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Baumgartner T, Théaudin M, Loser V. Diffuse and acute pain syndrome in a 60-year-old woman. Pract Neurol 2024; 24:169-172. [PMID: 38253380 DOI: 10.1136/pn-2023-004024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/24/2024]
Affiliation(s)
- Thomas Baumgartner
- Nerve-Muscle Unit, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Marie Théaudin
- Nerve-Muscle Unit, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Valentin Loser
- Nerve-Muscle Unit, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Mooshage CM, Schimpfle L, Kender Z, Tsilingiris D, Aziz-Safaie T, Hohmann A, Szendroedi J, Nawroth P, Sturm V, Heiland S, Bendszus M, Kopf S, Kurz FT, Jende JME. Association of Small Fiber Function with Microvascular Perfusion of Peripheral Nerves in Patients with Type 2 Diabetes : Study using Quantitative Sensory Testing and Magnetic Resonance Neurography. Clin Neuroradiol 2024; 34:55-66. [PMID: 37548682 PMCID: PMC10881621 DOI: 10.1007/s00062-023-01328-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/19/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION/AIMS Diabetic small fiber neuropathy (SFN) is caused by damage to thinly myelinated A‑fibers (δ) and unmyelinated C‑fibers. This study aimed to assess associations between quantitative sensory testing (QST) and parameters of peripheral nerve perfusion obtained from dynamic contrast enhanced (DCE) magnetic resonance neurography (MRN) in type 2 diabetes patients with and without SFN. METHODS A total of 18 patients with type 2 diabetes (T2D, 8 with SFN, 10 without SFN) and 10 healthy controls (HC) took part in this cross-sectional single-center study and underwent QST of the right leg and DCE-MRN of the right thigh with subsequent calculation of the sciatic nerve constant of capillary permeability (Ktrans), extravascular extracellular volume fraction (Ve), and plasma volume fraction (Vp). RESULTS The Ktrans (HC 0.031 min-1 ± 0.009, T2D 0.043 min-1 ± 0.015; p = 0.033) and Ve (HC 1.2% ± 1.5, T2D: 4.1% ± 5.1; p = 0.027) were lower in T2D patients compared to controls. In T2D patients, compound z‑scores of thermal and mechanical detection correlated with Ktrans (r = 0.73; p = 0.001, and r = 0.57; p = 0.018, respectively) and Ve (r = 0.67; p = 0.002, and r = 0.69; p = 0.003, respectively). Compound z‑scores of thermal pain and Vp (r = -0.57; p = 0.015) correlated negatively. DISCUSSION The findings suggest that parameters of peripheral nerve microcirculation are related to different symptoms in SFN: A reduced capillary permeability may result in a loss of function related to insufficient nutritional supply, whereas increased capillary permeability may be accompanied by painful symptoms related to a gain of function.
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Affiliation(s)
- Christoph M Mooshage
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Lukas Schimpfle
- Department of Endocrinology, Diabetology and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center of Diabetes Research, associated partner in the DZD, Munich-Neuherberg, Germany
- Institute for Diabetes and Cancer (IDC), Helmholtz Diabetes Center, Helmholtz Center, Munich, Neuherberg, Munich, Germany
| | - Zoltan Kender
- German Center of Diabetes Research, associated partner in the DZD, Munich-Neuherberg, Germany
- Institute for Diabetes and Cancer (IDC), Helmholtz Diabetes Center, Helmholtz Center, Munich, Neuherberg, Munich, Germany
| | - Dimitrios Tsilingiris
- Department of Endocrinology, Diabetology and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Taraneh Aziz-Safaie
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Anja Hohmann
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Julia Szendroedi
- Department of Endocrinology, Diabetology and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center of Diabetes Research, associated partner in the DZD, Munich-Neuherberg, Germany
- Joint Heidelberg-IDC Translational Diabetes Program, Inner Medicine 1, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Nawroth
- Department of Endocrinology, Diabetology and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center of Diabetes Research, associated partner in the DZD, Munich-Neuherberg, Germany
- Joint Heidelberg-IDC Translational Diabetes Program, Inner Medicine 1, Heidelberg University Hospital, Heidelberg, Germany
| | - Volker Sturm
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Department of Neuroradiology, Division of Experimental Radiology, Heidelberg, Germany
| | - Sabine Heiland
- Department of Neuroradiology, Division of Experimental Radiology, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Stefan Kopf
- Department of Endocrinology, Diabetology and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center of Diabetes Research, associated partner in the DZD, Munich-Neuherberg, Germany
- Institute for Diabetes and Cancer (IDC), Helmholtz Diabetes Center, Helmholtz Center, Munich, Neuherberg, Munich, Germany
| | - Felix T Kurz
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- German Cancer Research Center, Heidelberg, Germany
| | - Johann M E Jende
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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Kaplan H, Yüzbaşıoğlu S, Vural G, Gümüşyayla Ş. Investigation of small fiber neuropathy in patients with diabetes mellitus by corneal confocal microscopy. Neurophysiol Clin 2024; 54:102955. [PMID: 38422588 DOI: 10.1016/j.neucli.2024.102955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVES Corneal confocal microscopy (CCM) is a non-invasive technique that examines the corneal cellular structure. Its use in the detection of small fiber neuropathy is being researched. In our study, we examined the role of CCM in the detection of small fiber neuropathy in diabetic patients, as well as the differences between CCM findings in diabetic patients with and without overt polyneuropathy with neuropathic symptoms. METHODS 56 Diabetes Mellitus (DM) patients and 18 healthy controls were included in the study. The individuals included in the study were divided into three groups. Patients with diabetes who were found to have polyneuropathy according to electrophysiological diagnostic criteria were classified as Group 1, patients with diabetes and neuropathic symptoms without overt polyneuropathy according to electrophysiological diagnostic criteria were classified as Group 2, and healthy individuals were classified as Group 3. Electrophysiological examination and corneal imaging with CCM were performed in all groups. RESULTS The CNFD and CNFL values of individuals in the diabetic group were discovered to be lower. CNFD values differ statistically between the groups (p = 0.047). Group 1-Group 3 differs from Group 2-Group 3 (respectively; p = 0.018, p = 0.048). CONCLUSION Our study demonstrates that CCM can be used in patients with neuropathic symptoms and no polyneuropathy detected in EMG and thought to have small fiber neuropathy. CCM provides an opportunity for early diagnosis in small fiber neuropathy.
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Affiliation(s)
| | - Sema Yüzbaşıoğlu
- Department of Ophthalmology, Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkiye
| | - Gönül Vural
- Department of Neurology, Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkiye
| | - Şadiye Gümüşyayla
- Department of Neurology, Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkiye.
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Mooshage CM, Tsilingiris D, Schimpfle L, Seebauer L, Eldesouky O, Aziz-Safaie T, Hohmann A, Herzig S, Szendroedi J, Nawroth P, Heiland S, Bendszus M, Kurz FT, Kopf S, Jende JME, Kender Z. A diminished sciatic nerve structural integrity is associated with distinct peripheral sensory phenotypes in individuals with type 2 diabetes. Diabetologia 2024; 67:275-289. [PMID: 38019287 PMCID: PMC10789832 DOI: 10.1007/s00125-023-06050-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 10/10/2023] [Indexed: 11/30/2023]
Abstract
AIMS/HYPOTHESIS Quantitative sensory testing (QST) allows the identification of individuals with rapid progression of diabetic sensorimotor polyneuropathy (DSPN) based on certain sensory phenotypes. Hence, the aim of this study was to investigate the relationship of these phenotypes with the structural integrity of the sciatic nerve among individuals with type 2 diabetes. METHODS Seventy-six individuals with type 2 diabetes took part in this cross-sectional study and underwent QST of the right foot and high-resolution magnetic resonance neurography including diffusion tensor imaging of the right distal sciatic nerve to determine the sciatic nerve fractional anisotropy (FA) and cross-sectional area (CSA), both of which serve as markers of structural integrity of peripheral nerves. Participants were then assigned to four sensory phenotypes (participants with type 2 diabetes and healthy sensory profile [HSP], thermal hyperalgesia [TH], mechanical hyperalgesia [MH], sensory loss [SL]) by a standardised sorting algorithm based on QST. RESULTS Objective neurological deficits showed a gradual increase across HSP, TH, MH and SL groups, being higher in MH compared with HSP and in SL compared with HSP and TH. The number of participants categorised as HSP, TH, MH and SL was 16, 24, 17 and 19, respectively. There was a gradual decrease of the sciatic nerve's FA (HSP 0.444, TH 0.437, MH 0.395, SL 0.382; p=0.005) and increase of CSA (HSP 21.7, TH 21.5, MH 25.9, SL 25.8 mm2; p=0.011) across the four phenotypes. Further, MH and SL were associated with a lower sciatic FA (MH unstandardised regression coefficient [B]=-0.048 [95% CI -0.091, -0.006], p=0.027; SL B=-0.062 [95% CI -0.103, -0.020], p=0.004) and CSA (MH β=4.3 [95% CI 0.5, 8.0], p=0.028; SL B=4.0 [95% CI 0.4, 7.7], p=0.032) in a multivariable regression analysis. The sciatic FA correlated negatively with the sciatic CSA (r=-0.35, p=0.002) and markers of microvascular damage (high-sensitivity troponin T, urine albumin/creatinine ratio). CONCLUSIONS/INTERPRETATION The most severe sensory phenotypes of DSPN (MH and SL) showed diminishing sciatic nerve structural integrity indexed by lower FA, likely representing progressive axonal loss, as well as increasing CSA of the sciatic nerve, which cannot be detected in individuals with TH. Individuals with type 2 diabetes may experience a predefined cascade of nerve fibre damage in the course of the disease, from healthy to TH, to MH and finally SL, while structural changes in the proximal nerve seem to precede the sensory loss of peripheral nerves and indicate potential targets for the prevention of end-stage DSPN. TRIAL REGISTRATION ClinicalTrials.gov NCT03022721.
