DCCT and EDIC studies in type 1 diabetes: lessons for diabetic neuropathy regarding metabolic memory and natural history

The DCCT/EDIC (Diabetes Control and Complications Trial/ Epidemiology of Diabetes Interventions and Complications) provides a comprehensive characterization of the natural history of diabetic neuropathy in patients with type 1 diabetes and provides insight into the impact of intensive insulin therapy in disease progression. The lessons learned about the natural history of distal symmetrical polyneuropathy and cardiovascular autonomic neuropathy and the impact of glycemic control on neuropathy are discussed in this review.

[Acute panautonomic neuropathy: a report of 4 cases]

OBJECTIVE

To explore the clinical manifestations, diagnosis, treatment and prognosis of acute panautonomic neuropathy (APN).

METHODS

We reviewed the history, clinical findings, electrophysiological characteristics, laboratory features of CSF and treatment of 4 patients with APN.

RESULTS

All these patients showed acute onset with apparent involvement of the autonomic nervous system. The clinical features of autonomic involvement included fixed dilated pupils, abdominal pain, diarrhea, and anhidrosis. Electromyography showed evidence of peripheral neuropathy. Early treatment with corticosteroid and intravenous immunoglobulins resulted in improved prognosis of the patients.

CONCLUSION

APN is a rare autonomic nervous system disorder, and understanding of the clinical features may help in early diagnosis and treatment of the patients.

Anti-neuronal antibodies in acute pandysautonomia

We encountered two patients with acute pandysautonomia who subacutely exhibited extensive autonomic dysfunction after antecedent infections. Although these patients had been suffering from autonomic disturbance for several months, they both had a good clinical course after plasma exchange and intravenous immunoglobulin therapy. Thin-layer chromatography (TLC)-immunostaining did not demonstrate any antibodies against gangliosides, but immunoblot analysis showed antibodies against a neuroblastoma cell line, SH-SY5Y, in serum samples. Furthermore, ganglionic acetylcholine receptor autoantibodies were detected in one patient. These findings suggest that neuronal antibodies against the autonomic nervous system play an important role in the pathogenesis of acute pandysautonomia.

Harlequin syndrome: two new cases and a management proposal

The Harlequin syndrome is a rare autonomic disorder, characterized by unilateral diminished sweating and flushing of the face in response to heat or exercise. We present two new cases and evaluate the data of 83 patients described in the literature. We provide diagnostic and therapeutic guidelines.

[Two years' experience in a specific autonomic nervous system service]

INTRODUCTION

Despite the high incidence and prevalence of pathologies affecting the autonomic nervous system (ANS), this part of neurology has received very little specific attention in clinical care in our country.

AIM

To present the experience we have gained over a two-year period in an ANS-specific service.

PATIENTS AND METHODS

Our patients were referred to the ANS service by other colleagues, most of whom were neurologists, between April 2006 and April 2008, after proposing a set of eligibility and exclusion criteria. Clinical history, examination and general analysis were performed for all patients. The following tests were also carried out on an individualised basis: Ewing-Clarke test, the Spanish version of the autonomic symptom profile test, tilt table test, holter heart monitor, urodynamic study and reflex sympathetic test, among other complementary studies.

RESULTS

Thirty-four first visits and 62 successive visits were registered. The most frequent diagnoses were neurologically mediated syncopes and diabetic autonomic neuropathies, but other less prevalent conditions were also diagnosed. The most cost-effective complementary tests were the Ewing-Clarke test and the autonomic symptom profile test. Apart from benzodiazepines, the most commonly prescribed pharmacological treatments were paroxetine and pyridostigmine.

CONCLUSIONS

As expected, neurologically mediated syncopes and diabetic neuropathies with an autonomic component are the most frequent pathologies in an ANS service. Nevertheless, their diagnosis and individualised treatment, together with that of other less prevalent autonomic pathologies, may require specific attention. To our knowledge, this is the first service of its kind in our country.

