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The Pain in Neuropathy Study (PiNS): a cross-sectional observational study determining the somatosensory phenotype of painful and painless diabetic neuropathy. Pain 2017; 157:1132-1145. [PMID: 27088890 PMCID: PMC4834814 DOI: 10.1097/j.pain.0000000000000491] [Citation(s) in RCA: 210] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Supplemental Digital Content is Available in the Text. The Pain in Neuropathy Study (PiNS), an observational cross-sectional multicentre study, demonstrated a positive correlation between greater diabetic neuropathy severity and the presence and severity of neuropathic pain. Disabling neuropathic pain (NeuP) is a common sequel of diabetic peripheral neuropathy (DPN). We aimed to characterise the sensory phenotype of patients with and without NeuP, assess screening tools for NeuP, and relate DPN severity to NeuP. The Pain in Neuropathy Study (PiNS) is an observational cross-sectional multicentre study. A total of 191 patients with DPN underwent neurological examination, quantitative sensory testing, nerve conduction studies, and skin biopsy for intraepidermal nerve fibre density assessment. A set of questionnaires assessed the presence of pain, pain intensity, pain distribution, and the psychological and functional impact of pain. Patients were divided according to the presence of DPN, and thereafter according to the presence and severity of NeuP. The DN4 questionnaire demonstrated excellent sensitivity (88%) and specificity (93%) in screening for NeuP. There was a positive correlation between greater neuropathy severity (r = 0.39, P < 0.01), higher HbA1c (r = 0.21, P < 0.01), and the presence (and severity) of NeuP. Diabetic peripheral neuropathy sensory phenotype is characterised by hyposensitivity to applied stimuli that was more marked in the moderate/severe NeuP group than in the mild NeuP or no NeuP groups. Brush-evoked allodynia was present in only those with NeuP (15%); the paradoxical heat sensation did not discriminate between those with (40%) and without (41.3%) NeuP. The “irritable nociceptor” subgroup could only be applied to a minority of patients (6.3%) with NeuP. This study provides a firm basis to rationalise further phenotyping of painful DPN, for instance, stratification of patients with DPN for analgesic drug trials.
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Landowski LM, Dyck PJB, Engelstad J, Taylor BV. Axonopathy in peripheral neuropathies: Mechanisms and therapeutic approaches for regeneration. J Chem Neuroanat 2016; 76:19-27. [DOI: 10.1016/j.jchemneu.2016.04.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 03/18/2016] [Accepted: 04/30/2016] [Indexed: 01/01/2023]
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Van Acker N, Ragé M, Vermeirsch H, Schrijvers D, Nuydens R, Byttebier G, Timmers M, De Schepper S, Streffer J, Andries L, Plaghki L, Cras P, Meert T. NRP-1 Receptor Expression Mismatch in Skin of Subjects with Experimental and Diabetic Small Fiber Neuropathy. PLoS One 2016; 11:e0161441. [PMID: 27598321 PMCID: PMC5012683 DOI: 10.1371/journal.pone.0161441] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/07/2016] [Indexed: 12/27/2022] Open
Abstract
The in vivo cutaneous nerve regeneration model using capsaicin is applied extensively to study the regenerative mechanisms and therapeutic efficacy of disease modifying molecules for small fiber neuropathy (SFN). Since mismatches between functional and morphological nerve fiber recovery are described for this model, we aimed at determining the capability of the capsaicin model to truly mimic the morphological manifestations of SFN in diabetes. As nerve and blood vessel growth and regenerative capacities are defective in diabetes, we focused on studying the key regulator of these processes, the neuropilin-1 (NRP-1)/semaphorin pathway. This led us to the evaluation of NRP-1 receptor expression in epidermis and dermis of subjects presenting experimentally induced small fiber neuropathy, diabetic polyneuropathy and of diabetic subjects without clinical signs of small fiber neuropathy. The NRP-1 receptor was co-stained with CD31 vessel-marker using immunofluorescence and analyzed with Definiens® technology. This study indicates that capsaicin application results in significant loss of epidermal NRP-1 receptor expression, whereas diabetic subjects presenting small fiber neuropathy show full epidermal NRP-1 expression in contrast to the basal expression pattern seen in healthy controls. Capsaicin induced a decrease in dermal non-vascular NRP-1 receptor expression which did not appear in diabetic polyneuropathy. We can conclude that the capsaicin model does not mimic diabetic neuropathy related changes for cutaneous NRP-1 receptor expression. In addition, our data suggest that NRP-1 might play an important role in epidermal nerve fiber loss and/or defective regeneration and that NRP-1 receptor could change the epidermal environment to a nerve fiber repellant bed possibly through Sem3A in diabetes.