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Affiliation(s)
- Christoph M Mooshage
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Dimitrios Tsilingiris
- Department of Endocrinology, Diabetology, Metabolism and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Heidelberg, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Lukas Schimpfle
- Department of Endocrinology, Diabetology, Metabolism and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Heidelberg, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Lukas Seebauer
- Department of Endocrinology, Diabetology, Metabolism and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Heidelberg, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Omar Eldesouky
- Department of Endocrinology, Diabetology, Metabolism and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Heidelberg, Germany
| | - Taraneh Aziz-Safaie
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Anja Hohmann
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stephan Herzig
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
- Institute for Diabetes and Cancer (IDC), Helmholtz Diabetes Center, Helmholtz Center, Munich, Neuherberg, Germany
- Joint Heidelberg-IDC Translational Diabetes Program, Inner Medicine 1, Heidelberg University Hospital, Heidelberg, Germany
| | - Julia Szendroedi
- Department of Endocrinology, Diabetology, Metabolism and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Heidelberg, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
- Joint Heidelberg-IDC Translational Diabetes Program, Inner Medicine 1, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Nawroth
- Department of Endocrinology, Diabetology, Metabolism and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Heidelberg, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
- Joint Heidelberg-IDC Translational Diabetes Program, Inner Medicine 1, Heidelberg University Hospital, Heidelberg, Germany
| | - Sabine Heiland
- Division of Experimental Radiology, Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix T Kurz
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
- German Cancer Research Center, Heidelberg, Germany
| | - Stefan Kopf
- Department of Endocrinology, Diabetology, Metabolism and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Heidelberg, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Johann M E Jende
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Zoltan Kender
- Department of Endocrinology, Diabetology, Metabolism and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Heidelberg, Germany.
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany.
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Zirpoli GR, Farhad K, Klein MC, Downs S, Klein MM, Oaklander AL. Initial validation of the Mass. General Neuropathy Exam Tool (MAGNET) for evaluation of distal small-fiber neuropathy. Muscle Nerve 2024; 69:185-198. [PMID: 38112169 PMCID: PMC10842781 DOI: 10.1002/mus.28013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/14/2023] [Accepted: 11/19/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION/AIMS Diagnosis of small-fiber neuropathy (SFN) is hampered by its subjective symptoms and signs. Confirmatory testing is insufficiently available and expensive, so predictive examinations have value. However, few support the 2020 SFN consensus-case-definition requirements or were validated for non-diabetes neuropathies. Thus we developed the Massachusetts General Hospital Neuropathy Exam Tool (MAGNET) and measured diagnostic performance in 160 symptomatic patients evaluated for length-dependent SFN from any cause and 37 healthy volunteers. METHODS We compared prevalences of abnormalities (vital signs, pupil responses, lower-limb appearance, pin, light touch, vibration and position sensitivity, great-toe strength, muscle stretch reflexes), and validated diagnostic performance against objective SFN tests: lower-leg skin-biopsy epidermal neurite densities and autonomic function testing (AFT). Sensitivity/specificity, feasibility, test-retest and inter-rater reliability, and convergence with the Utah Early Neuropathy Scale were calculated. RESULTS Patients' ages averaged 48.5 ± 14.7 years and 70.6% were female. Causes of neuropathy varied, remaining unknown in 59.5%. Among the 46 with abnormal skin biopsies, the most prevalent abnormality was reduced pin sharpness at the toes (71.7%). Inter-rater reliability, test-retest reliability, and convergent validity excelled (range = 91.3-95.6%). Receiver operating characteristics comparing all symptomatic patients versus healthy controls indicated that a MAGNET threshold score of 14 maximized predictive accuracy for skin biopsies (0.74) and a 30 cut-off maximized accuracy for predicting AFT (0.60). Analyzing patients with any abnormal neuropathy-test results identified areas-under-the-curves of 0.87-0.89 for predicting a diagnostic result, accuracy = 0.80-0.89, and Youden's index = 0.62. Overall, MAGNET was 80%-85% accurate for stratifying patients with abnormal versus normal neuropathy test results. DISCUSSION MAGNET quickly generates research-quality metrics during clinical examinations.
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Affiliation(s)
- Gary R. Zirpoli
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Khosro Farhad
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Madeleine C. Klein
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sean Downs
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Max M. Klein
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Pathology (Neuropathology), Massachusetts General Hospital, Boston, MA, USA
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Bjørnkaer A, Gaist LM, Holbech JV, Gaist D, Wirenfeldt M, Sindrup SH, Krøigård T. Corneal confocal microscopy in small and mixed fiber neuropathy-Comparison with skin biopsy and cold detection in a large prospective cohort. J Peripher Nerv Syst 2023; 28:664-676. [PMID: 37651181 DOI: 10.1111/jns.12595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND AND AIMS The diagnosis of small fiber neuropathy (SFN) is supported by reduced intraepidermal nerve fiber density (IENFD). The noninvasive method corneal confocal microscopy (CCM) has the potential to be a practical alternative. We aimed to estimate the diagnostic accuracy of CCM compared with IENFD and cold detection thresholds (CDT) in SFN and mixed fiber neuropathy (MFN). METHODS CCM was performed in an unselected prospective cohort of patients with a clinical suspicion of polyneuropathy. Predefined criteria were used to classify SFN and MFN. Neuropathy scores, including the Utah early neuropathy scale (UENS), were used to describe severity. Patients with established other diagnoses were used for diagnostic specificity calculations. RESULTS Data were taken from 680 patients, of which 244 had SFN or MFN. There was no significant difference in sensitivities [95%CI] of CCM (0.44 [0.38-0.51]), IEFND (0.43 [0.36-0.49]), and CDT (0.34 [0.29-0.41]). CCM specificity (0.75 [0.69-0.81]) was lower (p = .044) than for IENFD (0.99 [0.96-1.00]) but not than for CDT (0.81 [0.75-0.86]). The AUCs of the ROC curves of 0.63, 0.63 and 0.74 respectively, was lower for corneal nerve fiber density (p = .0012) and corneal nerve fiber length (p = .0015) compared with IENFD. While UENS correlated significantly with IENFD (p = .0016; R2 = .041) and CDT (p = .0002; R2 = .056), it did not correlate with CCM measures. INTERPRETATION The diagnostic utility of CCM in SNF and MFN is limited by the low specificity compared with skin biopsy. Further, CCM is less suitable than skin biopsy and CDT as a marker for neuropathy severity.
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Affiliation(s)
- Asger Bjørnkaer
- Neurology Research Unit, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
| | - Laura M Gaist
- Neurology Research Unit, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
| | - Jakob V Holbech
- Neurology Research Unit, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
| | - David Gaist
- Neurology Research Unit, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
| | - Martin Wirenfeldt
- University of Southern Denmark, Odense, Denmark
- Pathology Research Unit, Odense University Hospital, Odense, Denmark
| | - Søren H Sindrup
- Neurology Research Unit, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
- Odense Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Thomas Krøigård
- Neurology Research Unit, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
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Lucarini E, Micheli L, Rajagopalan R, Ciampi C, Branca JJ, Pacini A, Leandri M, Rajagopalan P, Ghelardini C, Di Cesare Mannelli L. Broad-spectrum neuroprotection exerted by DDD-028 in a mouse model of chemotherapy-induced neuropathy. Pain 2023; 164:2581-2595. [PMID: 37556385 PMCID: PMC10578426 DOI: 10.1097/j.pain.0000000000002963] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/28/2023] [Accepted: 05/02/2023] [Indexed: 08/11/2023]
Abstract
ABSTRACT Neurotoxicity of chemotherapeutics involves peculiar alterations in the structure and function, including abnormal nerve signal transmission, of both the peripheral and central nervous system. The lack of effective pharmacological approaches to prevent chemotherapy-induced neurotoxicity necessitates the identification of innovative therapies. Recent evidence suggests that repeated treatment with the pentacyclic pyridoindole derivative DDD-028 can exert both pain-relieving and glial modulatory effects in mice with paclitaxel-induced neuropathy. This work is aimed at assessing whether DDD-028 is a disease-modifying agent by protecting the peripheral nervous tissues from chemotherapy-induced damage. Neuropathy was induced in animals by paclitaxel injection (2.0 mg kg -1 i.p). DDD-028 (10 mg kg -1 ) and the reference drug, pregabalin (30 mg kg -1 ), were administered per os daily starting concomitantly with the first injection of paclitaxel and continuing 10 days after the end of paclitaxel treatment. The behavioural tests confirmed the antihyperalgesic efficacy of DDD-028 on paclitaxel-induced neuropathic pain. Furthermore, the electrophysiological analysis revealed the capacity of DDD-028 to restore near-normal sensory nerve conduction in paclitaxel-treated animals. Histopathology evidence indicated that DDD-028 was able to counteract effectively paclitaxel-induced peripheral neurotoxicity by protecting against the loss of intraepidermal nerve fibers, restoring physiological levels of neurofilament in nerve tissue and plasma, and preventing morphological alterations occurring in the sciatic nerves and dorsal root ganglia. Overall, DDD-028 is more effective than pregabalin in preventing chemotherapy-induced neurotoxicity. Thus, based on its potent antihyperalgesic and neuroprotective efficacy, DDD-028 seems to be a viable prophylactic medication to limit the development of neuropathies consequent to chemotherapy.