[A method for non-medicamentous control of the adaptive mechanisms of cardiovascular homeostasis in patients with psychovegetative syndrome]

This study was designed to elucidate mechanisms underlying normalization of vegetative regulation of the cardiovascular function by a combined treatment including magnetopuncture, phytoaeroinotherapy, soft-tissue manual therapy, and graded physical exercises in young subjects presenting with psychovegetative syndrome and sympaticotonia. It was shown that beneficial effect of the above treatment on vegetative characteristics of the cardiovascular system is largely due to a few key factors responsible for normalization of the functional and dynamic state of the body's meridional system, optimization of central regulation of circulation, correction of excessive sympathetic activation, and improvement of protective vagal control over cardiac function. These findings confirm the possibility of corrective intervention into the central mechanisms of cardiovascular homeostasis mediated through the body's meridonal system.

Programmed atrial pacing for orthostatic hypotension

Programmable atrial inhibited pacemakers were implanted in two patients with orthostatic hypotension due to autonomic failure. They were paced at 95 beats/min during the day and programmed themselves to 55 beats at night. This treatment resulted in virtual disappearance of orthostatic symptoms during a two-year follow-up. Haemodynamic studies showed a mean increase in erect systolic blood pressure from 47 mmHg pre-implantation to 85 mmHg at nine months post-implant during pacing. Cardiac output averaged 3.0 l/min without pacing and 3.8 l/min with pacing at two investigations. Rapid heart rate and high supine blood pressure at night were avoided by programming the pacemaker.

Autoimmune autonomic ganglionopathy

Autoimmune autonomic ganglionopathy is an idiopathic acquired disorder of the autonomic nervous system associated with antibodies to the ganglionic nicotinic acetylcholine receptor found in sympathetic, parasympathetic and enteric ganglia. Symptoms and signs reflect diffuse impairment of autonomic functions. Prominent features are gastrointestinal dysmotility, orthostatic hypotension, and tonic pupils. Typical cases have a subacute onset (less than 3 months to maximum symptoms), are monophasic, and may show partial improvement over the course of several months. Other cases have a slowly progressive course which can resemble degenerative forms of autonomic failure. Treatment for milder cases is supportive care for symptom management. Anecdotally, plasma exchange, intravenous immunoglobulin, corticosteroids or immunosuppression have been used successfully to treat more severe cases. Autoimmune autonomic ganglionopathy represents one of a small group of autoimmune neuromuscular disorders that are caused by antibodies against ion channels.

[Magnetopuncture therapy in the combined corrective treatment of clinical manifestations of non-specific distress syndrome]

The efficiency of a combined approach to the correction of clinical manifestations of non-specific distress syndrome was evaluated in patients with psychovegetative syndrome by comparing effects of phytoaeroionotherapy, graduated physical exercises, and soft tissue manual therapy in different combinations with simultaneous magnetopuncture therapy and without it. It was shown that above therapeutic modalities combined with magnetotherapy decreased the degree of asymmetry of both right and left heart meridians (by 60.5%) and interhemisphere asymmetry of blood flow in the system of internal carotid arteries (by 74.19%), reduced the tone of cerebral arterioles and veins (by 40.7% and 8.6% respectively), improved symptomes of depression and asthenia (by 23.2% and 63.9% respectively), increased mental performance quotient and activity indices (by 34.7% and 28.7% respectively). These changes were far less significant in the absence of by magnetopuncture therapy.

[Effect of artificial mountain climate on the functional state of higher regions of the central nervous system in man]

The study included 97 patients with vegetative vascular dystonia and chronic non-specific pulmonary diseases exposed to artificial high-altitude climate in an Orotron climatic chamber during 2 weeks. Atmospheric conditions maintained in the chamber had the following parameters: partial pressure of oxygen--147-160 gPa, relative humidity--60-70%, air temperature--16-18 degrees C, light aeroion content--up to 6000 cub.cm. It was shown that the exposure to artificial mountain climatic conditions enhanced functional mobility of nervous processes and decreased the length of the sensorimotor reactions of the patients. Individual differences in the change of parameters being measured depended on the degree of initial functional flexibility of nervous processes.

