαT) and idiopathic mast cell activation syndrome (MCAS) can be associated with neurologic symptoms such as orthostatic intolerance, pain, and cognitive impairment. The origin of these symptoms is not well understood. OBJECTIVE To characterize neurologic findings in patients with HαT and MCAS through objective measurements. METHODS Patients with a confirmed diagnosis of HαT or MCAS with neurologic symptoms were referred for standardized autonomic testing encompassing Valsalva maneuver, deep breathing, sudomotor and tilt tests with cerebral blood flow velocity (CBFv) determination, and skin biopsies for small fiber neuropathy (SFN). RESULTS There were 15 patients with HαT (age 44.4 ± 15.9 years), 16 with MCAS (34.4 ± 15.5), and 14 matched controls who were evaluated. Baseline serum tryptase level was increased in patients with HαT when compared with patients with MCAS (14.3 ± 2.5 ng/mL vs 3.8 ± 1.8; P <.001) and neurologic symptoms were similar between the 2 groups. When compared with controls, orthostatic CBFv was reduced in HαT (-24.2 ± 14.3%; P <.001) and MCAS (-20.8 ± 5.5%; P <.001). Reduced nerve fibers consistent with SFN were found in 80% of patients with HαT and 81% of those with MCAS. Mild-to-moderate dysautonomia was detected in all patients with HαT and MCAS when results of sympathetic, parasympathetic, and sudomotor tests were combined. CONCLUSION We provide evidence of reduced orthostatic CBFv and SFN associated with mild-to-moderate autonomic dysfunction in patients with HαT and MCAS. Our findings suggest that comprehensive autonomic testing may be helpful to explain neurologic symptoms and guide treatment in patients with HαT and MCAS.
Collapse
Affiliation(s)
- Peter Novak
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Matthew P Giannetti
- Harvard Medical School, Boston, Massachusetts; Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emily Weller
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Matthew J Hamilton
- Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Endoscopy, and Hepatology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mariana Castells
- Harvard Medical School, Boston, Massachusetts; Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
23
|
Anoop S, Dasgupta R, Jebasingh FK, Ramachandran R, Kurian ME, Rebekah G, Balsubramanian KA, Thomas N. Exocrine pancreatic insufficiency related fat malabsorption and its association with autonomic neuropathy in Asian Indians with type 2 diabetes mellitus. Diabetes Metab Syndr 2021; 15:102273. [PMID: 34520998 DOI: 10.1016/j.dsx.2021.102273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS We aimed to estimate the prevalence of exocrine pancreatic insufficiency (EPI) related fat malabsorption & to correlate it with measures of autonomic neuropathy in patients with T2DM from India. METHODS Patients with T2DM (cases; n = 118) and normo-glycaemic individuals (controls; n = 82) underwent anthropometry and biochemical evaluation at baseline. The 72-hours fecal fat excretion was estimated by the Van de Kamer's titration method. Autonomic neuropathy was evaluated using an automated analyzer. RESULTS The prevalence of EPI related fat malabsorption in cases was 45% (n = 53; 72 hours mean fecal fat level = 22.7 ± 5.6 g/day). Dysfunctions in the parasympathetic nervous system (PNS; 86.7%; p < 0.05), sympathetic nervous system (SNS; 92.4%; p < 0.05), and both; PNS + SNS (83.1%; p < 0.05) were significant. Amongst measures of PNS dysfunction, there was a significantly higher percentage of abnormal expiration: inspiration ratio (45.3%) and the 30:15 ratio (84.9%) (p < 0.05) in patients with T2DM and EPI related fat malabsorption. CONCLUSION In this cross-sectional cohort of Asian Indian patients with T2DM (n = 118), EPI related fat malabsorption correlates significantly with autonomic dysfunction in patients with T2DM. However, these preliminary data need to confirmed in trials with more robust design.
Collapse
Affiliation(s)
- Shajith Anoop
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
| | - Riddhi Dasgupta
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
| | - Felix K Jebasingh
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
| | - Roshna Ramachandran
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
| | | | - Grace Rebekah
- Department of Biostatistics, Christian Medical College, Vellore, India
| | - K A Balsubramanian
- Division of Gastrointestinal Sciences, Wellcome Research Laboratory, Christian Medical College, Vellore, India
| | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India.
| |
Collapse
|
24
|
Affiliation(s)
- Dan Ziegler
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Department of Endocrinology and Diabetology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jutta Keller
- Department of Internal Medicine, Israelite Hospital, Hamburg, Germany
| | - Christoph Maier
- Department of Pain Medicine, Ruhr University, Bochum, Germany
| | - Jürgen Pannek
- Neuro-Urology, Swiss Paraplegic Center Nottwil, Switzerland
| |
Collapse
|
25
|
Zhang Y, Fan D, Zhang Y, Zhang S, Wang H, Liu Z, Wang H. Using corneal confocal microscopy to compare Mecobalamin intramuscular injections vs oral tablets in treating diabetic peripheral neuropathy: a RCT. Sci Rep 2021; 11:14697. [PMID: 34282267 PMCID: PMC8290034 DOI: 10.1038/s41598-021-94284-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/18/2021] [Indexed: 02/04/2023] Open
Abstract
This randomized controlled study used corneal confocal microscopy (CCM) to compare the efficacy of Mecobalamin intramuscular injections vs oral tablets in treating mild to moderate diabetic peripheral neuropathy (DPN) by detecting early nerve fiber repair. Enrolled patients were randomized approximately 1:1 to receive Mecobalamin intramuscular injections (0.5 mg/day, 3 times/week) or Mecobalamin oral tablets (1.5 mg/day) for 8 weeks. Primary outcome was change of inferior whorl length (IWL) from baseline. Secondary outcomes included changes of corneal nerve fibre length (CNFL), corneal nerve fibre density (CNFD), corneal nerve branch density (CNBD) and the Survey of Autonomic Symptoms (SAS). 15 (93.75%) patients in the injection group and 17 (89.47%) patients in the tablet group completed the study. The injection treatment significantly improved patients' IWL from baseline (21.64 ± 3.00 mm/mm2 vs 17.64 ± 4.83 mm/mm2, P < 0.01) while the tablet treatment didn't. Additionally, the injection treatment led to significantly improved CNFL, CNBD and SAS from baseline (all P < 0.05) while the tablet treatment did not. No patient experienced any adverse events. In conclusion, CCM is sensitive enough to detect the superior efficacy of 8-week Mecobalamin intramuscular injection treatment for DPN compared to the oral tablet treatment.ClinicalTrials.gov registration number: NCT04372316 (30/04/2020).
Collapse
Affiliation(s)
- Yuanjin Zhang
- Neurology Department, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China
- Beijing Municipal Key Laboratory of Biomarker and Translational Research in Neurodegenerative Disease, Beijing, China
| | - Dongsheng Fan
- Neurology Department, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China.