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Affiliation(s)
- Elena Lucarini
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), Pharmacology and Toxicology Section, University of Florence, Florence, Italy
| | - Laura Micheli
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), Pharmacology and Toxicology Section, University of Florence, Florence, Italy
| | | | - Clara Ciampi
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), Pharmacology and Toxicology Section, University of Florence, Florence, Italy
| | - Jacopo J.V. Branca
- Department of Experimental and Clinical Medicine, Anatomy and Histology Section, University of Florence, Florence, Italy
| | - Alessandra Pacini
- Department of Experimental and Clinical Medicine, Anatomy and Histology Section, University of Florence, Florence, Italy
| | - Massimo Leandri
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | | | - Carla Ghelardini
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), Pharmacology and Toxicology Section, University of Florence, Florence, Italy
| | - Lorenzo Di Cesare Mannelli
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), Pharmacology and Toxicology Section, University of Florence, Florence, Italy
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Marwaha B. Role of Tau protein in long COVID and potential therapeutic targets. Front Cell Infect Microbiol 2023; 13:1280600. [PMID: 37953801 PMCID: PMC10634420 DOI: 10.3389/fcimb.2023.1280600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 10/06/2023] [Indexed: 11/14/2023] Open
Abstract
Introduction Long COVID is an emerging public health burden and has been defined as a syndrome with common symptoms of fatigue, shortness of breath, cognitive dysfunction, and others impacting day-to-day life, fluctuating or relapsing over, occurring for at least two months in patients with a history of probable or confirmed SARS CoV-2 infection; usually three months from the onset of illness and cannot be explained by an alternate diagnosis. The actual prevalence of long-term COVID-19 is unknown, but it is believed that more than 17 million patients in Europe may have suffered from it during pandemic. Pathophysiology Currently, there is limited understanding of the pathophysiology of this syndrome, and multiple hypotheses have been proposed. Our literature review has shown studies reporting tau deposits in tissue samples of the brain from autopsies of COVID-19 patients compared to the control group, and the in-vitro human brain organoid model has shown aberrant phosphorylation of tau protein in response to SARS-CoV-2 infection. Tauopathies, a group of neurodegenerative disorders with the salient features of tau deposits, can manifest different symptoms based on the anatomical region of brain involvement and have been shown to affect the peripheral nervous system as well and explained even in rat model studies. Long COVID has more than 203 symptoms, with predominant symptoms of fatigue, dyspnea, and cognitive dysfunction, which tauopathy-induced CNS and peripheral nervous system dysfunction can explain. There have been no studies up till now to reveal the pathophysiology of long COVID. Based on our literature review, aberrant tau phosphorylation is a promising hypothesis that can be explored in future studies. Therapeutic approaches for tauopathies have multidimensional aspects, including targeting post-translational modifications, tau aggregation, and tau clearance through the autophagy process with the help of lysosomes, which can be potential targets for developing therapeutic interventions for the long COVID. In addition, future studies can attempt to find the tau proteins in CSF and use those as biomarkers for the long COVID.
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Affiliation(s)
- Bharat Marwaha
- Department of Cardiology, Adena Health System, Chillicothe, OH, United States
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Ludwig B, Deckert M, Krajnc N, Keritam O, Macher S, Bsteh G, Zulehner G, Thurnher M, Berger T, Seidel S, Willinger U, Rommer P. Reported neurological symptoms after severe acute respiratory syndrome coronavirus type 2 infection: A systematic diagnostic approach. Eur J Neurol 2023; 30:2713-2725. [PMID: 37306533 DOI: 10.1111/ene.15923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/08/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND PURPOSE Following increasing demands of patients with suspected neurological symptoms after infection with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2), the Department of Neurology at the Medical University of Vienna established a new outpatient clinic to systematically assess, diagnose, and document neurological complaints potentially associated with a prior SARS-CoV-2 infection. METHODS The data presented here include prospectively collected 156 outpatients from May 2021 to April 2022. Patients underwent semistandardized interviewing about symptoms with reported onset after SARS-CoV-2 infection, neurological examination, and comprehensive diagnostic workup. RESULTS Reported new onset symptoms after infection included fatigue (77.6%), subjective cognitive impairment (72.4%), headache (47.7%), loss of smell and/or taste (43.2%), and sleep disturbances (42.2%). Most patients had a mild coronavirus disease (COVID-19) disease course (84%) and reported comorbidities (71%), of which the most frequent were psychiatric disorders (34%). Frequency of symptoms was not associated with age, sex, or severity of COVID-19 course. A comprehensive diagnostic workup revealed no neurological abnormalities in the clinical examination, or electrophysiological or imaging assessments in the majority of patients (n = 143, 91.7%). Neuropsychological assessment of a subgroup of patients (n = 28, 17.9%) showed that cognitive impairments in executive functions and attention, anxiety, depression, and somatization symptoms were highly common. CONCLUSIONS In this systematic registry, we identified fatigue, cognitive impairment, and headache as the most frequently reported persisting complaints after SARS-CoV-2 infection. Structural neurological findings were rare. We also suspect a link between the growing burden of the COVID-19 pandemic on personal lives and the increase in reported neurological and psychiatric complaints.
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Affiliation(s)
- Birgit Ludwig
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Matthias Deckert
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Omar Keritam
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Gudrun Zulehner
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Majda Thurnher
- Section of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Stefan Seidel
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
- Rehabilitation Clinic Pirawarth, Bad Pirawarth, Austria
| | - Ulrike Willinger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
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Raasing LR, Veltkamp M, Datema M, Grutters JC, Vogels OJ. Thermal threshold testing: call for a balance between the number of measurements and abnormalities in the diagnosis of sarcoidosis-associated small fiber neuropathy. Pain Rep 2023; 8:e1095. [PMID: 37674973 PMCID: PMC10479475 DOI: 10.1097/pr9.0000000000001095] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/19/2023] [Accepted: 07/27/2023] [Indexed: 09/08/2023] Open
Abstract
Introduction Several recent studies of diagnosing small fiber neuropathy (SFN) have shown a lack of uniformity in thermal threshold testing (TTT) or quantitative sensory testing (QST) which makes it a challenge to compare the data. It is known that the chance of finding an abnormality increases with increasing number of measurements. Objectives With this study, we first wanted to investigate whether TTT could benefit from a new approach focusing on the balance between the number of measurements, depending on the selection of parameters and measuring sites, and on number of abnormalities (NOAs). Second, we wanted to address the role of the method of levels (MLe) in possible desensitization during TTT measurements. Methods One hundred seventeen participants were included (48 patients with sarcoidosis with probable SFN, 49 without SFN, and 20 healthy controls). Thermal threshold testing measurements and Small Fiber Neuropathy Screening List (SFNSL) questionnaire were used to assess SFN. Results A combination of measuring all thermal threshold parameters at both feet except for MLe showed the best diagnostic performance. Increasing TTT NOAs correlates with the severity of SFN. Adding the SFNSL questionnaire further improves diagnostic performance. Discussion Looking at TTT NOAs in all TTT parameters except for MLe at both feet should be considered as a new approach to improve the consistency and balance between the selection of TTT parameters, measuring sites, and definition of "abnormal QST." Moreover, the SFNSL questionnaire is a valuable tool to quantify SFN symptoms and could improve SFN diagnosis.