Acute autonomic, sensory and motor neuropathy: successful treatment with IVIg

Acute autonomic, sensory and motor neuropathy (AASMN) is a rare peripheral nerve disorder characterized by prominent dysautonomia with somatic sensory and motor impairment. Dysautonomia in AASMN is intractable even with corticosteroid therapy or plasmapheresis. Here we report a case of AASMN with severe orthostatic hypotension. Although the effectiveness of corticosteroid was insufficient, high dose intravenous immunoglobulin therapy (IVIg) was effective for not only sensorimotor symptoms but also autonomic symptoms. This is the first case of AASMN showing favorable responses to IVIg treatment, suggesting that IVIg should be considered when corticosteroid therapy or plasmapheresis is ineffective or insufficient.

[Transcranial magnetic therapy in the treatment of psychoautonomous disturbances in children with diabetes mellitus type 1]

Results of a clinical-physiological study of 80 children with diabetes mellitus type 1 with psychoautonomous disturbances are presented. Forty patients of the main group received transcranial magnetic therapy (TcMT), 40 patients of the control group had placebo sessions of TcMT with magnetic power supply switched off. TcMT was applied using bitemporal method, running regime with modulation frequency 1-10 Hz. Patients received 10 sessions. Positive changes were found in the main group compared to the controls. In the main group, TcMT sessions allowed to normalize the autonomous status in 75% of children and to improve psychoemotional state in 55%. The correction of psychoemotional status of children changed their behavior towards diabetes, improved control and compensation of the disease.

[Autonomic nervous system and primary open angle glaucoma--pathogenetic and clinical correlations]

Primary open angle glaucoma is linked to autonomic nervous system dysfunction. In a review the role of autonomic nervous system as an important determinant of systemic hemodynamic parameters such as heart rate and blood pressure, was presented. Human circadian clock and its impact on autonomic nervous system was emphasized. Finally some autonomic function tests and therapeutical implications were described.

Optimizing therapeutic effects in patients with comorbidities: drug-resistant tremor, autonomic dysfunction, psychiatric disorders, and cognitive impairment

Parkinsonism is a syndrome characterized by a combination of cardinal features including resting tremor, bradykinesia, rigidity, and loss of postural reflexes. The most common presentation of parkinsonism is the idiopathic variety first described by James Parkinson in 1817 now known as Parkinson's disease (PD). This article focuses on identifying the different subtypes of PD, with the recognition that treatment approaches may differ depending on the initial presenting feature. It also addresses issues related to the recognition and treatment of nonmotor comorbidities of PD, such as autonomic dysfunction and neuropsychiatric problems including depression and dementia.

Cardiac autonomic diabetic neuropathy

Cardiovascular autonomic diabetic neuropathy (CADN) is one of the most common diabetes-associated complications. Disturbed heart rate variability (HRV) is very often the earliest symptom, even in clinically asymptomatic patients. The following article offers a topical overview for those working or interested in the fields of diabetology and cardiology.

[Differential approach to the combined correction of adaptive capabilities in patients with psychovegetative syndrome]

Differential approach to the correction of functional state in young subjects with psychovegetative syndrome, simpatico-tonic vegetative tone, and hypersympatico-tonic vascular reactivity is described. It involves the use of combined treatment including physical factors (a constant magnetic field and negatively polarized phytoaeroions), soft-tissue manual therapy, and dosed physical exercises. This approach made it possible to influence different aspects of adaptive functional self-regulation of the organism, energo-informative homeostasis, sympatic-parasympatic balance, and mechanisms controlling cerebral circulation, cardiovascular, psycho-emotional, cognitive and physical activities.

Neurovegetative symptoms and complaints before and after voice therapy for nonorganic habitual dysphonia

In a previous study, female patients in all age categories with a nonorganic dysphonia were found to report significantly more autonomic symptoms and complaints than healthy controls. This could not be confirmed for the male subgroup. The present study is to corroborate and nuance this observation by investigating larger groups, and to determine if, after voice therapy, the number of autonomic symptoms and complaints-particularly those ones that have no obvious relation to voice function-decreases. It is a prospective study with a matched control group; 184 patients with nonorganic dysphonia and 126 normal controls answered a questionnaire of 46 questions with 3 subsets and a consistency control. One hundred and one patients received functional voice therapy and completed the questionnaire before and after treatment. A matched control group of 42 normal subjects also filled in the questionnaire two times, with an interval of about 6 months. Neurovegetative symptoms and complaints-voice related and not related-are reported in highly significant excess by patients (especially but not exclusively females) with habitual nonorganic voice disorder. After therapy, there is a highly significant reduction in the number of autonomic symptoms and complaints (related or not related to voice), to such an extent that patients report on average no more general neurovegetative symptoms and complaints than healthy controls (even less). The number of neurovegetative symptoms and complaints connected with voice function is also strongly reduced in patients after therapy, but remains in significant excess when compared with controls.