- Beijing Municipal Key Laboratory of Biomarker and Translational Research in Neurodegenerative Disease, Beijing, China.
| | - Yixuan Zhang
- Neurology Department, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China
- Beijing Municipal Key Laboratory of Biomarker and Translational Research in Neurodegenerative Disease, Beijing, China
| | - Shuo Zhang
- Neurology Department, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China
- Beijing Municipal Key Laboratory of Biomarker and Translational Research in Neurodegenerative Disease, Beijing, China
| | - Haikun Wang
- Department of Ophthalmology, Peking University Third Hospital, Beijing, China
| | - Ziyuan Liu
- Department of Ophthalmology, Peking University Third Hospital, Beijing, China
| | - Hongli Wang
- Neurology Department, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China
| |
Collapse
|
26
|
Siepmann T, Ohle P, Sedghi A, Simon E, Arndt M, Pallesen LP, Ritschel G, Barlinn J, Reichmann H, Puetz V, Barlinn K. Randomized Sham-Controlled Pilot Study of Neurocardiac Function in Patients With Acute Ischaemic Stroke Undergoing Heart Rate Variability Biofeedback. Front Neurol 2021; 12:669843. [PMID: 34122314 PMCID: PMC8187903 DOI: 10.3389/fneur.2021.669843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 04/16/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Neurocardiac dysfunction worsens clinical outcome and increases mortality in stroke survivors. We hypothesized that heart rate variability (HRV) biofeedback improves neurocardiac function by modulating autonomic nervous system activity after acute ischaemic stroke (AIS). Methods: We randomly allocated (1:1) 48 acute ischaemic stroke patients to receive nine sessions of HRV- or sham biofeedback over 3 days in addition to comprehensive stroke unit care. Before and after the intervention patients were evaluated for HRV via standard deviation of normal-to-normal intervals (SDNN, primary outcome), root mean square of successive differences between normal heartbeats (RMSSD), a predominantly parasympathetic measure, and for sympathetic vasomotor and sudomotor function. Severity of autonomic symptoms was assessed via survey of autonomic symptom scale total impact score (TIS) at baseline and after 3 months. Results: We included 48 patients with acute ischaemic stroke [19 females, ages 65 (4.4), median (interquartile range)]. Treatment with HRV biofeedback increased HRV post intervention [SDNN: 43.5 (79.0) ms vs. 34.1 (45.0) ms baseline, p = 0.015; RMSSD: 46.0 (140.6) ms vs. 29.1 (52.2) ms baseline, p = 0.015] and alleviated autonomic symptoms after 3 months [TIS 3.5 (8.0) vs. 7.5 (7.0) baseline, p = 0.029], which was not seen after sham biofeedback (SDNN: p = 0.63, RMSSD: p = 0.65, TIS: 0.06). There were no changes in sympathetic vasomotor and sudomotor function (p = ns). Conclusions: Adding HRV biofeedback to standard stroke unit care led to improved neurocardiac function and sustained alleviation of autonomic symptoms after acute ischaemic stroke, which was likely mediated by a predominantly parasympathetic mechanism. Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT03865225.
Collapse
Affiliation(s)
- Timo Siepmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Paulin Ohle
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Annahita Sedghi
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Erik Simon
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Martin Arndt
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Lars-Peder Pallesen
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Gerhard Ritschel
- Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jessica Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| |
Collapse
|
27
|
Berenbaum F, Schnitzer TJ, Kivitz AJ, Viktrup L, Hickman A, Pixton G, Brown MT, Davignon I, West CR. General Safety and Tolerability of Subcutaneous Tanezumab for Osteoarthritis: A Pooled Analysis of 3 Randomized, Placebo-Controlled Trials. Arthritis Care Res (Hoboken) 2021; 74:918-928. [PMID: 33973384 PMCID: PMC9310640 DOI: 10.1002/acr.24637] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/07/2021] [Accepted: 04/27/2021] [Indexed: 11/08/2022]
Abstract
Objective This pooled analysis of 3 randomized, placebo‐controlled trials (16–24 week treatment and 8–24 week follow‐up) assessed safety of subcutaneous tanezumab (2.5–10 mg every 8 weeks) in 1,840 patients with hip or knee osteoarthritis. Methods Overall treatment‐emergent adverse events (TEAEs) and TEAEs of abnormal peripheral sensation (APS) were prospectively assessed in 3 trials. Joint safety events (primary osteonecrosis, rapidly progressive osteoarthritis [RPOA], subchondral insufficiency fracture, and pathologic fracture; adjudicated by an independent expert committee) and TEAEs potentially associated with sympathetic neuropathy were prospectively assessed in 2 trials. Results During the treatment period, overall TEAE rates were 51.7% for placebo and 39.5–54.8% for tanezumab 2.5–10 mg; treatment discontinuation rates were 2.0% for placebo and 0–1.3% for tanezumab. Rates of composite joint safety events (predominantly RPOA type 1) over the treatment plus follow‐up period were 0% for placebo and 0.5–3.2% for tanezumab 2.5–5 mg (5 mg was statistically greater than placebo); total joint replacement rates with tanezumab (5.9–7.0%) were not significantly different from placebo (4.5%). Rates of TEAEs of APS (predominantly paresthesia and hypoesthesia) were 2.2% for placebo and 3.2–12.8% for tanezumab 2.5–10 mg. Rates of TEAEs potentially associated with sympathetic neuropathy (predominantly bradycardia and orthostatic hypotension) were 0.8% for placebo and 0.5–2.8% for tanezumab 2.5–5 mg (exposure‐adjusted rates were not significantly different from placebo). Conclusion Tanezumab was generally well tolerated. TEAEs of APS (mostly mild and transient) and joint safety events were infrequent but more common with tanezumab than placebo. A tanezumab dose of 2.5 mg demonstrated a more favorable safety profile than higher doses.
Collapse
Affiliation(s)
- Francis Berenbaum
- Sorbonne Université, INSERM, AP-HP Hospital Saint Antoine, Paris, France
| | - Thomas J Schnitzer
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alan J Kivitz
- Altoona Center for Clinical Research, Duncansville, Pennsylvania, USA
| | | | | | | | | | | | | |
Collapse
|
28
|
Trevino JA, Novak P. TS‐HDS
and
FGFR3
antibodies in small fiber neuropathy and Dysautonomia. Muscle Nerve 2021; 64:70-76. [DOI: 10.1002/mus.27245] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 03/23/2021] [Accepted: 03/28/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Jorge A. Trevino
- Department of Neurology Brigham and Women's Hospital, Harvard Medical School Boston Massachusetts USA
| | - Peter Novak
- Department of Neurology Brigham and Women's Hospital, Harvard Medical School Boston Massachusetts USA
| |
Collapse
|
29
|
Rocha EA, Mehta N, Távora-Mehta MZP, Roncari CF, Cidrão AADL, Elias J. Dysautonomia: A Forgotten Condition - Part 1. Arq Bras Cardiol 2021; 116:814-835. [PMID: 33886735 PMCID: PMC8121406 DOI: 10.36660/abc.20200420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/29/2020] [Accepted: 09/09/2020] [Indexed: 11/18/2022] Open
Abstract
Dysautonomia covers a range of clinical conditions with different characteristics and prognoses. They are classified as Reflex Syndromes, Postural Orthostatic Tachycardia Syndrome (POTS), Chronic Fatigue Syndrome, Neurogenic Orthostatic Hypotension (nOH) and Carotid Sinus Hypersensitivity Syndrome. Reflex (vasovagal) syndromes will not be discussed in this article. Reflex (vasovagal) syndromes are mostly benign and usually occur in patients without an intrinsic autonomic nervous system (ANS) or heart disease. Therefore, they are usually studied separately. Cardiovascular Autonomic Neuropathy (CAN) is the term most currently used to define dysautonomia with impairment of the sympathetic and/or parasympathetic cardiovascular autonomic nervous system. It can be idiopathic, such as multisystemic atrophy or pure autonomic failure, or secondary to systemic pathologies such as diabetes mellitus, neurodegenerative diseases, Parkinson's disease, dementia syndromes, chronic renal failure, amyloidosis and it may also occur in the elderly. The presence of Cardiovascular Autonomic Neuropathy (CAN) implies greater severity and worse prognosis in various clinical situations. Detection of Orthostatic Hypotension (OH) is a late sign and means greater severity in the context of dysautonomia, defined as Neurogenic Orthostatic Hypotension (nOH). It