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Affiliation(s)
- Nathalie Van Acker
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- HistoGeneX NV, Antwerp, Belgium
- * E-mail:
| | - Michael Ragé
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
| | | | | | - Rony Nuydens
- Janssen Research and Development, Janssen Pharmaceutics NV, Beerse, Belgium
| | - Geert Byttebier
- Janssen Research and Development, Janssen Pharmaceutics NV, Beerse, Belgium
| | - Maarten Timmers
- Janssen Research and Development, Janssen Pharmaceutics NV, Beerse, Belgium
- Reference Center for Biological Markers of Dementia (BIODEM), Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
| | | | - Johannes Streffer
- Janssen Research and Development, Janssen Pharmaceutics NV, Beerse, Belgium
- Reference Center for Biological Markers of Dementia (BIODEM), Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
| | | | - Léon Plaghki
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
| | - Patrick Cras
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Neurology, Antwerp University Hospital, Born Bunge Institute, University of Antwerp, Antwerp, Belgium
| | - Theo Meert
- Janssen Research and Development, Janssen Pharmaceutics NV, Beerse, Belgium
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Menichella DM, Jayaraj ND, Wilson HM, Ren D, Flood K, Wang XQ, Shum A, Miller RJ, Paller AS. Ganglioside GM3 synthase depletion reverses neuropathic pain and small fiber neuropathy in diet-induced diabetic mice. Mol Pain 2016; 12:12/0/1744806916666284. [PMID: 27590073 PMCID: PMC5011393 DOI: 10.1177/1744806916666284] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 07/22/2016] [Indexed: 12/23/2022] Open
Abstract
Background Small fiber neuropathy is a well-recognized complication of type 2 diabetes and has been shown to be responsible for both neuropathic pain and impaired wound healing. In previous studies, we have demonstrated that ganglioside GM3 depletion by knockdown of GM3 synthase fully reverses impaired wound healing in diabetic mice. However, the role of GM3 in neuropathic pain and small fiber neuropathy in diabetes is unknown. Purpose Determine whether GM3 depletion is able to reverse neuropathic pain and small fibers neuropathy and the mechanism of the reversal. Results We demonstrate that GM3 synthase knockout and the resultant GM3 depletion rescues the denervation in mouse footpad skin and fully reverses the neuropathic pain in diet-induced obese diabetic mice. In cultured dorsal root ganglia from diet-induced diabetic mice, GM3 depletion protects against increased intracellular calcium influx in vitro. Conclusions These studies establish ganglioside GM3 as a new candidate responsible for neuropathic pain and small fiber neuropathy in diabetes. Moreover, these observations indicate that systemic or topically applied interventions aimed at depleting GM3 may improve both the painful neuropathy and the wound healing impairment in diabetes by protecting against nerve end terminal degeneration, providing a disease-modifying approach to this common, currently intractable medical issue.