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Affiliation(s)
- Lisette R.M. Raasing
- ILD Center of Excellence, Department of Pulmonology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Marcel Veltkamp
- ILD Center of Excellence, Department of Pulmonology, St Antonius Hospital, Nieuwegein, the Netherlands
- Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mirjam Datema
- Department of Clinical Neurophysiology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Jan C. Grutters
- ILD Center of Excellence, Department of Pulmonology, St Antonius Hospital, Nieuwegein, the Netherlands
- Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Oscar J.M. Vogels
- ILD Center of Excellence, Department of Neurology, St Antonius Hospital, Nieuwegein, the Netherlands
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11
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Truini A, Aleksovska K, Anderson CC, Attal N, Baron R, Bennett DL, Bouhassira D, Cruccu G, Eisenberg E, Enax-Krumova E, Davis KD, Di Stefano G, Finnerup NB, Garcia-Larrea L, Hanafi I, Haroutounian S, Karlsson P, Rakusa M, Rice ASC, Sachau J, Smith BH, Sommer C, Tölle T, Valls-Solé J, Veluchamy A. Joint European Academy of Neurology-European Pain Federation-Neuropathic Pain Special Interest Group of the International Association for the Study of Pain guidelines on neuropathic pain assessment. Eur J Neurol 2023; 30:2177-2196. [PMID: 37253688 DOI: 10.1111/ene.15831] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND AND PURPOSE In these guidelines, we aimed to develop evidence-based recommendations for the use of screening questionnaires and diagnostic tests in patients with neuropathic pain (NeP). METHODS We systematically reviewed studies providing information on the sensitivity and specificity of screening questionnaires, and quantitative sensory testing, neurophysiology, skin biopsy, and corneal confocal microscopy. We also analysed how functional neuroimaging, peripheral nerve blocks, and genetic testing might provide useful information in diagnosing NeP. RESULTS Of the screening questionnaires, Douleur Neuropathique en 4 Questions (DN4), I-DN4 (self-administered DN4), and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) received a strong recommendation, and S-LANSS (self-administered LANSS) and PainDETECT weak recommendations for their use in the diagnostic pathway for patients with possible NeP. We devised a strong recommendation for the use of skin biopsy and a weak recommendation for quantitative sensory testing and nociceptive evoked potentials in the NeP diagnosis. Trigeminal reflex testing received a strong recommendation in diagnosing secondary trigeminal neuralgia. Although many studies support the usefulness of corneal confocal microscopy in diagnosing peripheral neuropathy, no study specifically investigated the diagnostic accuracy of this technique in patients with NeP. Functional neuroimaging and peripheral nerve blocks are helpful in disclosing pathophysiology and/or predicting outcomes, but current literature does not support their use for diagnosing NeP. Genetic testing may be considered at specialist centres, in selected cases. CONCLUSIONS These recommendations provide evidence-based clinical practice guidelines for NeP diagnosis. Due to the poor-to-moderate quality of evidence identified by this review, future large-scale, well-designed, multicentre studies assessing the accuracy of diagnostic tests for NeP are needed.
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Affiliation(s)
- Andrea Truini
- Department of Human Neuroscience, University Sapienza, Rome, Italy
| | - Katina Aleksovska
- European Academy of Neurology, Vienna, Austria
- Department of Neurology, Ss. Cyril and Methodius University, Skopje, North Macedonia
| | - Christopher C Anderson
- Division of Clinical and Translational Research, Department of Anesthesiology, Pain Center, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Nadine Attal
- Université Versailles Saint Quentin en Yvelines, Versailles, France
- Inserm U987, Pathophysiology and Clinical Pharmacology of Pain, Centre d'évaluation et de Traitement de la Douleur, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - David L Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Didier Bouhassira
- Inserm U987, Pathophysiology and Clinical Pharmacology of Pain, Centre d'évaluation et de Traitement de la Douleur, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Giorgio Cruccu
- Department of Human Neuroscience, University Sapienza, Rome, Italy
| | - Elon Eisenberg
- Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Elena Enax-Krumova
- Department of Neurology, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Karen Deborah Davis
- Division of Brain, Imaging, and Behaviour, Krembil Brain Institute, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Nanna B Finnerup
- Department of Clinical Medicine, Danish Pain Research Centre, Aarhus University, Aarhus, Denmark
| | - Luis Garcia-Larrea
- Central Integration of Pain (NeuroPain) Lab-Lyon Neuroscience Research Centre, INSERM U1028, CNRS, UMR5292, Université Claude Bernard, Bron, France
- Centre D'évaluation et de Traitement de la Douleur, Hôpital Neurologique, Lyon, France
| | - Ibrahem Hanafi
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Simon Haroutounian
- Division of Clinical and Translational Research, Department of Anesthesiology, Pain Center, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Pall Karlsson
- Department of Clinical Medicine, Danish Pain Research Centre, Aarhus University, Aarhus, Denmark
- Core Centre for Molecular Morphology, Section for Stereology and Microscopy, Aarhus University, Aarhus, Denmark
| | - Martin Rakusa
- Division of Neurology, University Medical Centre Maribor, Maribor, Slovenia
| | - Andrew S C Rice
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Juliane Sachau
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Blair H Smith
- Division of Population Health and Genomics, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Claudia Sommer
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Thomas Tölle
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Josep Valls-Solé
- Institut d'Investigació Biomèdica August Pi i Sunyer, Barcelona, Spain
| | - Abirami Veluchamy
- Division of Population Health and Genomics, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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12
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Tang J, Lin M, Ou C. High-throughput transcriptome sequencing reveals the critical role of long non-coding RNA Gm14376 in the occurrence of neuropathic pain. Neurosci Lett 2023; 810:137312. [PMID: 37236343 DOI: 10.1016/j.neulet.2023.137312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/02/2023] [Accepted: 04/18/2023] [Indexed: 05/28/2023]
Abstract
Long noncoding RNAs (lncRNAs) have been suggested as important regulators in neuropathic pain. Our study aims to explore the possible molecular mechanism underlying the role of long non-coding RNA (lncRNA) Gm14376 in neuropathic pain in mice by high-throughput transcriptome sequencing. A mouse model of spared nerve injury (SNI) was constructed for mechanical, thermal and spontaneous pain testing. Transcriptomic changes in lncRNAs and mRNAs in the dorsal root ganglion (DRG) of SNI mice were analyzed using RNA-sequencing techniques in conjunction with public data analysis. AAV5 viral vector was constructed to assess the effect of Gm14376 on SNI-induced pain hypersensitivity and inflammatory response. Cis-target genes of Gm14376 were obtained and the functions of Gm14376 were analyzed by GO and KEGG pathway enrichment analyses. Results from bioinformatic analysis identified a conserved Gm14376, which was up-regulated in the DRG of SNI mice, specifically in response to nerve injury. Overexpression of Gm14376 in DRG induced neuropathic pain-like symptoms in mice. Furthermore, the functions of Gm14376 were related to the phosphatidylinositol 3-kinase (PI3K)/Akt pathway and fibroblast growth factor 3 (Fgf3) was identified as the cis-target gene of Gm14376. Gm14376 could directly up-regulate Fgf3 expression to activate the PI3K/Akt pathway, which alleviated pain hypersensitivity to mechanical and thermal stimuli and reduced the release of inflammatory factors in SNI mice. From our data, we conclude that SNI-induced up-regulation of Gm14376 expression in DRG activates the PI3K/Akt pathway through up-regulation of Fgf3 expression, thereby promoting the development of neuropathic pain in mice.
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Affiliation(s)
- Jian Tang
- Department of Pain Management, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Department of Anesthesiology, Southwest Medical University, Luzhou, Sichuan Province 64600, 0, China
| | - Min Lin
- Department of Pain Management, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Department of Anesthesiology, Southwest Medical University, Luzhou, Sichuan Province 64600, 0, China
| | - Cehua Ou
- Department of Pain Management, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China.
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13
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Van Den Berg B, Berfelo T, Gefferie SR, Krabbenbos IP, Buitenweg JR. Identification of Diabetic Small-Fiber Neuropathy Based on Electrophysiological and Psychophysical Responses to Intra-Epidermal Electric Stimulation using a Naïve Bayes Classifier. Annu Int Conf IEEE Eng Med Biol Soc 2023; 2023:1-4. [PMID: 38083622 DOI: 10.1109/embc40787.2023.10340455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Diagnosis and stratification of small-fiber neuropathy patients is difficult due to a lack of methods that are both sensitive and specific. Our lab recently developed a method to accurately measure psychophysical and electrophysiological responses to intra-epidermal electric stimulation, specifically targeting small nerve fibers in the skin. In this work, we study whether using one or a combination of psychophysical and electrophysiological outcome measures can be used to identify diabetic small-fiber neuropathy. It was found that classification of small-fiber neuropathy based on psychophysical and electrophysiological responses to intra-epidermal electric stimulation could match or even outperform current state-of-the-art methods for the diagnosis of small-fiber neuropathy.Clinical Relevance-Neuropathy is damage or dysfunction of nerves in the skin, often leading to the development of chronic pain. Small-fiber neuropathy is the most prevalent type of neuropathy and occurs frequently in patients with diabetes mellitus, but can also occur in other diseases or in response to chemotherapy. Early detection of neuropathy could help diabetic patients to adapt glucose management, and doctors to adjust treatment strategies to prevent nerve loss and chronic pain, but is impeded by a lack of clinical tools to monitor small nerve fiber function.