must be differentiated from hypotension due to hypovolemia or medications, called non-neurogenic orthostatic hypotension (nnOH). OH can result from benign causes, such as acute, chronic hypovolemia or use of various drugs. However, these drugs may only reveal subclinical pictures of Dysautonomia. All drugs of patients with dysautonomic conditions should be reevaluated. Precise diagnosis of CAN and the investigation of the involvement of other organs or systems is extremely important in the clinical suspicion of pandysautonomia. In diabetics, in addition to age and time of disease, other factors are associated with a higher incidence of CAN, such poor glycemic control, hypertension, dyslipidemia and obesity. Among diabetic patients, 38-44% can develop Dysautonomia, with prognostic implications and higher cardiovascular mortality. In the initial stages of DM, autonomic dysfunction involves the parasympathetic system, then the sympathetic system and, later on, it presents as orthostatic hypotension. Valsalva, Respiratory and Orthostatic tests (30:15) are the gold standard methods for the diagnosis of CAN. They can be associated with RR Variability tests in the time domain, and mainly in the frequency domain, to increase the sensitivity (protocol of the 7 tests). These tests can detect initial or subclinical abnormalities and assess severity and prognosis. The Tilt Test should not be the test of choice for investigating CAN at an early stage, as it detects cases at more advanced stages. Tilt response with a dysautonomic pattern (gradual drop in blood pressure without increasing heart rate) may suggest CAN. Treatment of patients at moderate to advanced stages of dysautonomia is quite complex and often refractory, requiring specialized and multidisciplinary evaluation. There is no cure for most types of Dysautonomia at a late stage. NOH patients can progress with supine hypertension in more than 50% of the cases, representing a major therapeutic challenge. The immediate risk and consequences of OH should take precedence over the later risks of supine hypertension and values greater than 160/90 mmHg are tolerable. Sleeping with the head elevated (20-30 cm), not getting up at night, taking short-acting antihypertensive drugs for more severe cases, such as losartan, captopril, clonidine or nitrate patches, may be necessary and effective in some cases. Preventive measures such as postural care; good hydration; higher salt intake; use of compression stockings and abdominal straps; portioned meals; supervised physical activity, mainly sitting, lying down or exercising in the water are important treatment steps. Various drugs can be used for symptomatic nOH, especially fludrocortisone, midodrine and droxidopa, the latter not available in Brazil. The risk of exacerbation or triggering supine hypertension should be considered. Chronic Fatigue Syndrome represents a form of Dysautonomia and has been renamed as a systemic disease of exercise intolerance, with new diagnostic criteria: 1 - Unexplained fatigue, leading to occupational disability for more than 6 months; 2 - Feeling ill after exercising; 3 - Non-restorative sleep; 4 - One of the following findings: cognitive impairment or orthostatic intolerance. Several pathologies today have evolved with chronic fatigue, being called chronic diseases associated with chronic fatigue. Postural orthostatic tachycardia syndrome (POTS), another form of presentation of dysautonomic syndromes, is characterized by sustained elevation of heart rate (HR) ≥30 bpm (≥40 bpm if <20 years) or HR ≥120 bpm, in the first 10 minutes in an orthostatic position or during the tilt test, without classical orthostatic hypotension associated. A slight decrease in blood pressure may occur. Symptoms appear or get worse in an orthostatic position, with dizziness, weakness, pre-syncope, palpitations, and other systemic symptoms being common.
Collapse
Affiliation(s)
- Eduardo Arrais Rocha
- Universidade Federal do CearáHospital Universitário Walter CantídioFaculdade de Medicina da UFCFortalezaCEBrasilHospital Universitário Walter Cantídio da Universidade Federal do Ceará (UFC) - Programa de Pós-graduação em Ciências Cardiovasculares da Faculdade de Medicina da UFC, Fortaleza, CE - Brasil
| | - Niraj Mehta
- Universidade Federal do ParanáCuritibaPRBrasilUniversidade Federal do Paraná, Curitiba, PR - Brasil
- Clínica de Eletrofisiologia do ParanáCuritibaPRBrasilClínica de Eletrofisiologia do Paraná, Curitiba, PR - Brasil
| | - Maria Zildany Pinheiro Távora-Mehta
- Universidade Federal do ParanáCuritibaPRBrasilUniversidade Federal do Paraná, Curitiba, PR - Brasil
- Clínica de Eletrofisiologia do ParanáCuritibaPRBrasilClínica de Eletrofisiologia do Paraná, Curitiba, PR - Brasil
| | - Camila Ferreira Roncari
- Universidade Federal do CearáFaculdade de MedicinaDepartamento de Fisiologia e FarmacologiaFortalezaCEBrasilDepartamento de Fisiologia e Farmacologia - Faculdade de Medicina da Universidade Federal do Ceará (UFC), Fortaleza, CE - Brasil
| | - Alan Alves de Lima Cidrão
- Faculdade de Medicina da UFCFortalezaCEBrasilPrograma de Pós-graduação em Ciências Cardiovasculares da Faculdade de Medicina da UFC, Fortaleza, CE - Brasil
| | - Jorge Elias
- Serviço de Eletrofisiologia do Vitória Apart HospitalVitóriaESBrasilServiço de Eletrofisiologia do Vitória Apart Hospital, Vitória, ES - Brasil
| |
Collapse
|
30
|
Abstract
It is increasingly recognized that diabetic neuropathy is associated with early diabetes, prediabetes, and the metabolic syndrome. Early detection and diagnosis are important to slow progression and prevent complications. Although strict glucose control is an effective treatment in type 1 diabetes, it is less effective in type 2 diabetes. There is a growing body of literature that lifestyle interventions may be able to prevent or slow progression of neuropathy in type 2 diabetes. In addition to the typical distal symmetric polyneuropathy, there are many types of "atypical" diabetic neuropathies that are important to recognize.
Collapse
Affiliation(s)
- Lindsay A Zilliox
- Department of Neurology, University of Maryland School of Medicine & Maryland VA Healthcare System, 3S-130, 110 South Paca Street, Baltimore, MD 21201-1595, USA.
| |
Collapse
|
31
|
|
32
|
DiRenzo D, Russell J, Bingham CO, McMahan Z. The Relationship Between Autonomic Dysfunction of the Gastrointestinal Tract and Emotional Distress in Patients With Systemic Sclerosis. J Clin Rheumatol 2021; 27:11-17. [PMID: 31524844 PMCID: PMC7065966 DOI: 10.1097/rhu.0000000000001144] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND/OBJECTIVES We hypothesized that emotional distress in systemic sclerosis (SSc) patients with moderate to severe gastrointestinal (GI) dysfunction is associated with dysautonomia. We sought to determine (1) the clinical characteristics associated with emotional distress in SSc, (2) the odds of having dysautonomia in those with emotional distress, and (3) whether GI dysautonomia, as measured by the Survey of Autonomic Symptoms (SAS), correlates with GI dysautonomia on the Composite Autonomic Symptom Score-31 (COMPASS-31). METHODS Clinical and demographic features from our prospective cohort study were compared among SSc patients with and without GI-associated emotional distress (University of California at Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract 2.0 well-being subscale >0.5 or ≤0.5) in cross-sectional analysis. Covariates/confounders independently associated with emotional distress were used to construct multivariable logistic regression models. The COMPASS-31 and SAS GI subdomains were compared with Spearman correlation. RESULTS Forty-six patients with SSc were enrolled in the study. In univariate analyses, age (odds ratio [OR], 1.06; p = 0.026), severity of GI dysautonomia (COMPASS-31: OR, 1.41; p = 0.003), anti-centromere (A/B) antibodies (OR, 3.60; p = 0.044), and anti-PM-Scl (75/100) antibodies (OR, 0.15; p = 0.035) were associated with emotional distress. In the adjusted model, those with more severe GI dysautonomia remained more likely to have emotional distress (OR, 1.85; p = 0.026); those with anti-PM-Scl (75/100) antibodies were less likely to have emotional distress (OR, 0.03; p = 0.031). The SAS and COMPASS-31 GI subdomains moderately correlated (ρ = 0.68, p < 0.001). CONCLUSIONS In SSc, increased symptom burden related to GI dysautonomia is associated with emotional distress. Multidisciplinary approaches addressing both the physical and emotional needs of the SSc patient may be warranted to optimize patient care.
