36 months continuous subcutaneous insulin infusion (CSII) in insulin dependent diabetes (IDDM)--influence on early stages of retinopathy, nephropathy and neuropathy--psychological analysis

In extremely unstable (brittle) IDDM patients (n = 11) the metabolic effect of long-term (36 months) CSII proved to be superior to conventional insulin treatment (CIT) (statistical twins, n = 11): HbA1 = 8.6 +/- 0.3 versus 10.4 +/- 0.4, MBG = 5.6 +/- 0.3 versus 8.5 +/- 0.8, M (80)- value = 23.6 +/- 0.6 versus 56.7 +/- 10.2, GCI) = 37.3 +/- 15.6 versus 132 +/- 24.2. In addition, in CSII patients the metabolic control was significantly better than intensified conventional insulin treatment (ICT) before. Retinal morphology improved under CSII in 1 eye, did not change in 10 eyes and deteriorated in 11 eyes. Under CIT retinal findings improved in none, did not change in 16 and deteriorated in 16 eyes. Deteriorations under CSII appeared more frequently during the first than during the second and third year of treatment and seemed to be a consequence of too strict metabolic control and/or too fast decrease of the glycemia at the beginning of CSII. During 36 months of CSII no deterioration but in one case normalization of microproteinuria was observed. Under CIT three cases changed from normal into microproteinuria. Reduced motor nerve conduction velocity (MCV) and/or sensory nerve conduction velocity (SCV) could be normalized in most cases under CSII, but respiratory heart arrhythmia (RHA) at rest could not. Most patients--if highly motivated before starting CSII--remained positively motivated for long-term pump therapy.

IN CONCLUSION

Our experiences over three years demonstrate a positive effect of CSII on the metabolism as well as on the course of early stages of microangiopathy and neuropathy. A longer period of observations will be necessary to evaluate this, conclusively.

[Autonomic symptoms in diabetic polyneuropathies]

200 years have gone by since the autonomic disturbance in diabetes mellitus has been described for the first time ever. There is a great deal of information on the close relationship between somatic and visceral symptoms in diabetic polyneuropathy (PNP), so that there should be talked about only of one form of manifestations within the meaning of a distal symmetric somatovisceral PNP. The longer fibres such as the vagal fibres of the viscus, sympathetic fibres of the eye are affected at first and more intensively in the autonomic region same as in the sensory and motor region. Due to the fact that for reasons of fragmentary knowledge pathogenetically substantiated classification of the autonomic disturbances in diabetic PNP is not at hand, such a classification is being made from organotopic and phenomenologic aspects. Frequently, afferent denervation of an organ results in enhancing the effects of an autonomic innervation dysfunction, as for instance in unnoticed hypoglycaemia, in order to modify the symptoms, as for instance in rectal incontinence with unnoticed defecation, or rather to let new symptoms appear, for instance loss of testicular pain. In recent years, appropriate methods of examinations were tested for the clinical routine, permitting to give evidence of autonomic dysfunctions before clinical manifestation. It is still unclear to what extent such subclinical abnormalities are reversible with a more favourable regulation of the metabolic process, for instance with the aid of continuous subcutaneous insulin injections. An impressive symptom of innervation dysfunctions of the cardiovascular system is orthostatic hypertension that may, in exceptional cases, even lead to confinement to bed. The most important pathogenic factor seems to be vascular denervation. A pronounced tachycardia at rest, frequently found in diabetics, is the result of the failure of the vagal autonomic system, and, after additional destruction of the sympathetic fibres, it adjusts itself to a lower level that cannot be changed by reflex mechanisms. Cardialgia absent in the case of myocardial ischemia is a factor of an increased mortality of long-term diabetics. The correlation between vascular denervation and arteriosclerosis or mediasclerosis, respectively, is being under discussion. Denervation on the gastrointestinal tract has an effect on the motility and excretory functions. The innvervation dysfunctions lead to sialadenosis by changing the composition of saliva. In most cases esophageal dysfunction is not perceived by the patient.(ABSTRACT TRUNCATED AT 400 WORDS)

[Diagnosis of autonomic disorders in polyneuropathies--methodology and evaluation of simple cardiovascular function tests]

In recent years there ist a growing interest in autonomic dysfunctions in polyneuropathies. It is reported on four vagal function tests und two tests of the sympathetic system carried out and evaluated. These tests can be conducted without any instrumental application, and permit diagnostic and prognostic statements.

[Polyneuropathy and residual insulin secretion in diabetes mellitus type I]

In 145 patients suffering from type-I-diabetes with or without signs or symptoms of polyneuropathy basal and glucose-glucagon-induced secretion of insulin was determined. Patients without remaining insulin secretion exhibited somewhat more often polyneuropathies, slowing of nerve conduction, or reduced respiratory heart arrhythmia. If diabetes lasts for more than 10 years, insulin secretion ist reduced to such a low level that its may not have any significant preventive capability with respect to polyneuropathy.

The influence of CSII treatment on the function of the peripheral and visceral nerves in type I diabetics

The distal latencies, motor and sensory nerve conduction velocities, and respiratory heart arrhythmia (RHA) were measured in 14 patients with type I diabetes but without clinical signs of polyneuropathy. The electroneurographic parameters tended to improve as the HbA1 value decreased. The RHA was not affected.

[Volume conduction in the electroneurographic study of arm and leg nerves]

Two arm and two leg nerves in each of a group of healthy subjects were stimulated electrically and the muscle action potentials were taken from the corresponding regions by surface electrodes. Volumetrically conducted potentials appeared in almost all cases, and other nerves were stimulated at the same time in many cases. The resultant errors in the calculation of the speed of pulse transmission are considerable. The use of a concentric needle electrode is recommended for recording evoked muscle action potentials.