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14
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Bennet BM, Pardo ID, Assaf BT, Buza E, Cramer S, Crawford LK, Engelhardt JA, Grubor B, Morrison JP, Osborne TS, Sharma AK, Bolon B. Scientific and Regulatory Policy Committee Points to Consider: Sampling, Processing, Evaluation, Interpretation, and Reporting of Test Article-Related Ganglion Pathology for Nonclinical Toxicity Studies. Toxicol Pathol 2023; 51:176-204. [PMID: 37489508 DOI: 10.1177/01926233231179707] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Certain biopharmaceutical products consistently affect dorsal root ganglia, trigeminal ganglia, and/or autonomic ganglia. Product classes targeting ganglia include antineoplastic chemotherapeutics, adeno-associated virus-based gene therapies, antisense oligonucleotides, and anti-nerve growth factor agents. This article outlines "points to consider" for sample collection, processing, evaluation, interpretation, and reporting of ganglion findings; these points are consistent with published best practices for peripheral nervous system evaluation in nonclinical toxicity studies. Ganglion findings often occur as a combination of neuronal injury (e.g., degeneration, necrosis, and/or loss) and/or glial effects (e.g., increased satellite glial cell cellularity) with leukocyte accumulation (e.g., mononuclear cell infiltration or inflammation). Nerve fiber degeneration and/or glial reactions may be seen in nerves, dorsal spinal nerve roots, spinal cord, and occasionally brainstem. Interpretation of test article (TA)-associated effects may be confounded by incidental background changes or experimental procedure-related changes and limited historical control data. Reports should describe findings at these sites, any TA relationship, and the criteria used for assigning severity grades. Contextualizing adversity of ganglia findings can require a weight-of-evidence approach because morphologic changes of variable severity occur in ganglia but often are not accompanied by observable overt in-life functional alterations detectable by conventional behavioral and neurological testing techniques.
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Affiliation(s)
| | | | | | - Elizabeth Buza
- University of Pennsylvania, Gene Therapy Program, Philadelphia, Pennsylvania, USA
| | | | - LaTasha K Crawford
- University of Wisconsin-Madison, School of Veterinary Medicine, Madison, Wisconsin, USA
| | | | | | - James P Morrison
- Charles River Laboratories, Inc., Shrewsbury, Massachusetts, USA
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15
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Lefaucheur JP. The value of electrochemical skin conductance measurement by Sudoscan® for assessing autonomic dysfunction in peripheral neuropathies beyond diabetes. Neurophysiol Clin 2023; 53:102859. [PMID: 36966705 DOI: 10.1016/j.neucli.2023.102859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/28/2023] Open
Abstract
The diagnosis and follow-up of peripheral neuropathies involving small-diameter nerve fibers require specific examinations beyond conventional nerve conduction studies which only concern large-diameter nerve fibers. Among these tests, some are dedicated to the investigation of cutaneous innervation by the autonomic nervous system, mainly by unmyelinated sympathetic C fibers. To this end, various laboratory tests have been proposed, but the measurement of electrochemical skin conductance (ESC) by Sudoscan® is increasingly becoming the most widely used technique, because it allows a quick and simple assessment of the sudomotor function of the limb extremities. This technique is based on the principles of reverse iontophoresis and chronoamperometry and since its introduction in 2010, has been the source of nearly 200 publications. In the clinical field, most of these publications concern the evaluation of diabetic polyneuropathy, for which the value of Sudoscan® no longer needs to be demonstrated. However, there is also evidence for a role for Sudoscan® in the testing of the autonomic nervous system in various peripheral neuropathies of other origins or diseases primarily affecting the central nervous system. In this article, a comprehensive review of the literature on the clinical value of Sudoscan® outside of diabetes is presented, detailing ESC changes in neuropathies associated with various clinical conditions, such as hereditary amyloidosis or other genetic pathologies, chemotherapy neurotoxicity, dysimmune or infectious disorders, fibromyalgia, parkinsonism or other neurodegenerative diseases.
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16
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Galiero R, Caturano A, Vetrano E, Beccia D, Brin C, Alfano M, Di Salvo J, Epifani R, Piacevole A, Tagliaferri G, Rocco M, Iadicicco I, Docimo G, Rinaldi L, Sardu C, Salvatore T, Marfella R, Sasso FC. Peripheral Neuropathy in Diabetes Mellitus: Pathogenetic Mechanisms and Diagnostic Options. Int J Mol Sci 2023; 24:ijms24043554. [PMID: 36834971 PMCID: PMC9967934 DOI: 10.3390/ijms24043554] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/01/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
Diabetic neuropathy (DN) is one of the main microvascular complications of both type 1 and type 2 diabetes mellitus. Sometimes, this could already be present at the time of diagnosis for type 2 diabetes mellitus (T2DM), while it appears in subjects with type 1 diabetes mellitus (T1DM) almost 10 years after the onset of the disease. The impairment can involve both somatic fibers of the peripheral nervous system, with sensory-motor manifestations, as well as the autonomic system, with neurovegetative multiorgan manifestations through an impairment of sympathetic/parasympathetic conduction. It seems that, both indirectly and directly, the hyperglycemic state and oxygen delivery reduction through the vasa nervorum can determine inflammatory damage, which in turn is responsible for the alteration of the activity of the nerves. The symptoms and signs are therefore various, although symmetrical painful somatic neuropathy at the level of the lower limbs seems the most frequent manifestation. The pathophysiological aspects underlying the onset and progression of DN are not entirely clear. The purpose of this review is to shed light on the most recent discoveries in the pathophysiological and diagnostic fields concerning this complex and frequent complication of diabetes mellitus.
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Affiliation(s)
- Raffaele Galiero
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Alfredo Caturano
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Erica Vetrano
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Domenico Beccia
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Chiara Brin
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Maria Alfano
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Jessica Di Salvo
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Raffaella Epifani
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Alessia Piacevole
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Giuseppina Tagliaferri
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Maria Rocco
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Ilaria Iadicicco
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Giovanni Docimo
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Luca Rinaldi
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Teresa Salvatore
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Ferdinando Carlo Sasso
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
- Correspondence: ; Tel.: +39-08-1566-5010
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17
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Franz S, Heutehaus L, Tappe-Theodor A, Weidner N, Treede RD, Schuh-Hofer S. Noxious radiant heat evokes bi-component nociceptive withdrawal reflexes in spinal cord injured humans-A clinical tool to study neuroplastic changes of spinal neural circuits. Front Hum Neurosci 2023; 17:1141690. [PMID: 37200949 PMCID: PMC10185789 DOI: 10.3389/fnhum.2023.1141690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/04/2023] [Indexed: 05/20/2023] Open
Abstract
Investigating nocifensive withdrawal reflexes as potential surrogate marker for the spinal excitation level may widen the understanding of maladaptive nociceptive processing after spinal cord injury (SCI). The aim of this prospective, explorative cross-sectional observational study was to investigate the response behavior of individuals with SCI to noxious radiant heat (laser) stimuli and to assess its relation to spasticity and neuropathic pain, two clinical consequences of spinal hyperexcitability/spinal disinhibition. Laser stimuli were applied at the sole and dorsum of the foot and below the fibula head. Corresponding reflexes were electromyography (EMG) recorded ipsilateral. Motor responses to laser stimuli were analyzed and related to clinical readouts (severity of injury/spasticity/pain), using established clinical assessment tools. Twenty-seven participants, 15 with SCI (age 18-63; 6.5 years post-injury; AIS-A through D) and 12 non-disabled controls, [non-disabled controls (NDC); age 19-63] were included. The percentage of individuals with SCI responding to stimuli (70-77%; p < 0.001), their response rates (16-21%; p < 0.05) and their reflex magnitude (p < 0.05) were significantly higher compared to NDC. SCI-related reflexes clustered in two time-windows, indicating involvement of both A-delta- and C-fibers. Spasticity was associated with facilitated reflexes in SCI (Kendall-tau-b p ≤ 0.05) and inversely associated with the occurrence/severity of neuropathic pain (Fisher's exact p < 0.05; Eta-coefficient p < 0.05). However, neuropathic pain was not related to reflex behavior. Altogether, we found a bi-component motor hyperresponsiveness of SCI to noxious heat, which correlated with spasticity, but not neuropathic pain. Laser-evoked withdrawal reflexes may become a suitable outcome parameter to explore maladaptive spinal circuitries in SCI and to assess the effect of targeted treatment strategies. Registration: https://drks.de/search/de/trial/DRKS00006779.