Collapse
Affiliation(s)
- Dana DiRenzo
- Johns Hopkins University School of Medicine, Division of Rheumatology
| | | | | | - Zsuzsanna McMahan
- Johns Hopkins University School of Medicine, Division of Rheumatology
| |
Collapse
|
33
|
Raasing LR, Vogels OJ, Veltkamp M, van Swol CF, Grutters JC. Current View of Diagnosing Small Fiber Neuropathy. J Neuromuscul Dis 2021; 8:185-207. [PMID: 33337383 PMCID: PMC8075405 DOI: 10.3233/jnd-200490] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Small fiber neuropathy (SFN) is a disorder of the small myelinated Aδ-fibers and unmyelinated C-fibers [5, 6]. SFN might affect small sensory fibers, autonomic fibers or both, resulting in sensory changes, autonomic dysfunction or combined symptoms [7]. As a consequence, the symptoms are potentially numerous and have a large impact on quality of life [8]. Since diagnostic methods for SFN are numerous and its pathophysiology complex, this extensive review focusses on categorizing all aspects of SFN as disease and its diagnosis. In this review, sensitivity in combination with specificity of different diagnostic methods are described using the areas under the curve. In the end, a diagnostic work-flow is suggested based on different phenotypes of SFN.
Collapse
Affiliation(s)
- Lisette R.M. Raasing
- ILD Center of Excellence, Department of Pulmonology,St Antonius Hospital, CM, Nieuwegein, The Netherlands
| | - Oscar J.M. Vogels
- Department of Neurology, St Antonius Hospital, CM, Nieuwegein, The Netherlands
| | - Marcel Veltkamp
- ILD Center of Excellence, Department of Pulmonology,St Antonius Hospital, CM, Nieuwegein, The Netherlands
- Division of Heart and Lungs, University Medical Center Utrecht, CX, Utrecht, The Netherlands
| | | | - Jan C. Grutters
- ILD Center of Excellence, Department of Pulmonology,St Antonius Hospital, CM, Nieuwegein, The Netherlands
- Division of Heart and Lungs, University Medical Center Utrecht, CX, Utrecht, The Netherlands
| |
Collapse
|
34
|
Lutchmansingh K, Venkatesh YS, Boppana LKT, Seemungal T, Rao A, Sandy S, Teelucksingh S. The Slipping Slipper Sign: A Poor Man's Test for Severe Diabetic Peripheral Neuropathy. J Neuromuscul Dis 2020; 7:175-181. [PMID: 31929118 DOI: 10.3233/jnd-190422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Neuropathic feet are at very high risk for infection and amputation. The slipping slipper sign (SSS) is elicited by a simple questionnaire test reported to detect the presence of severe diabetic peripheral neuropathy. This test can be administered by non-medical staff. In this study, subjects with and without the SSS were evaluated by nerve conduction studies (NCS) and ultrasound measurements of the right sural nerve diameters as well as with traditional scoring systems for peripheral and autonomic neuropathy. OBJECTIVE To demonstrate that the Slipping Slipper Sign can be used as an index of severe diabetic peripheral neuropathyMethod:This was a prospective cross sectional study in which 74 patients with diabetes (38 positive and 36 negative for SSS) underwent ultrasonography and NCS of the right sural nerve by an examiner blinded to SSS status. Findings were evaluated against demography, clinical history, anthropometry as well as traditional clinical and autonomic neuropathic scores. RESULTS Patients without the SSS [median (IQR) = 10.0 years (4.0-20.3)] had a significantly shorter duration of diabetes compared with those with the SSS [median (IQR) = 15.0 years (8.5-25.0)], p = 0.028. The frequencies of retinopathy (36.8% vs 2.8%, p < 0.05) and cerebrovascular accidents (18.4% vs 13.9 %, p < 0.05) were higher among those with SSS compared with those without. Differences in nerve conduction characteristics were markedly significant. The amplitude of the sural sensory nerve action potential (SNAP) was ([median (IQR)] 0 microvolts vs 4.0 microvolts (0.0-10.8) p < 0.002) between those with and without SSS, respectively whilst none of patients with SSS had a recordable SNAP vs 78% without a SSS. Similarly, maximal thickness of the right sural nerve at the ankle 3.0 mm (2.3-3.4) vs 3.5 mm (3.0-3.9), and leg 3.4 mm (2.7-3.8) vs 3.9 mm (3.3-4.2) was reduced, p < 0.01 in patients with the SSS compared with those with a negative SSS. CONCLUSION The SSS identifies feet with objective neurophysiological and imaging characteristics of severe neuropathy.
Collapse
Affiliation(s)
- Khama Lutchmansingh
- Department of Clinical Medical Sciences, The University of the West Indies, St Augustine Campus, Trinidad and Tobago
| | - Y Swamy Venkatesh
- Department of Neurology, University of South Carolina School of Medicine, SC, USA
| | - Leela Krishna Teja Boppana
- Department of Clinical Medical Sciences, The University of the West Indies, St Augustine Campus, Trinidad and Tobago
| | - Terence Seemungal
- Department of Clinical Medical Sciences, The University of the West Indies, St Augustine Campus, Trinidad and Tobago
| | - Ambika Rao
- Department of Endocrinology, Diabetes and Metabolism, William Jennings Bryan Dorn VA Medical Center, SC, USA
| | - Sherry Sandy
- Department of Clinical Medical Sciences, The University of the West Indies, St Augustine Campus, Trinidad and Tobago
| | - Surujpal Teelucksingh
- Department of Clinical Medical Sciences, The University of the West Indies, St Augustine Campus, Trinidad and Tobago
| |
Collapse
|
35
|
Zilliox LA, Russell JW. Is there cardiac autonomic neuropathy in prediabetes? Auton Neurosci 2020; 229:102722. [PMID: 33011523 DOI: 10.1016/j.autneu.2020.102722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 06/09/2020] [Accepted: 08/24/2020] [Indexed: 02/09/2023]
Abstract
Although there is considerably more data showing an association between type 2 diabetes mellitus (T2DM) and autonomic neuropathy, accumulating evidence indicates that cardiovascular autonomic neuropathy (CAN) is common in persons with impaired glucose tolerance (IGT). Furthermore, CAN may occur early after a metabolic insult and obesity, especially among mean, and seems to play an important role in the early pathogenesis of CAN. Autonomic symptoms are common in subjects with IGT. In addition to defects in CAN, in subjects with IGT, there is impaired sudomotor function and abnormalities of endothelial peripheral vasoreactivity. At the present time, the only interventions that may be effective in preventing or reversing IGT associated autonomic neuropathy are lifestyle improvement. These include a tailored diet and exercise program. Other approaches that may be beneficial include modulation of oxidative stress and improvement of metabolic regulation in subjects with IGT. Interventions are most likely to be effective early in the course of disease and therefore it is extremely important to have early diagnosis of IGT and autonomic neuropathy.