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Affiliation(s)
- Daniela M Menichella
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nirupa D Jayaraj
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Heather M Wilson
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dongjun Ren
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kelsey Flood
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Xiao-Qi Wang
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andrew Shum
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard J Miller
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Amy S Paller
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Rizzetti DA, Fernandez F, Moreno S, Uranga Ocio JA, Peçanha FM, Vera G, Vassallo DV, Castro MM, Wiggers GA. Egg white hydrolysate promotes neuroprotection for neuropathic disorders induced by chronic exposure to low concentrations of mercury. Brain Res 2016; 1646:482-489. [DOI: 10.1016/j.brainres.2016.06.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 06/22/2016] [Accepted: 06/24/2016] [Indexed: 01/01/2023]
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Rivas E, Newmire DE, Ben-Ezra V. Obese type 2 diabetics have a blunted hypotensive response to acute hyperthermia therapy that does not affect the perception of thermal stress or physiological strain compared to healthy adults. Physiol Behav 2016; 165:374-82. [PMID: 27570191 DOI: 10.1016/j.physbeh.2016.08.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 08/21/2016] [Accepted: 08/24/2016] [Indexed: 11/15/2022]
Abstract
PURPOSE The objective of this study was to test the hypothesis that a hyperthermia-hypotensive challenge via whole body hot water immersion would alter the perception of hyperthermia and physiological strain in obese type 2 diabetics (T2DM) compared to healthy non-obese (HC) individuals. Additionally, we hypothesize that the mechanisms would be attributed to impaired blood pressure adjustments and afferent signals (via changes in internal and mean skin temperatures). METHODS In random order, eleven obese T2DM (50±12y, 45±7% fat mass, 7.5±1.8% HbA1c) and nine similar aged (41±14y, P>0.05) HC non-obese (33±8% fat mass, P<0.01) non-diabetic (5.3±0.4% HbA1c, P<0.01) underwent a 60min bout of whole body passive hyperthermia followed by 60min of recovery or a 2h resting control condition. The perception of thermal sensation (TS, scale range: 1-13), calculated physiological strain (PSI), internal (Tre, rectal) and mean skin (Tsk) temperatures, heart rate (HR) and blood pressures (BP) were the primary dependent variables. RESULTS Hyperthermia similarly increased Tre by 1.4±0.4°C, Tsk by 6.5±0.8°C and HR by 34±8bpm in both groups (P>0.5). Hyperthermia reduced diastolic BP (27% in T2DM and 33% in HC, P<0.05) and mean arterial BP (reduced by 15% in T2DM and by 19% in HC) relative to control conditions (P<0.05). The reduction of mean arterial BP area under the curve was attenuated in T2DM (12%) compared to HC (30%) (group×condition, P<0.01). TS and PSI during hyperthermia were not different between groups. Pearson product correlation reported strong correlations (r=0.69-0.89) with Tre and Tsk with TS in both populations. The linear stepwise regression analysis revealed similar relative contributions for Tre (~60%) and Tsk (~40%) on TS for both groups. CONCLUSIONS These data indicate that obese T2DM with moderate metabolic control have an attenuated hyperthermia-hypotensive response that does not affect TS and PSI. This also may suggest behavioral thermoregulation is intact in this study group.
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Affiliation(s)
- Eric Rivas
- Division of Rehabilitation Sciences, The University of Texas Medical Branch at Galveston, Galveston, TX, USA.
| | - Dan E Newmire
- Department of Kinesiology, Texas Woman's University, Denton, TX, USA
| | - Vic Ben-Ezra
- Department of Kinesiology, Texas Woman's University, Denton, TX, USA
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Ochoa N, Gogola GR, Gorniak SL. Contribution of tactile dysfunction to manual motor dysfunction in type II diabetes. Muscle Nerve 2016; 54:895-902. [PMID: 27061801 PMCID: PMC6645679 DOI: 10.1002/mus.25137] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 03/15/2016] [Accepted: 04/05/2016] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Changes in sensory and motor functions of the hand in type II diabetes (T2D) patients have been reported; there is speculation that these changes are driven by tactile dysfunction. The purpose of this study was to evaluate the effects of tactile feedback on manual function in T2D patients. METHODS T2D patients and healthy controls underwent median nerve blocks at the wrist and elbow. All participants underwent traditional timed motor evaluations, force dynamometry, laboratory-based kinetic evaluations, and sensory evaluation. RESULTS Tactile sensation in the T2D group at baseline was found to be equivalent to tactile function of the control group after median nerve block. Traditional timed evaluation results were negatively impacted by anesthesia, but more sensitive kinetic measures were not impacted. CONCLUSIONS These data suggest that mechanisms outside of tactile dysfunction play a significant role in motor dysfunction in T2D. Muscle Nerve 54: 895-902, 2016.
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Affiliation(s)
- Nereyda Ochoa
- Department of Health and Human Performance, University of Houston, 3875 Holman Street, Garrison 104N, Houston, Texas, 77204, USA.,Center for Neuromotor and Biomechanics Research, University of Houston, Houston, Texas, USA
| | - Gloria R Gogola
- Hand and Upper Extremity Surgery, Shriners Hospitals for Children, Houston, Houston, Texas, USA
| | - Stacey L Gorniak
- Department of Health and Human Performance, University of Houston, 3875 Holman Street, Garrison 104N, Houston, Texas, 77204, USA. .,Center for Neuromotor and Biomechanics Research, University of Houston, Houston, Texas, USA. .,Texas Obesity Research Center, University of Houston, Houston, Texas, USA.