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Affiliation(s)
- Steffen Franz
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
- Steffen Franz,
| | - Laura Heutehaus
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Anke Tappe-Theodor
- Department of Molecular Pharmacology, Medical Faculty Heidelberg, Institute of Pharmacology, Heidelberg University, Heidelberg, Germany
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Rolf-Detlef Treede
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience, Medical Faculty Mannheim, Ruprecht-Karls-University of Heidelberg, Mannheim, Germany
| | - Sigrid Schuh-Hofer
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience, Medical Faculty Mannheim, Ruprecht-Karls-University of Heidelberg, Mannheim, Germany
- Department of Neurology and Epileptology, University of Tübingen, Tübingen, Germany
- *Correspondence: Sigrid Schuh-Hofer,
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Abstract
Rheumatoid arthritis is an autoimmune disease commonly found in humans. It is characterized by stiffness and swelling of the joints, along with fatigue and malaise. Rheumatoid neuropathy is a neuropathy that arises as a complication of rheumatoid arthritis. The primary objective of this review article is to provide a detailed account of the various aspects of this neurological complication ranging from its incidence, clinical features, and diagnosis. After searching through various published review articles and textbooks, rheumatoid neuropathy is one of the most common complications of rheumatoid arthritis. Out of all types of neuropathies. the most observed is entrapment neuropathy. Carpel tunnel syndrome is the most common type of entrapment neuropathy. There seems to be a greater predilection of rheumatoid neuropathy in females compared to males. A direct relation exists between rheumatoid factor and the occurrence of neuropathy. Some clinical features of rheumatoid neuropathy include stiffness in hands and feet, burning and tingling, stabbing pain, occasional weakness, and numbness in several cases. The common modalities of diagnosis are history, clinical examination, blood test, magnetic resonance imaging, nerve conduction study, and tissue biopsy. From the above-mentioned modalities, nerve conduction studies must be chosen as they can detect latent cases quickly and effective treatment can be initiated immediately. Finally, we outline the treatment plan for the disease which can be divided into medical and surgical management. Medical management consists of symptomatic treatment such as analgesics, anticonvulsants, and antidepressants, while surgical management is the last resort and consists of nerve compression.
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Affiliation(s)
- Bhavya Rajeshwari
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sunil Kumar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Dumolard A, Lefaucheur JP, Hodaj E, Liateni Z, Payen JF, Hodaj H. Central Sensitization and Small-fiber Neuropathy Are Associated in Patients With Fibromyalgia. Clin J Pain 2023; 39:8-14. [PMID: 36524768 DOI: 10.1097/AJP.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/16/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To study the prevalence of small-fiber neuropathy (SFN) in a large cohort of patients with fibromyalgia (FM) and to better characterize the subset of patients with both FM and SFN. METHODS This 1-year, retrospective, observational cohort study included 265 patients with FM. They all performed electrochemical skin conductance (ESC) using the Sudoscan device, 1 of the simplest and most reliable technique to assess the distal autonomic nerve fibers. They completed 4 self-assessment questionnaires: (1) the Central Sensitization Inventory (CSI), (2) the Neuropathic Pain Symptom Inventory (NPSI), and (3) the Hospital Anxiety and Depression Scale (HADS), the Fibromyalgia Impact Questionnaire (FIQ). RESULTS Fifty-three patients (20%) had reduced ESC values. These patients had higher CSI and HADS scores, and a larger intake of analgesic drugs compared with patients with no ESC abnormalities. Central sensitization, which was extreme in 69% of the patients (CSI score ≥60), was 1 of the main determinants of ESC abnormalities and was associated with a higher NPSI score, even though these 2 factors were not correlated. CONCLUSION Over the past 10 years, studies have shown that a significant proportion of patients with FM have signs of small nerve fiber impairment. The possible involvement of SFN, in the occurrence and presentation of clinical symptoms in FM patients, remains however unclear. This is the first study that showed an association between central sensitization and both small nerve fiber impairment and neuropathic pain features in FM patients, rather than a direct association between SFN and neuropathic pain.
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20
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Muacevic A, Adler JR. Skin Biopsy and Quantitative Sudomotor Axon Reflex Testing in Patients With Postural Orthostatic Tachycardia Syndrome. Cureus 2022; 14:e31021. [PMID: 36349067 PMCID: PMC9629858 DOI: 10.7759/cureus.31021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE No formal diagnostic criteria exist for the neuropathic subtype of postural orthostatic tachycardia syndrome (POTS). Skin biopsy and quantitative sudomotor axon reflex testing (QSORT) are preferred methods of assessment for autonomic small fiber neuropathy (SFN). This study characterizes the utility of these testing methods at a tertiary center and identifies clinical features associated with abnormal testing. METHODS Medical records of 2658 patients undergoing tilt table testing at a single institution between June 2018 and December 2020 were reviewed. Patients with postural orthostatic tachycardia syndrome were included for analysis of intraepidermal nerve fiber density (IENFD), sweat output, comorbidities, symptoms, measures of cardiovascular autonomic function, and serum antibody levels. RESULTS 356 patients (90% female, mean age 31 ± 10) met the diagnostic criteria for postural orthostatic tachycardia syndrome. Of 211 patients who underwent quantitative sudomotor axon reflex testing, 70 (33%) demonstrated reduced sweat output. These patients were more likely to demonstrate sympathetic impairment during the Valsalva maneuver. Of 80 patients who underwent skin biopsies, 19 (24%) demonstrated reduced intraepidermal nerve fiber density. These patients tended to be older and have reduced heart rate variability during deep breathing. Neither test was associated with specific serum antibodies, symptoms, or comorbidities, though there was a trend toward higher rates of comorbid autoimmune disease in patients with abnormal testing. CONCLUSION A subset of patients with postural orthostatic tachycardia syndrome have evidence of small fiber neuropathy. These patients tend to have impaired cardiovascular autonomic function but are otherwise similar to patients with no evidence of small fiber neuropathy.
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21
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Dohrn MF, Dumke C, Hornemann T, Nikolin S, Lampert A, Espenkott V, Vollert J, Ouwenbroek A, Zanella M, Schulz JB, Gess B, Rolke R. Deoxy-sphingolipids, oxidative stress, and vitamin C correlate with qualitative and quantitative patterns of small fiber dysfunction and degeneration. Pain 2022; 163:1800-1811. [PMID: 35239546 PMCID: PMC9393801 DOI: 10.1097/j.pain.0000000000002580] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 12/05/2022]
Abstract
ABSTRACT Defined by dysfunction or degeneration of Aδ and C fibers, small fiber neuropathies (SFNs) entail a relevant health burden. In 50% of cases, the underlying cause cannot be identified or treated. In 100 individuals (70% female individuals; mean age: 44.8 years) with an idiopathic, skin biopsy-confirmed SFN, we characterized the symptomatic spectrum and measured markers of oxidative stress (vitamin C, selenium, and glutathione) and inflammation (transforming growth factor beta, tumor necrosis factor alpha), as well as neurotoxic 1-deoxy-sphingolipids. Neuropathic pain was the most abundant symptom (95%) and cause of daily life impairment (72%). Despite the common use of pain killers (64%), the painDETECT questionnaire revealed scores above 13 points in 80% of patients. In the quantitative sensory testing (QST), a dysfunction of Aδ fibers was observed in 70% and of C fibers in 44%, affecting the face, hands, or feet. Despite normal nerve conduction studies, QST revealed Aβ fiber involvement in 46% of patients' test areas. Despite absence of diabetes mellitus or mutations in SPTLC1 or SPTLC2 , plasma 1-deoxy-sphingolipids were significantly higher in the sensory loss patient cluster when compared with those in patients with thermal hyperalgesia ( P < 0.01) or those in the healthy category ( P < 0.1), correlating inversely with the intraepidermal nerve fiber density (1-deoxy-SA: P < 0.05, 1-deoxy-SO: P < 0.01). Patients with arterial hypertension, overweight (body mass index > 25 kg/m 2 ), or hyperlipidemia showed significantly lower L-serine (arterial hypertension: P < 0.01) and higher 1-deoxy-sphingolipid levels (arterial hypertension: P < 0.001, overweight: P < 0.001, hyperlipidemia: P < 0.01). Lower vitamin C levels correlated with functional Aβ involvement ( P < 0.05). Reduced glutathione was lower in patients with Aδ dysfunction ( P < 0.05). Idiopathic SFNs are heterogeneous. As a new pathomechanism, plasma 1-deoxy-sphingolipids might link the metabolic syndrome with small fiber degeneration.