Collapse
Affiliation(s)
- Lindsay A Zilliox
- Department of Neurology, University of Maryland and Maryland VA Healthcare System, Baltimore, MD, United States of America
| | - James W Russell
- Department of Neurology, University of Maryland and Maryland VA Healthcare System, Baltimore, MD, United States of America.
| |
Collapse
|
36
|
Ziegler D, Keller J, Maier C, Pannek J. Diabetische Neuropathie. DIABETOL STOFFWECHS 2020. [DOI: 10.1055/a-1194-1692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Dan Ziegler
- Institut für Klinische Diabetologie, Deutsches Diabetes-Zentrum an der Heinrich-Heine-Universität, Leibniz-Zentrum für Diabetesforschung; Klinik für Endokrinologie und Diabetologie, Universitätsklinikum Düsseldorf
| | - Jutta Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg
| | - Christoph Maier
- Abteilung für Schmerzmedizin, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Ruhr-Universität, Bochum
| | - Jürgen Pannek
- Neuro-Urologie, Schweizer Paraplegiker-Zentrum Nottwil, Schweiz
| |
Collapse
|
37
|
Syngle A, Chahal S, Vohra K. Efficacy and tolerability of DPP4 inhibitor, teneligliptin, on autonomic and peripheral neuropathy in type 2 diabetes: an open label, pilot study. Neurol Sci 2020; 42:1429-1436. [PMID: 32803534 DOI: 10.1007/s10072-020-04681-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 08/08/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Diabetic neuropathy increases risk of cardiovascular disease, peripheral artery disease, foot amputation and overall mortality. Not only hyperglycaemia induced nerve damage is harder to repair using currently approved medications, but also, the use of these agents is often limited by the extent of pain relief provided and side effects. METHODOLOGY In this prospective, open-label, pilot study, 20 type-2 diabetes mellitus patients (male/female=13/7, mean age- 56.1±8.04 years), meeting inclusion/exclusion criteria, were treated with dipeptidyl peptidase-4 (DPP-4) inhibitor, Teneligliptin, 20mg once a day for three months. Efficacy parameters: Sudomotor function (Sudoscan score); parasympathetic dysfunction assessed using Ewing's criteria i.e. heart rate response to -standing (HRS), -valsalva (HRV) and -deep breath (HRD); sympathetic dysfunction assessed as blood pressure response to -standing (BPS) and -handgrip (BPH); ankle brachial index (ABI), vibration perception threshold (VPT), C-reactive protein, glycemic profile and health related quality of life (HRQoL); and, tolerability parameters: complete blood count, liver function tests, serum creatinine, thyroid stimulating hormone, QT- interval and serum vitamin B12 levels, were measured. RESULTS There was no statistical difference in BMI, SBP, DBP, HRD, BPH and all safety parameters. After 12 weeks treatment, there was improvement in HRS (p<0.01) and HRV (p<0.01), but not in HRD (p=0.12). BPS was significantly lowered (p <0.01), but not the BPH (p =0.06). Sudoscan score was increased, while VPT was significantly decreased (both p<0.01). CONCLUSION Teneligliptin not only improves the glycemic status but also improves sudomotor function, peripheral and autonomic neuropathy, and reduces vascular inflammation in type 2 diabetes.
Collapse
Affiliation(s)
- Ashit Syngle
- Healing Touch City Clinic, # 547, Sector 16-D, Chandigarh, India.,Fortis Multi Specialty Hospital, Mohali, Punjab, India
| | - Simran Chahal
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, India
| | - Kanchan Vohra
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, India.
| |
Collapse
|
38
|
Patel K, Horak H, Tiryaki E. Diabetic neuropathies. Muscle Nerve 2020; 63:22-30. [DOI: 10.1002/mus.27014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 06/20/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Kamakshi Patel
- Department of Neurology, University of Texas Medical Branch Galveston Texas USA
| | - Holli Horak
- Department of Neurology, University of Arizona Tucson Arizona USA
| | - Ezgi Tiryaki
- Department of Neurology, University of Minnesota Minneapolis Minnesota USA
| |
Collapse
|
39
|
Kotagal V, Szpara A, Albin RL, Bohnen NI. Fatigue in Parkinson's Disease Associates with Lower Ambulatory Diastolic Blood Pressure. JOURNAL OF PARKINSONS DISEASE 2020; 9:575-581. [PMID: 31156183 PMCID: PMC6682445 DOI: 10.3233/jpd-191579] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND/OBJECTIVE Fatigue is a common debilitating symptom in Parkinson's disease (PD) of unclear etiology. Hypotension and blood pressure variability are common in PD though their relationship to other non-motor symptoms is less well understood. METHODS We conducted a cross-sectional study to explore differences in 24-hour ambulatory blood pressure measurements in PD subjects (n = 35) with and without fatigue. Subjects underwent hourly systolic (SBP) and diastolic (DBP) blood pressure testing in their home environment. The presence of fatigue was assessed using the Movement Disorders Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part 1. We compared blood pressure measurements in fatigued vs. non-fatigued PD subjects, assessed over 4 epochs: overnight, morning, midday, and evening. RESULTS PD subjects with symptoms of fatigue demonstrated lower mean DBP, compared to those without fatigue (67.8±4.8 mmHg vs. 75.6±9.4 t = 2.57, p = 0.014). These intergroup differences were most notable in the morning. The two groups did not differ in scoring on the Survey of Autonomic Symptoms or on an office-based blood assessment of SBP or DBP performed on the day of 24-hour monitor initiation. CONCLUSIONS Fatigue in PD may be a clinical manifestation of low-grade systemic hypotension.
Collapse
Affiliation(s)
- Vikas Kotagal
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Health System (VAAAHS) and GRECC, Ann Arbor, MI, USA
| | - Ashley Szpara
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Health System (VAAAHS) and GRECC, Ann Arbor, MI, USA
| | - Roger L Albin
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Health System (VAAAHS) and GRECC, Ann Arbor, MI, USA.,University of Michigan Morris K. Udall Center of Excellence for Parkinson's Disease Research, Ann Arbor, MI, USA
| | - Nicolaas I Bohnen
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Health System (VAAAHS) and GRECC, Ann Arbor, MI, USA.,University of Michigan Morris K. Udall Center of Excellence for Parkinson's Disease Research, Ann Arbor, MI, USA.,Department of Radiology, Division of Nuclear Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
40
|
Resham K, Khare P, Bishnoi M, Sharma SS. Neuroprotective effects of isoquercitrin in diabetic neuropathy via Wnt/β-catenin signaling pathway inhibition. Biofactors 2020; 46:411-420. [PMID: 31960520 DOI: 10.1002/biof.1615] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 11/28/2019] [Indexed: 12/12/2022]
Abstract
Diabetic neuropathy is a peripheral nervous system disorder affecting both somatic and autonomic components of nervous system. A growing body of evidence have depicted that high glucose levels can induce activation of the Wnt/β-catenin pathway, however there are no studies targeting this pathway in DN. The intent of the present study was to investigate the effects of isoquercitrin (ISQ), a Wnt/β-catenin signaling pathway inhibitor, in diabetic neuropathy. Streptozotocin (50 mg/kg, i.p.) was used to induce diabetes in rats. 6-week diabetic rats were treated intrathecally with ISQ at 10 and 30 μM doses for 3 days. Furthermore, to confirm the results of the intrathecal study, a 2-week intraperitoneal treatment of ISQ was given to diabetic rats. After 6 weeks, diabetic rats developed neuropathy which was evident from reduced thermal and mechanical hyperalgesia thresholds and significant deterioration in motor nerve conduction velocity (MNCV), nerve blood flow (NBF). Sciatic nerves of diabetic neuropathy rats showed increased expression of Wnt pathway proteins namely β-catenin, c-myc and MMP2. Treatment with ISQ, both intrathecally (10 and 30 μM) and intraperitoneally (10 mg/kg), significantly ameliorated the alterations in behavioral pain thresholds and improved functional parameters in diabetic rats. Moreover, ISQ also downregulated the expression of Wnt/β-catenin pathway proteins significantly in diabetic rats as compared to vehicle-treated diabetic rats. Results of the present study suggest the neuroprotective potential of ISQ in the treatment of DN via inhibition of Wnt/β-catenin signaling pathway.