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108
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Han HY, Kim HM, Park SY, Kim MW, Kim JM, Jang DH. Clinical Findings of Asymptomatic Carpal Tunnel Syndrome in Patients With Diabetes Mellitus. Ann Rehabil Med 2016; 40:489-95. [PMID: 27446786 PMCID: PMC4951368 DOI: 10.5535/arm.2016.40.3.489] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/13/2015] [Indexed: 11/05/2022] Open
Abstract
Objective To evaluate the clinical differences between patients with diabetes mellitus (DM) who have asymptomatic carpal tunnel syndrome (CTS) and those who have symptomatic CTS. Methods Sixty-three patients with DM were assessed using the Boston Carpal Tunnel Questionnaire (BCTQ), nerve conduction studies (NCS), and ultrasonographic evaluation of the cross-sectional area (CSA) of the median nerve. According to the BCTQ responses and NCS results, the patients were divided into the following three groups: group 1 (n=16), in which NCS results did not reveal CTS; group 2 (n=19), in which NCS results revealed CTS but the group scored 0 points on the BCTQ (asymptomatic); and group 3 (n=28), in which NCS results revealed CTS and the group scored >1 point on the BCTQ (symptomatic). The clinical findings, NCS results, and CSA of the median nerve were compared among the three groups. Results There were no significant differences in age, DM duration, glycated hemoglobin levels, and presence of diabetic polyneuropathy among the three groups. The peak latency of the median sensory nerve action potential was significantly shorter in group 1 than in groups 2 and 3 (p<0.001); however, no difference was observed between groups 2 and 3. CSA of the median nerve at the carpal tunnel in group 2 was significantly larger than that in group 1 and smaller than that in group 3 (p<0.05). Conclusion The results of our study suggest that the symptoms of CTS in patients with diabetes are related to CSA of the median nerve, which is consistent with swelling of the nerve.
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Affiliation(s)
- Hye Young Han
- Department of Rehabilitation Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Ha Min Kim
- GwangGyo Charm and Good Hospital, Yongin, Korea
| | - So Young Park
- Department of Rehabilitation Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Min-Wook Kim
- Department of Rehabilitation Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Jae Min Kim
- Department of Rehabilitation Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Dae-Hyun Jang
- Department of Rehabilitation Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
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Rivas E, Newmire DE, Crandall CG, Hooper PL, Ben-Ezra V. An acute bout of whole body passive hyperthermia increases plasma leptin, but does not alter glucose or insulin responses in obese type 2 diabetics and healthy adults. J Therm Biol 2016; 59:26-33. [PMID: 27264884 DOI: 10.1016/j.jtherbio.2016.04.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 03/28/2016] [Accepted: 04/26/2016] [Indexed: 01/02/2023]
Abstract
Acute and chronic hyperthermic treatments in diabetic animal models repeatedly improve insulin sensitivity and glycemic control. Therefore, the purpose of this study was to test the hypothesis that an acute 1h bout of hyperthermic treatment improves glucose, insulin, and leptin responses to an oral glucose challenge (OGTT) in obese type 2 diabetics and healthy humans. Nine obese (45±7.1% fat mass) type 2 diabetics (T2DM: 50.1±12y, 7.5±1.8% HbA1c) absent of insulin therapy and nine similar aged (41.1±13.7y) healthy non-obese controls (HC: 33.4±7.8% fat mass, P<0.01; 5.3±0.4% HbA1c, P<0.01) participated. Using a randomized design, subjects underwent either a whole body passive hyperthermia treatment via head-out hot water immersion (1h resting in 39.4±0.4°C water) that increased internal temperature above baseline by ∆1.6±0.4°C or a control resting condition. Twenty-four hours post treatments, a 75g OGTT was administered to evaluate changes in plasma glucose, insulin, C-peptide, and leptin concentrations. Hyperthermia itself did not alter area under the curve for plasma glucose, insulin, or C-peptide during the OGTT in either group. Fasting absolute and normalized (kg·fat mass) plasma leptin was significantly increased (P<0.01) only after the hyperthermic exposure by 17% in T2DM and 24% in HC groups (P<0.001) when compared to the control condition. These data indicate that an acute hyperthermic treatment does not improve glucose tolerance 24h post treatment in moderate metabolic controlled obese T2DM or HC individuals.