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Affiliation(s)
- Maike F. Dohrn
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Dr. John T. Macdonald Foundation, Department of Human Genetics and John P. Hussman Institute for Human Genomics, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Christina Dumke
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Thorsten Hornemann
- Institute of Clinical Chemistry, University Hospital Zürich, Zurich, Switzerland
| | - Stefan Nikolin
- Institute of Neuropathology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Angelika Lampert
- Institute of Physiology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Volker Espenkott
- Department of Palliative Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer (MSK), Imperial College London, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Annabelle Ouwenbroek
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Martina Zanella
- Institute of Clinical Chemistry, University Hospital Zürich, Zurich, Switzerland
| | - Jörg B. Schulz
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Burkhard Gess
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Roman Rolke
- Department of Palliative Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
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22
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Hocquel A, Ravel JM, Lambert L, Bonnet C, Banneau G, Kol B, Tissier L, Hopes L, Meyer M, Dillier C, Michaud M, Lardin A, Kaminsky AL, Schmitt E, Liao L, Zhu F, Myriam B, Bossenmeyer-Pourié C, Verger A, Renaud M. Reduced penetrance of an eastern French mutation in ATL1 autosomal-dominant inheritance (SPG3A): extended phenotypic spectrum coupled with brain 18F-FDG PET. Neurogenetics 2022; 23:241-255. [DOI: 10.1007/s10048-022-00695-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 06/19/2022] [Indexed: 10/17/2022]
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23
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Sopacua M, Gorissen-Brouwers CM, de Greef BT, Joosten IB, Faber CG, Merkies IS, Hoeijmakers JG. The applicability of the digit wrinkle scan to quantify sympathetic nerve function. Clin Neurophysiol Pract 2022; 7:115-119. [PMID: 35434427 PMCID: PMC9006743 DOI: 10.1016/j.cnp.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/16/2022] [Accepted: 03/23/2022] [Indexed: 11/23/2022] Open
Abstract
Normative values for stimulated skin wrinkling are age-dependent. Stimulated skin wrinkling has never been evaluated quantitatively. The clinical application of the stimulated skin wrinkling in an ordinal fashion is doubtful.
Objective Stimulated skin wrinkling test (SSW) has been launched as a non-invasive diagnostic procedure. However, no normative age dependent values have been reported that can be applied in clinical practice. The objectives of the study were to (1) collect age-dependent normative values according to the 5-point scale assessment for the SSW, to (2) determine reliability scores for the obtained norm values, and to (3) introduce a new digital method for SSW assessment, the Digit Wrinkle Scan© (DWS©) for detection of wrinkles in a more quantitative manner. Methods Firstly, 82 healthy participants were included, divided in 5 age groups. The participants underwent SSW using lidocaine and prilocaine topical cream. Secondly, 35 healthy participants were included to test whether the DWS© could be a novel manner to assess the grade of wrinkling quantitatively. We determined the inter-observer reliability of both methods. Also, the intra-observer reliability was calculated for the DWS©. Results We found a decrease in normative values over age. The inter-observer reliability of assessment by the 5-point scale method was moderate after SSW (Cohen’s k: 0.53). Results of the DWS© indicate that total wrinkle length per mm2 showed moderate to good agreement for the 4th and 5th digits after SSW, and a low agreement for the other digits. Conclusions Age-dependent normative values were obtained according to the 5-point scale, but its clinical application is doubtful since we found a moderate inter-observer reliability. We introduced the DWS© as a possible new method in order to quantify the grade of wrinkling. Significance We found unsatisfactory reliability scores, which hampers its usefulness for clinical practice.
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24
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Newlin Lew K, Arnold T, Cantelmo C, Jacque F, Posada-Quintero H, Luthra P, Chon KH. Diabetes Distal Peripheral Neuropathy: Subtypes and Diagnostic and Screening Technologies. J Diabetes Sci Technol 2022; 16:295-320. [PMID: 34994241 PMCID: PMC8861801 DOI: 10.1177/19322968211035375] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Diabetes distal symmetrical peripheral neuropathy (DSPN) is the most prevalent form of neuropathy in industrialized countries, substantially increasing risk for morbidity and pre-mature mortality. DSPN may manifest with small-fiber disease, large-fiber disease, or a combination of both. This review summarizes: (1) DSPN subtypes (small- and large-fiber disease) with attention to clinical signs and patient symptoms; and (2) technological diagnosis and screening for large- and small-fiber disease with inclusion of a comprehensive literature review of published studies from 2015-present (N = 66). Review findings, informed by the most up-to-date research, advance critical understanding of DSPN large- and small-fiber screening technologies, including those designed for point-of-care use in primary care and endocrinology practices.
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Affiliation(s)
- Kelley Newlin Lew
- School of Nursing, University of
Connecticut (UConn), Storrs, CT, USA
- Kelley Newlin Lew, School of Nursing,
University of Connecticut (UConn), 231 Glenbrook Road, Storrs, CT 06269, USA.
| | - Tracey Arnold
- School of Nursing, University of
Connecticut (UConn), Storrs, CT, USA
| | | | - Francky Jacque
- Hispanic Alliance of Southeastern
Connecticut, New London, CT, USA
| | - Hugo Posada-Quintero
- Biomedical Engineering Department,
University of Connecticut (UConn), Storrs, CT, USA
| | - Pooja Luthra
- Division of Endocrinology and
Metabolism, UConn Health, Farmington, CT, USA
| | - Ki H. Chon
- Biomedical Engineering Department,
University of Connecticut (UConn), Storrs, CT, USA
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25
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Sheen YJ, Sheu WHH, Wang HC, Chen JP, Sun YH, Chen HM. Assessment of diabetic small-fiber neuropathy by using short-wave infrared hyperspectral imaging. J Biophotonics 2022; 15:e202100220. [PMID: 34766729 DOI: 10.1002/jbio.202100220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 09/02/2021] [Accepted: 11/05/2021] [Indexed: 06/13/2023]
Abstract
Among patients with type 2 diabetes mellitus (T2DM), the association between hyperspectral imaging (HSI) examination and diabetic neuropathy (DN) is ascertained using HSI of the feet using four types of spectral difference measurements. DN was evaluated by traditional Michigan Neuropathy Screening Instrument (MNSI), evaluation of painful neuropathy (ID-Pain, DN4) and sudomotor function by measuring electrochemical skin conductance (ESC). Of the 120 T2DM patients and 20 healthy adults enrolled, T2DM patients are categorized into normal sudomotor (ESC >60 μS) and sudomotor dysfunction (ESC ≤ 60 μS) groups. Spectral difference analyses reveal significant intergroup differences, whereas traditional examinations cannot distinguish between the two groups. HSI waveform reflectance gradually increases with disease severity, at 1400 to 1600 nm. The area under the curve (AUC) of receiver operating characteristic (ROC) analysis for abnormal ESC is ≥0.8 for all four HSI methods. HSI could be an objective, sensitive, rapid, noninvasive and remote approach to identify early small-fiber DN.
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Affiliation(s)
- Yi-Jing Sheen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Wayne Huey-Herng Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Institute of Medical Technology, College of Life Science, National Chung-Hsing University, Taichung, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Hsin-Che Wang
- Research and Development Department, ISUZU Optics, Hsinchu, Taiwan
- Center for Quantitative Imaging in Medicine (CQUIM), Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jun-Peng Chen
- Biostatistics Task Force, Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Hsuan Sun
- Center for Quantitative Imaging in Medicine (CQUIM), Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsian-Min Chen
- Center for Quantitative Imaging in Medicine (CQUIM), Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Biomedical Engineering, Hung Kuang University, Taichung, Taiwan
- Department of Computer Science & Information Engineering, National United University, Miaoli, Taiwan
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26
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Mathew A, John T. Efficiency of 90-Min Extended EMLA-Induced Stimulated Skin-Wrinkling Test in the Diagnosis of Carpal Tunnel Syndrome. Ann Indian Acad Neurol 2022; 25:92-99. [PMID: 35342267 PMCID: PMC8954309 DOI: 10.4103/aian.aian_305_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/07/2021] [Accepted: 08/25/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Previous researchers have used a 30-min eutectic mixture of local anesthetic (EMLA) test, which assesses the sympathetically mediated vasomotor function, in diagnosing carpal tunnel syndrome (CTS). However, its specificity was low, limiting its clinical diagnostic utility. In this study, we assessed the efficiency of 90-min extended EMLA-induced stimulated skin-wrinkling (SSW) test in CTS diagnosis. Methods: A cross-sectional study was designed among patients clinically diagnosed with CTS. Hands of healthy volunteers and the asymptomatic hands of selected patients served as control. The Boston symptom severity scale (SSS) and the neuropathic pain severity inventory (NPSI) were used to assess symptom severity, and nerve conduction study (NCS) was used to assess electrophysiological severity. EMLA-induced SSW was visually graded after 90 min of application and correlated with symptom and NCS severities. Results: Forty-two symptomatic hands and 30 asymptomatic hands were enrolled as cases and controls, respectively. The diagnostic efficiency of the extended EMLA test was found to be 83.4% for digit 2 and 87.3% for the lateral 4 digits (mean), whereas the diagnostic efficiency of standard NCS was 88.1%. Boston SSS and NPSI were better correlated with EMLA positivity than NCS positivity. A linear regression analysis showed negative correlation of wrinkling grade with NCS grade. Conclusion: With its improved diagnostic efficiency, the 90-min extended EMLA test can feasibly be used as an alternative to NCS, especially in general practice settings. Its potential clinical utility should be explored in a large population of CTS patients showing varying clinical and electrophysiological severities.