Collapse
Affiliation(s)
- Kahkashan Resham
- Department of Pharmacology & Toxicology, National Institute of Pharmaceutical Education and Research, Punjab, India
| | - Pragyanshu Khare
- Food and Nutritional Biotechnology Division, National Agri-Food Biotechnology Institute, Punjab, India
| | - Mahendra Bishnoi
- Food and Nutritional Biotechnology Division, National Agri-Food Biotechnology Institute, Punjab, India
| | - Shyam S Sharma
- Department of Pharmacology & Toxicology, National Institute of Pharmaceutical Education and Research, Punjab, India
| |
Collapse
|
41
|
Porubcin MG, Novak P. Diagnostic Accuracy of Electrochemical Skin Conductance in the Detection of Sudomotor Fiber Loss. Front Neurol 2020; 11:273. [PMID: 32425871 PMCID: PMC7212463 DOI: 10.3389/fneur.2020.00273] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 03/24/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Small fiber neuropathy (SFN) is a common health problem. SFN is associated with loss of small fibers, either sensory, autonomic or both. Reduced autonomic sudomotor sweat gland nerve fiber density (SGNFD) and sensory epidermal nerve fiber density (ENFD) can be seen in SFN. Electrochemical skin conductance (ESC) is a non-invasive test for measurement of sudomotor function. This study evaluated the diagnostic accuracy of ESC to detect abnormal SGNFD and ENFD. Methods: This was a retrospective blinded study of participants referred for evaluation of SFN. The primary outcome measure was the specificity and sensitivity of ESC to diagnose loss of small fibers using SGNFD and ENFD as reference tests. The secondary outcome measures were the correlation between ESC and neuropathy severity, pain, and autonomic clinical scales. Results: Two hundred ten patients were enrolled in the study, age (mean ± sd) 45.5 ± 16.1 years, men/women = 52/158. ESC adjusted for weight (ESC/kg) was reduced in subjects with abnormally low SGNFD (normal/abnormal, ESC/kg = 1.19 ± 0.31/0.94 ± 0.37 μS/kg, p < 0.0001) and abnormally low ENFD (normal/abnormal ESC/kg 1.20 ± 0.37/1.04 ± 0.33 μS/kg, p < 0.0011). ESC/kg correlated with SGNFD (ρ = 0.39, p < 0.0001) and ENFD (ρ = 0.47, p < 0.0001). ESC/kg did not correlate with symptom scales. ESC/kg had 64% sensitivity and 77% specificity (ROC 0.73, p = 0.0001) to predict abnormal SGNFD and 69% sensitivity and 55% specificity (ROC 0.63, p = 0.0017) to predict abnormal ENFD. In comparison, SGNFD had 50.1% sensitivity and 85.1% specificity to predict abnormal ENFD (ROC 0.69, p = 0.0001). Conclusion: ESC/kg has modest accuracy to detect SGNFD loss. ESC may be a useful test in characterization of small fiber neuropathy.
Collapse
Affiliation(s)
- Michal G Porubcin
- Brigham and Women's Faulkner Hospital, Harvard Medical School, Boston, MA, United States
| | - Peter Novak
- Brigham and Women's Faulkner Hospital, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
42
|
Berenbaum F, Blanco FJ, Guermazi A, Miki K, Yamabe T, Viktrup L, Junor R, Carey W, Brown MT, West CR, Verburg KM. Subcutaneous tanezumab for osteoarthritis of the hip or knee: efficacy and safety results from a 24-week randomised phase III study with a 24-week follow-up period. Ann Rheum Dis 2020; 79:800-810. [PMID: 32234715 PMCID: PMC7286052 DOI: 10.1136/annrheumdis-2019-216296] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/28/2020] [Accepted: 01/29/2020] [Indexed: 11/21/2022]
Abstract
Objective Tanezumab, a nerve growth factor inhibitor, was investigated for osteoarthritis (OA) of the hip or knee in a study with 24-week treatment and 24-week safety follow-up. Methods This double-blind, randomised, phase III study enrolled adults in Europe and Japan with moderate-to-severe OA who had not responded to or could not tolerate standard-of-care analgesics. Patients were randomised to tanezumab 2.5 mg or 5 mg subcutaneously or matching placebo every 8 weeks (three doses). Co-primary end points were change from baseline to week 24 in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain and Physical Function, and Patient’s Global Assessment of OA (PGA-OA). Joint safety and neurological assessments continued throughout the 48-week study. Results From March 2016 to December 2017, 849 patients were randomised and evaluated (placebo n=282, tanezumab 2.5 mg n=283, tanezumab 5 mg n=284). At week 24, there was a statistically significant improvement from baseline for tanezumab 5 mg compared with placebo for WOMAC Pain (least squares mean difference±SE –0.62±0.18, p=0.0006), WOMAC Physical Function (–0.71±0.17, p<0.0001) and PGA-OA (–0.19±0.07, p=0.0051). For tanezumab 2.5 mg, there was a statistically significant improvement in WOMAC Pain and Physical Function, but not PGA-OA. Rapidly progressive osteoarthritis (RPOA) was observed in 1.4% (4/283) and 2.8% (8/284) of patients in the tanezumab 2.5 mg and tanezumab 5 mg groups, respectively and none receiving placebo. Total joint replacements (TJRs) were similarly distributed across all three treatment groups (6.7%–7.8%). Tanezumab-treated patients experienced more paraesthesia (5 mg) and hypoaesthesia (both doses) than placebo. Conclusion Tanezumab 5 mg statistically significantly improved pain, physical function and PGA-OA, but tanezumab 2.5 mg only achieved two co-primary end points. RPOA occurred more frequently with tanezumab 5 mg than tanezumab 2.5 mg. TJRs were similarly distributed across all three groups. Trial registration number NCT02709486.
Collapse
Affiliation(s)
- Francis Berenbaum
- Department of Rheumatology, Sorbonne Université, INSERM CRSA, AP-HP Hopital Saint Antoine, Paris, France
| | - Francisco J Blanco
- Servicio de Reumatología, INIBC-Complejo Hospitalario Universitario A Coruña, La Coruña, Spain
| | - Ali Guermazi
- Department of Radiology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Kenji Miki
- Faculty of Health Science, Osaka Yukioka College of Health Science, Hayaishi Hospital, Osaka, Japan
| | | | - Lars Viktrup
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | | | | | | | | |
Collapse
|
43
|
Callaghan BC, Reynolds EL, Banerjee M, Chant E, Villegas-Umana E, Gardner TW, Votruba K, Giordani B, Pop-Busui R, Pennathur S, Feldman EL. The Prevalence and Determinants of Cognitive Deficits and Traditional Diabetic Complications in the Severely Obese. Diabetes Care 2020; 43:683-690. [PMID: 31932459 PMCID: PMC7035591 DOI: 10.2337/dc19-1642] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/24/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the prevalence of cognitive deficits and traditional diabetic complications and the association between metabolic factors and these outcomes. RESEARCH DESIGN AND METHODS We performed a cross-sectional study in severely obese individuals before bariatric surgery. Lean control subjects were recruited from a research website. Cognitive deficits were defined by the National Institutes of Health (NIH) Toolbox (<5th percentile for lean control subjects). Cardiovascular autonomic neuropathy (CAN) was defined by an expiration-to-inspiration (E-to-I) ratio of <5th percentile for lean control subjects. Retinopathy was based on retinal photographs and nephropathy on the estimated glomerular filtration rate (<60 mg/dL) and/or the albumin-to-creatinine ratio (ACR) (≥30 mg/g). NIH Toolbox, E-to-I ratio, mean deviation on frequency doubling technology testing, and ACR were used as sensitive measures of these outcomes. We used multivariable linear regression to explore associations between metabolic factors and these outcomes. RESULTS We recruited 138 severely obese individuals and 46 lean control subjects. The prevalence of cognitive deficits, CAN, retinopathy, and nephropathy were 6.5%, 4.4%, 0%, and 6.5% in lean control subjects; 22.2%, 18.2%, 0%, and 6.1% in obese participants with normoglycemia; 17.7%, 21.4%, 1.9%, and 17.9% in obese participants with prediabetes; and 25.6%, 31.9%, 6.1%, and 16.3% in obese participants with diabetes. Waist circumference was significantly associated with cognitive function (-1.48; 95% CI -2.38, -0.57) and E-to-I ratio (-0.007; 95% CI -0.012, -0.002). Prediabetes was significantly associated with retinal function (-1.78; 95% CI -3.56, -0.002). CONCLUSIONS Obesity alone is likely sufficient to cause cognitive deficits but not retinopathy or nephropathy. Central obesity is the key metabolic risk factor.