[Is there are needs treating the adolescents with syndrome of vegetative dysfunction?]

Article presents the pathogenesis aspects and clinical data of adolescents with syndrome of vegetative dysfunction. The authors observe the structure of different clinical forms, reflect on conditions and situation, when adolescents needs a stable complex of etiopathogenetic therapy to control autonomic nervous system dysfunction.

Management of non-motor symptoms in advanced Parkinson disease

Progress in pharmacology has markedly improved the treatment of early Parkinson's disease. The management of advanced Parkinson's symptoms, however, remains a challenge. These symptoms are divided into motor and non-motor symptoms. Non-motor symptoms may appear early or late in the disease and sometimes even before the onset of the first motor symptoms confirming the diagnosis. The spectrum of non-motor symptoms encompasses autonomic dysfunctions, sleep disorders, mood disorders, impulse control disorders, cognitive dysfunction, dementia, paranoia and hallucinations. They are often less appreciated than motor symptoms but are important sources of disability for many PD patients. This review describes these non-motor symptoms and their managements.

Effects of chronic subthalamic stimulation on nonmotor fluctuations in Parkinson's disease

The aim of this study was to assess the outcome of nonmotor fluctuations (NMF) after chronic Subthalamic nucleus (STN) Deep Brain Stimulation (DBS) in Parkinson's disease(PD). Chronic stimulation of the STN has proved to be an effective treatment for advanced PD with motor complications. The outcome of NMF, which are also disabling, remains unknown. Forty-patients underwent bilateral STN stimulation. Each patient was interviewed before and after 1 yr of STN DBS with a structured questionnaire about their NMF. After 1 yr of chronic stimulation, the improvement in the motor score (UPDRS III) and dyskinesia amounted respectively to 67.4 and 76.3%. The decrease in motor fluctuations (MF) was 59% and 13 patients reported that their MF had disappeared. Comparatively, a reduction of the total number of NMF was also observed (mean number preoperatively: 15.6 per patient, postoperatively: 6.6). Most of the nonmotor fluctuating symptoms occurred in the "off" state preoperatively and no longer depended on the patient's motor state after surgery. The improvement in NMF was not identical for the different categories: pain/sensory fluctuations showed the best response to STN DBS (84.2%). Dysautonomic and cognitive fluctuations were also markedly improved (>60%) while psychic fluctuations remained the most frequent postoperative NMF observed. Some incapacitating manifestations such as drenching sweats and akathisia showed a remarkably good response to STN stimulation. In conclusion STN DBS alleviates NMF. It has strikingly successful effects on sensory, dysautonomic and cognitive fluctuations. However, psychic fluctuations respond less consistently to this treatment.

[State-of-the-art corrective and diagnostic technologies in medical rehabilitation of patients with vegetative vascular dystonia]

Including of balneological therapy with the use of the baths Bi-olong in the programs of medical rehabilitation makes possible to improve considerable the state of peripheral haemodynamics, the indices of adaptation and regulation in patients with vegetative vascular dystonia. This fact can be explained with the positive corrective effect of bath Biolong reactant mitophen on cell respiration by the system cytochrome P450 activation. Also it is possible to assume that mitophen leads to decrease imbalance between sympathetic and parasympathetic nervous systems participating in regulation and adaptation of vascular wall. Use of bath Biolong in the therapy of patient with hypertonic vegetative vascular dystonia ought to consider as an effective, harmless and pathogenetically reasonable method which can be recommended to include in combined rehabilitation.

Anesthetic implications of undiagnosed late onset central hypoventilation syndrome in a child: from elective tonsillectomy to tracheostomy

Late onset central hypoventilation syndrome is a neurological disorder that can present with postoperative respiratory complications and delayed emergence in children after anesthesia. We present a child who had unanticipated respiratory complications following an elective tonsillectomy who eventually required a tracheostomy and long-term ventilatory support.