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27
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Tucker-Bartley A, Lemme J, Gomez-Morad A, Shah N, Veliu M, Birklein F, Storz C, Rutkove S, Kronn D, Boyce AM, Kraft E, Upadhyay J. Pain Phenotypes in Rare Musculoskeletal and Neuromuscular Diseases. Neurosci Biobehav Rev 2021; 124:267-90. [PMID: 33581222 DOI: 10.1016/j.neubiorev.2021.02.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 01/18/2021] [Accepted: 02/03/2021] [Indexed: 12/11/2022]
Abstract
For patients diagnosed with a rare musculoskeletal or neuromuscular disease, pain may transition from acute to chronic; the latter yielding additional challenges for both patients and care providers. We assessed the present understanding of pain across a set of ten rare, noninfectious, noncancerous disorders; Osteogenesis Imperfecta, Ehlers-Danlos Syndrome, Achondroplasia, Fibrodysplasia Ossificans Progressiva, Fibrous Dysplasia/McCune-Albright Syndrome, Complex Regional Pain Syndrome, Duchenne Muscular Dystrophy, Infantile- and Late-Onset Pompe disease, Charcot-Marie-Tooth Disease, and Amyotrophic Lateral Sclerosis. Through the integration of natural history, cross-sectional, retrospective, clinical trials, & case studies we described pathologic and genetic factors, pain sources, phenotypes, and lastly, existing therapeutic approaches. We highlight that while rare diseases possess distinct core pathologic features, there are a number of shared pain phenotypes and mechanisms that may be prospectively examined and therapeutically targeted in a parallel manner. Finally, we describe clinical and research approaches that may facilitate more accurate diagnosis, monitoring, and treatment of pain as well as elucidation of the evolving nature of pain phenotypes in rare musculoskeletal or neuromuscular illnesses.
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28
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Hinduja A, Moutairou A, Calvet JH. Sudomotor dysfunction in patients recovered from COVID-19. Neurophysiol Clin 2021; 51:193-196. [PMID: 33551341 PMCID: PMC7835104 DOI: 10.1016/j.neucli.2021.01.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 02/06/2023] Open
Abstract
Dysautonomia has been reported in COVID-19. Sweat function testing has been proposed to assess autonomic neuropathy. Fifty Indian patients consulting for neurological symptoms participated in this observational study. The NHS questionnaire for neurological symptoms was completed and electrochemical skin conductance was measured using Sudoscan. The 26% of patients with sweat dysfunction i) were older (p = 0.001), ii) were more frequently treated at home (p = 0.008), iii) were more likely to have received antiviral treatment (p = 0.0006), and iv) more frequently reported at least one motor, sensory or autonomic symptom (p = 0.04). This preliminary study suggests that patients with COVID-19 should be screened for dysautonomia.
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29
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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.
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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
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30
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Kharoubi M, Roche F, Bézard M, Hupin D, Silva S, Oghina S, Chalard C, Zaroui A, Galat A, Guendouz S, Canoui-Poitrine F, Hittinger L, Teiger E, Lefaucheur JP, Damy T. Prevalence and prognostic value of autonomic neuropathy assessed by Sudoscan® in transthyretin wild-type cardiac amyloidosis. ESC Heart Fail 2020; 8:1656-1665. [PMID: 33354901 PMCID: PMC8006719 DOI: 10.1002/ehf2.13131] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 10/18/2020] [Accepted: 11/15/2020] [Indexed: 12/14/2022] Open
Abstract
Aims The prevalence of autonomic neuropathy (AN) is high in patients with hereditary transthyretin amyloidosis but remains unknown in transthyretin wild‐type cardiac amyloidosis (ATTRwt‐CA). This study aimed to determine the prevalence of AN in patients with ATTRwt‐CA using Sudoscan®, a non‐invasive method used to provide evidence of AN in clinical practice and based on measurement of electrochemical skin conductance at the hands and feet (fESC). Methods and results A series of 62 non‐diabetic patients with ATTRwt‐CA was prospectively included over 2 years and compared with healthy elderly subjects, matched by age, gender, and body mass index. The presence of AN was defined as electrochemical skin conductance at the hands <60 μS and/or fESC <70 μS, and conductances were analysed according to clinical, biological, and echocardiographic data. Mean fESC was significantly lower in patients with ATTRwt‐CA compared with elderly controls: 68.3 (64.1–72.5) vs. 76.9 (75.6–78.1) μS (P < 0.0001), respectively. Prevalence of fESC <70 μS was higher in ATTRwt‐CA patients than in controls: 48.4% vs. 19.9%, P < 0.05. Univariate analysis showed that fESC, N‐terminal pro‐B‐type natriuretic peptide, creatinine plasma levels, and echocardiographic global longitudinal strain were associated with decompensated cardiac failure and death. Multivariate analysis revealed that fESC was an independent prognostic factor, and Kaplan–Meier estimator evidenced a greater occurrence of cardiac decompensation and death in patients with fESC <70 μS, P = 0.046. Conclusions Reduced fESC was observed in almost 50% of patients with ATTRwt‐CA and was associated with a worse prognosis. Sudoscan® could easily be used to screen ATTRwt‐CA patients for the presence of AN and identify patients at higher risk for a poor outcome.
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Affiliation(s)
- Mounira Kharoubi
- Cardiology Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Henri Mondor University Hospital, 51 Avenue du Marechal de Lattre de Tassigny, Créteil, F-94010, France.,French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Créteil, France.,GRC Amyloid Research Institute, Créteil, France.,DHU-ATVB, Créteil, France
| | - Fréderic Roche
- CHU Saint Etienne, Clinical Physiology and Exercise Department, VISAS Centre, Saint-Etienne, France.,University Jean Monnet, EA 4607, SNA EPIS, Saint-Etienne, France
| | - Mélanie Bézard
- Cardiology Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Henri Mondor University Hospital, 51 Avenue du Marechal de Lattre de Tassigny, Créteil, F-94010, France.,French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Créteil, France.,GRC Amyloid Research Institute, Créteil, France.,DHU-ATVB, Créteil, France
| | - David Hupin
- CHU Saint Etienne, Clinical Physiology and Exercise Department, VISAS Centre, Saint-Etienne, France.,University Jean Monnet, EA 4607, SNA EPIS, Saint-Etienne, France
| | - Sidney Silva
- Cardiology Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Henri Mondor University Hospital, 51 Avenue du Marechal de Lattre de Tassigny, Créteil, F-94010, France.,French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Créteil, France.,GRC Amyloid Research Institute, Créteil, France.,DHU-ATVB, Créteil, France
| | - Silvia Oghina
- Cardiology Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Henri Mondor University Hospital, 51 Avenue du Marechal de Lattre de Tassigny, Créteil, F-94010, France.,French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Créteil, France.,GRC Amyloid Research Institute, Créteil, France.,DHU-ATVB, Créteil, France
| | - Coraline Chalard
- Cardiology Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Henri Mondor University Hospital, 51 Avenue du Marechal de Lattre de Tassigny, Créteil, F-94010, France.,French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Créteil, France.,GRC Amyloid Research Institute, Créteil, France.,DHU-ATVB, Créteil, France
| | - Amira Zaroui
- Cardiology Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Henri Mondor University Hospital, 51 Avenue du Marechal de Lattre de Tassigny, Créteil, F-94010, France.,French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Créteil, France.,Cardiology Department, CHU la Rabta, Jebbari Tunis, Tunisia
| | - Arnault Galat
- Cardiology Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Henri Mondor University Hospital, 51 Avenue du Marechal de Lattre de Tassigny, Créteil, F-94010, France.,French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Créteil, France.,GRC Amyloid Research Institute, Créteil, France.,DHU-ATVB, Créteil, France
| | - Soulef Guendouz
- Cardiology Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Henri Mondor University Hospital, 51 Avenue du Marechal de Lattre de Tassigny, Créteil, F-94010, France.,French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Créteil, France.,GRC Amyloid Research Institute, Créteil, France.,DHU-ATVB, Créteil, France
| | - Florence Canoui-Poitrine
- Public Health Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Henri Mondor University Hospital, Créteil, France
| | - Luc Hittinger
- Cardiology Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Henri Mondor University Hospital, 51 Avenue du Marechal de Lattre de Tassigny, Créteil, F-94010, France.,French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Créteil, France.,GRC Amyloid Research Institute, Créteil, France.,DHU-ATVB, Créteil, France
| | - Emmanuel Teiger
- Cardiology Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Henri Mondor University Hospital, 51 Avenue du Marechal de Lattre de Tassigny, Créteil, F-94010, France.,French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Créteil, France.,GRC Amyloid Research Institute, Créteil, France.,DHU-ATVB, Créteil, France
| | - Jean-Pascal Lefaucheur
- Université Paris-Est Créteil, EA 4391, ENT, Créteil, France.,Clinical Neurophysiology Unit, AP-HP (Assistance Publique-Hôpitaux de Paris), Henri Mondor University Hospital, Créteil, France
| | - Thibaud Damy
- Cardiology Department, AP-HP (Assistance Publique-Hôpitaux de Paris), Henri Mondor University Hospital, 51 Avenue du Marechal de Lattre de Tassigny, Créteil, F-94010, France.,French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Créteil, France.,GRC Amyloid Research Institute, Créteil, France.,DHU-ATVB, Créteil, France.,Clinical Investigation Center, Inserm 1430, Henri Mondor University Hospital, Créteil, France
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