Collapse
|
44
|
D'Amato C, Greco C, Lombardo G, Frattina V, Campo M, Cefalo CMA, Izzo V, Lauro D, Spallone V. The diagnostic usefulness of the combined COMPASS 31 questionnaire and electrochemical skin conductance for diabetic cardiovascular autonomic neuropathy and diabetic polyneuropathy. J Peripher Nerv Syst 2020; 25:44-53. [PMID: 31985124 DOI: 10.1111/jns.12366] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 01/18/2020] [Accepted: 01/21/2020] [Indexed: 01/01/2023]
Abstract
The study investigated the diagnostic performance for diabetic cardiovascular autonomic neuropathy (CAN) and diabetic polyneuropathy (DPN) of the combined use of composite autonomic symptom score (COMPASS) 31, validated questionnaire for autonomic symptoms of CAN, and electrochemical skin conductance (ESC), proposed for detecting DPN and CAN. One-hundred and two participants with diabetes (age 57 ± 14 years, duration 17 ± 13 years) completed the COMPASS 31 before assessing cardiovascular reflex tests (CARTs), neuropathic symptoms, signs, vibratory perception threshold (VPT), thermal thresholds (TT), and ESC using Sudoscan. Two patterns were evaluated: (a) the combined abnormalities in both tests (COMPASS 31+ESC), and (b) the abnormality in COMPASS 31 and/or ESC (COMPASS 31 and/or ESC). CAN (≥1 abnormal CART) and confirmed CAN (≥2 abnormal CARTs) were present in 28.1% and 12.5%, DPN (two abnormalities among symptoms, signs, VPT, and TT) in 52%, abnormal COMPASS 31 (total weighted score >16.44) in 48% and abnormal ESC (hands ESC <50 μS and/or feet ESC <70 μS) in 47.4%. Both the patterns-COMPASS 31+ESC and COMPASS 31 and/or ESC-were associated with CAN and DPN (P < .01). COMPASS 31 and ESC reached a sensitivity of 75% and 83% for confirmed CAN, and a specificity of 65% and 67% for DPN. When combining the tests, the sensitivity for CAN rose by up to 100% for CAN and the specificity up to 89% for DPN. The combination of the tests can allow a stepwise screening strategy for CAN, by suggesting CAN absence with combined normality, and prompting to CARTs with combined abnormality.
Collapse
Affiliation(s)
- Cinzia D'Amato
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Carla Greco
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giorgio Lombardo
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Valentina Frattina
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Mariagrazia Campo
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Chiara M A Cefalo
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Valentina Izzo
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Davide Lauro
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Vincenza Spallone
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| |
Collapse
|
45
|
Sicca Symptoms in Parkinson's Disease: Association with Other Nonmotor Symptoms and Health-Related Quality of Life. PARKINSONS DISEASE 2020; 2020:2958635. [PMID: 32104559 PMCID: PMC7038154 DOI: 10.1155/2020/2958635] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/11/2019] [Accepted: 01/22/2020] [Indexed: 12/13/2022]
Abstract
Background Frequently used nonmotor scales do not cover all aspects of dysautonomia in Parkinson's disease (PD). This study explores the association between autonomic symptoms and sicca symptoms with other nonmotor symptoms and health-related quality of life (QoL) in PD. Methods Autonomic symptoms (Survey of Autonomic Symptoms, SASs), motor function (Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale III, MDS-UPDRS III), nonmotor symptoms (nonmotor symptoms questionnaire, NMS-Quest), and QoL (PD Questionnaire-39, PDQ-39) were analysed in 93 PD patients without dementia. Multivariable and multivariate analyses were performed to study the association between clinical parameters and PDQ-39 domains. Results Among the autonomic symptoms, sicca symptoms (xerostomia and dry eyes) were the most commonly reported (69%), followed by sexual dysfunction in men, leaking of urine, vasomotor dysfunction, constipation, sudomotor dysfunction, and orthostatic symptoms. The autonomic symptom burden (SAS total) correlated with the NMS-Quest and Hoehn and Yahr stage, but not with age, levodopa equivalent daily dose, disease duration, and the MDS-UPDRS III. The SAS total score was an independent predictor of the PDQ-39 summary index and mainly affected the PDQ-39 cognition and emotional well-being domains. Sicca symptoms were not associated with age, MDS-UPDRS III, disease duration, Hoehn and Yahr stage, and levodopa equivalent daily dose but aggravated the PDQ-39 domains: cognition, emotional well-being, bodily discomfort, and mobility. Sicca symptoms frequently occur together with other nonmotor symptoms, namely, urine urgency, orthostatic problems, and concentration problems. Overall, 75% of the subjects took at least one drug that can cause sicca symptoms (anti-PD medication, antidepressant drugs, antihypertensive drugs, antipsychotic drugs, antimuscarinic drugs, and analgesic drugs). Conclusion Sicca symptoms are common in PD and negatively influence QoL. The observed association between sicca symptoms and other nonmotor symptoms provides further preliminary evidence for the growing recognition of different nonmotor clusters in PD.
Collapse
|
46
|
Lai HY, Foo LL, Lim SM, Yong CF, Loh PS, Chaw SH, Hasan MS, Wang CY. The hemodynamic and pain impact of peripheral nerve block versus spinal anesthesia in diabetic patients undergoing diabetic foot surgery. Clin Auton Res 2020; 30:53-60. [PMID: 29196938 DOI: 10.1007/s10286-017-0485-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 11/18/2017] [Indexed: 01/31/2023]
Abstract
PURPOSE Comparison of hemodynamic profiles and pain scores in diabetic patients undergoing diabetic foot surgery receiving peripheral nerve block (PNB) or spinal anesthesia [subarachnoid block (SAB)]. METHODS This was a prospective, randomised controlled trial. We recruited diabetic patients aged > 18 years, American Society of Anesthesiologists class II-III, who were scheduled for unilateral diabetic foot surgery below the knee. All patients were assessed for autonomic dysfunction using the Survey of Autonomic Symptoms score. Participants were randomly assigned to receive either PNB or SAB for the surgery. Hemodynamic data, including usage of vasopressors, were recorded at 5-min intervals for up to 1 h after the induction of anesthesia. Pain scores were recorded postoperatively, and follow-up was done via telephone 6 months later. RESULTS Compared to the PNB group, the SAB group had a larger number of patients with significant hypotension (14 vs. 1; p = 0.001) and more patients who required vasopressor boluses (6 vs. 0 patients). Compared to SAB group, the patients in the PNB group had a longer postoperative pain-free duration (9 vs. 4.54 h; p = 0.002) and lower pain scores 1 day after surgery (3.63 vs. 4.69; p = 0.01). CONCLUSION Peripheral nerve block should be considered, whenever possible, as the first option of anesthesia for lower limb surgery in diabetic patients as it provides hemodynamic stability and superior postoperative pain control compared to SAB. TRIAL REGISTRATION Clinical trial registry: ClinicalTrials.gov. ID NCT02727348.