Results of treatment with continuous subcutaneous insulin infusion (CSII) in insulin-dependent (type I) diabetics

10 labile insulin-dependent diabetic patients treated with CSII were followed up for 6 to 16 months under conditions of everyday life. The mean blood glucose (MBG), glycosylated haemoglobin (HbA1), motor nerve conduction velocity (MCV), and respiratory heart arrhythmia at rest (RHA) were investigated. A significant improvement of metabolic control was observed (MBG 8.03 +/- 1.40 vs 5.18 +/- 0.87 mmol/l, p less than 0.01; HbA1 10.7 +/- 1.3 vs 8.7 +/- 1.6%, p less than 0.05) in comparison with the control values under intensified conventional therapy. MCV increased gradually but the average RHA remained unchanged. The psychological examination employing a questionnaire reflects that all patients selected were highly motivated and that their positive attitudes were further stabilized during pump treatment. An average of three mild hypoglycaemic episodes occurred per month per patient; these were no more than under intensified conventional treatment. Other minor clinical and technical complications occurred at a total frequency of one per month per patient and did not achieve therapeutical relevance.

Classification of diabetic neuropathy from pathogenetic aspects

A report is given on experience gained during the electroneurographic examination of 800 diabetics of all ages and on the results of respiratory heart arrhythmia measurement on 215 diabetics. It is proposed that diabetic nervous disturbances should be divided into the following groups: 1--early diabetic and subclinical disturbances, 2--somatovisceral polyneuropathy in type I diabetics, 3--polyneuropathy in type II diabetics, 4--mononeuropathy, mononeuropathy multiplex and proximal amyotrophy. The disturbances in group 1 can be reversed by metabolic control. Only the PNP in group 2 shows a firm statistical correlation to duration of diabetes mellitus and to microangiopathy. This appears to be a dying back neuropathy, probably caused by the chronically catabolic metabolic situation.

[The prognostic significance of electromyographic and electroneurographic results in Landry-Guillain-Barré-Strohl polyradiculoneuritis]

On the basis of an analysis of electromyographic and electroneurographic findings in patients with polyradiculoneuritis Landry - Guillain - Barré - Strohl courses of the diseases with different prognoses are found. In pure demyelinisation processes, a rapid and complete restitution can be expected. The regression of the pareses, however, will show a delayed, frequently an incomplete onset when electrophysiologically and axon loss can be proved.

[Visceral diabetic polyneuropathy - quantitative determination of respiratory cardiac arrhythmia]

In 100 insulin-dependent diabetics, the degree of the respiratory cardiac arrhythmia as a measure of the participation of the N. vagus in the polyneuropathy is determined by means of the triggered cross-correlation function. The impairment of the respiratory cardiac arrhythmia shows statistical relations to the electroneurographic changes of somatic nerves, to the duration of diabetes and to the occurrence of microangiopathies.

[Electromyographic examinations of the musculus sphincter urethrae in children with meningomyelocele]

Thirty children with neurogenic voiding attendant upon myelomeningoceles were examined, and for twenty-three children the electromyographic findings were compared with urodynamic measuring results. The authors conclude that an increase in subvesical resistance is due not to an increase of tonicity of somatic sphincter muscles but to a predominance of sympathetic over parasympathetic innervation.

[Method for studying spinal evoked potentials]

The authors describe a new method of examing evoked spinal potentials. Derivation is by means of unipolar needle electrodes which are ventrolaterally introduced into the cervical disk space as far as the posterior longitudinal ligament. Detection of a spinal potential following the stimulation of brachial and crural nerves allows to exclude the possibility of complete transverse lesion of the spinal cord or severing of the peripheral nerve or plexus.

[Determination of the variation in conduction speed of motor fibers and the effects of diphenylhydantoin (Phenytoin) and diazepam (Faustan)]

The variation in the speed of conduction of motor fibers of the ulnar nerve was determined by Hopf's double-stimulus method and compared with values obtained from the duration of muscular response potentials for differently spaced points of stimulation. However, the values obtained from the difference of the duration of response potentials are inadequate since the duration of potentials cannot always be determined accurately. After a ten-day administration of faustan (15 mg per day) or phenytoin (300 mg per day) there was observed a decrease especially in the minimum rate of conduction of motor fibers of the ulnar nerve.

[Determination of distal latency of the motor nerves of the hand]

The authors show the methodological problems connected with the determination of distal latency and the possibility of misinterpretation. They recommend the use of concentric needle electrodes together with surface electrodes for the determination of the distal latency of the hand nerves and also to always register both nerves.

[Alcohol-induced lesions of the nerve and muscle]

A review is given on the most important neurologic sequelae after long lasting abuse of alcohol. The paper especially deals with the clinical features of neuropathic and myopathic disorders in alcoholics. Electromyography (including electroneurography) is considered to be a major diagnostic aid in these conditions.

The action of quartz in the presence of iron hydroxides in the human lung

In 1932 Kettle reported that the fibrogenic action of quartz particles is inhibited when they are coated with iron. Many authors subsequently confirmed this finding. Reif et al., who studied the effect of different iron-ore mine dusts, showed that, like aluminium hydroxide, iron hydroxide has a strong effect in inhibiting the fibrogenic action due to quartz. The findings of this paper, based on an X-ray survey of a group of 7735 iron ore miners, on autopsy examinations, tissue dust analysis and physiological examinations, confirm the view that FeO(OH) is a most powerful inhibiting substance.