Collapse
Affiliation(s)
- Hou Yee Lai
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Li Lian Foo
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Siu Min Lim
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Chen Fei Yong
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Pui San Loh
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Sook Hui Chaw
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Mohd Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Chew Yin Wang
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| |
Collapse
|
47
|
Yan A, Issar T, Tummanapalli SS, Markoulli M, Kwai NCG, Poynten AM, Krishnan AV. Relationship between corneal confocal microscopy and markers of peripheral nerve structure and function in Type 2 diabetes. Diabet Med 2020; 37:326-334. [PMID: 30897245 DOI: 10.1111/dme.13952] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2019] [Indexed: 01/03/2023]
Abstract
AIMS To investigate changes in corneal nerve morphology in Type 2 diabetes and to establish relationships between in vivo corneal confocal microscopy and markers of peripheral nerve structure and function. PARTICIPANTS AND METHODS We recruited 57 participants with Type 2 diabetes and 26 healthy controls of similar age and sex distribution. We also recruited a disease control group of 54 participants with Type 1 diabetes. All participants were assessed for distal symmetrical polyneuropathy using the Total Neuropathy Score. In vivo corneal confocal microscopy was used to assess corneal nerve fibre length, corneal nerve fibre density, corneal nerve branch density and inferior whorl length. Peripheral nerve structure was assessed using median nerve ultrasonography. Large fibre function was assessed according to median nerve axonal excitability. Small fibre function was assessed using SudoscanTM and the Survey of Autonomic Symptoms. RESULTS Corneal nerve fibre length, fibre density and branch density and inferior whorl length were significantly lower in individuals with Type 2 diabetes compared to controls (P<0.001 for all). In the Type 2 diabetes cohort, correlations were observed between neuropathy severity and corneal nerve fibre density (P=0.004), corneal nerve branch density (P=0.003), corneal nerve fibre length (P=0.002) and inferior whorl length (P=0.01). Significant correlations were observed between corneal confocal outcomes and axonal excitability measurements. No association was found between corneal confocal microscopy and median nerve cross-sectional area, Sudoscan measurements or the Survey of Autonomic Symptoms. CONCLUSIONS This study demonstrated significant changes in corneal nerves in individuals with Type 2 diabetes. Reductions in corneal nerve measures correlated with increasing neuropathy severity. Associations were found between corneal confocal microscopy and markers of voltage-gated potassium channel function.
Collapse
Affiliation(s)
- A Yan
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - T Issar
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - S S Tummanapalli
- School of Optometry and Vision Science, University of New South Wales, Sydney, NSW, Australia
| | - M Markoulli
- School of Optometry and Vision Science, University of New South Wales, Sydney, NSW, Australia
| | - N C G Kwai
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - A M Poynten
- Department of Endocrinology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - A V Krishnan
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| |
Collapse
|
48
|
Ziegler D, Keller J, Maier C, Pannek J. Diabetische Neuropathie. DER DIABETOLOGE 2020; 16:40-53. [DOI: 10.1007/s11428-019-00569-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
49
|
Chicharro-Luna E, Pomares-Gómez FJ, Ortega-Ávila AB, Marchena-Rodríguez A, Blanquer-Gregori JFJ, Navarro-Flores E. Predictive model to identify the risk of losing protective sensibility of the foot in patients with diabetes mellitus. Int Wound J 2019; 17:220-227. [PMID: 31691513 DOI: 10.1111/iwj.13263] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 12/15/2022] Open
Abstract
Diabetic neuropathy is defined as the presence of symptoms and signs of peripheral nerve dysfunction in diabetics. The aim of this study is to develop a predictive logistic model to identify the risk of losing protective sensitivity in the foot. This descriptive cross-sectional study included 111 patients diagnosed with diabetes mellitus. Participants completed a questionnaire designed to evaluate neuropathic symptoms, and multivariate analysis was subsequently performed to identify an optimal predictive model. The explanatory capacity was evaluated by calculating the R2 coefficient of Nagelkerke. Predictive capacity was evaluated by calculating sensitivity, specificity, and estimation of the area under the receiver operational curve. Protective sensitivity loss was detected in 19.1% of participants. Variables associated by multivariate analysis were: educational level (OR: 31.4, 95% CI: 2.5-383.3, P = .007) and two items from the questionnaire: one related to bleeding and wet socks (OR: 28.3, 95% CI: 3.7-215.9, P = .001) and the other related to electrical sensations (OR: 52.9, 95% CI: 4.3-643.9, P = .002), which were both statistically significant. The predictive model included the variables of age, sex, duration of diabetes, and educational level, and it had a sensitivity of 81.3% and a specificity of 95.5%. This model has a high predictive capacity to identify patients at risk of developing sensory neuropathy.
Collapse
Affiliation(s)
- Esther Chicharro-Luna
- Department of Behavioral Sciences and Health, Nursing Area, Faculty of Medicine, University Miguel Hernández, San Juan de Alicante, Spain
| | | | - Ana Belen Ortega-Ávila
- Department of Nursing and Podiatry, Faculty of Health Sciences, University of Malaga, Malaga, Spain
| | - Ana Marchena-Rodríguez
- Department of Nursing and Podiatry, Faculty of Health Sciences, University of Malaga, Malaga, Spain
| | | | - Emmanuel Navarro-Flores
- Department of Nursing, Faculty of Nursing and Podiatry, Frailty Research Organized Group, Universidad de Valencia, Valencia, Spain
| |
Collapse
|
50
|
Oaklander AL, Nolano M. Scientific Advances in and Clinical Approaches to Small-Fiber Polyneuropathy: A Review. JAMA Neurol 2019; 76:1240-1251. [PMID: 31498378 PMCID: PMC10021074 DOI: 10.1001/jamaneurol.2019.2917] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Small-fiber polyneuropathy involves preferential damage to the thinly myelinated A-delta fibers, unmyelinated C sensory fibers, or autonomic or trophic fibers. Although this condition is common, most patients still remain undiagnosed and untreated because of lagging medical and public awareness of research advances. Chronic bilateral neuropathic pain, fatigue, and nausea are cardinal symptoms that can cause disability and dependence, including pain medication dependence. OBSERVATIONS Biomarker confirmation is recommended, given the nonspecificity of symptoms. The standard test involves measuring epidermal neurite density within a 3-mm protein gene product 9.5 (PGP9.5)-immunolabeled lower-leg skin biopsy. Biopsies and autonomic function testing confirm that small-fiber neuropathy not uncommonly affects otherwise healthy children and young adults, in whom it is often associated with inflammation or dysimmunity. A recent meta-analysis concluded that small-fiber neuropathy underlies 49% of illnesses labeled as fibromyalgia. Initially, patients with idiopathic small-fiber disorders should be screened by medical history and blood tests for potentially treatable causes, which are identifiable in one-third to one-half of patients. Then, secondary genetic testing is particularly important for familial and childhood cases. Treatable genetic causes include Fabry disease, transthyretin and primary systemic amyloidosis, hereditary sensory autonomic neuropathy-1, and ion-channel mutations. Immunohistopathologic evidence suggests that small-fiber dysfunction and denervation, especially of blood vessels, contributes to diverse symptoms, including postexertional malaise, postural orthostatic tachycardia, and functional gastrointestinal distress. Preliminary evidence implicates acute or chronic autoreactivity in some cases, particularly in female patients and otherwise healthy children and young adults. Different temporal patterns akin to Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy have been described; here, corticosteroids and immunoglobulins, which are often efficacious for inflammatory neuropathic conditions, are increasingly considered. CONCLUSIONS AND RELEVANCE Because small fibers normally grow throughout life, improving contributory conditions may permit regrowth, slow progression, and prevent permanent damage. The prognosis is often hopeful for improving quality of life and sometimes for abatement or resolution, particularly in the young and otherwise healthy individuals. Examples include diabetic, infectious, toxic, genetic, and inflammatory causes. The current standard of care requires prompt diagnosis and treatment, particularly in children and young adults, to restore life trajectory. Consensus diagnostic and tracking metrics should be established to facilitate treatment trials.
Collapse
Affiliation(s)
- Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Pathology (Neuropathology), Massachusetts General Hospital, Boston
| | - Maria Nolano
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University "Federico II" of Naples, Naples, Italy.,Skin Biopsy Laboratory, Department of Neurology, IRCCS, Istituti Clinici Scientifici Maugeri, SpA SB, Telese Terme, Italy
| |
Collapse
|