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Affiliation(s)
- Eric Rivas
- Institute for Clinical and Translational Science & Department of Pediatrics, The University of California, Irvine, CA, USA; Department of Kinesiology, Texas Woman's University, Denton, TX, USA; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital of Dallas, Dallas, TX, USA and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Dan E Newmire
- Department of Kinesiology, Texas Woman's University, Denton, TX, USA
| | - Craig G Crandall
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital of Dallas, Dallas, TX, USA and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Philip L Hooper
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Vic Ben-Ezra
- Department of Kinesiology, Texas Woman's University, Denton, TX, USA
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Ohyama K, Koike H, Hashimoto R, Takahashi M, Kawagashira Y, Iijima M, Katsuno M, Sobue G. Intraepidermal nerve fibre density in POEMS (Crow-Fukase) syndrome and the correlation with sural nerve pathology. J Neurol Sci 2016; 365:207-11. [PMID: 27206908 DOI: 10.1016/j.jns.2016.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 04/02/2016] [Accepted: 04/13/2016] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To examine intraepidermal nerve fibre densities (IENFDs) in patients with polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin change (POEMS) syndrome. METHODS The IENFDs of 11 patients with POEMS syndrome were estimated. We determined whether IENFD was associated with patient clinical features or the estimated number of nerve fibres on complete cross-sections of biopsied sural nerves. RESULTS IENFD was significantly reduced (9.7±4.4fibres/mm) compared with normal controls (p<0.05), although the individual values varied from 1.4 to 14.4fibres/mm. The presence of glucose intolerance was significantly associated with a reduction of IENFD (p<0.05). The number of unmyelinated fibres was preserved at the sural nerve level and was not correlated with IENFD. In contrast, the number of myelinated fibres was correlated with IENFD (p<0.05). CONCLUSIONS Some of the patients presented with a severe IENFD reduction. Because the number of unmyelinated fibres was well preserved at the level of the sural nerve biopsy, this severe reduction may indicate involvement at the most distal nerve terminals of unmyelinated fibres. Although the reduction of IENFD becomes evident as polyneuropathy becomes severe, the effects of glucose intolerance should also be considered in patients with moderate to severe reductions.
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Affiliation(s)
- Ken Ohyama
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Rina Hashimoto
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mie Takahashi
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuichi Kawagashira
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiro Iijima
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Gen Sobue
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan; Research Division of Dementia and Neurodegenerative Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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Mainka T, Malewicz N, Baron R, Enax-Krumova E, Treede RD, Maier C. Presence of hyperalgesia predicts analgesic efficacy of topically applied capsaicin 8% in patients with peripheral neuropathic pain. Eur J Pain 2016; 20:116-129. [DOI: 10.1002/ejp.703] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- T. Mainka
- Department of Pain Medicine; Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil GmbH; Ruhr-University Bochum; Germany
- Department of Neurology; University Medical Center Hamburg-Eppendorf; Germany
| | - N.M. Malewicz
- Department of Pain Medicine; Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil GmbH; Ruhr-University Bochum; Germany
| | - R. Baron
- Sektion Neurologische Schmerzforschung und Therapie; Klinik für Neurologie; Universitätsklinikum Schleswig-Holstein; Kiel Germany
| | - E.K. Enax-Krumova
- Department of Neurology; Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil GmbH; Ruhr-University Bochum; Germany
| | - R.-D. Treede
- Center for Biomedicine and Medical Technology Mannheim; Heidelberg University; Germany
| | - C. Maier
- Department of Pain Medicine; Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil GmbH; Ruhr-University Bochum; Germany
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Timar B, Popescu S, Timar R, Baderca F, Duica B, Vlad M, Levai C, Balinisteanu B, Simu M. The usefulness of quantifying intraepidermal nerve fibers density in the diagnostic of diabetic peripheral neuropathy: a cross-sectional study. Diabetol Metab Syndr 2016; 8:31. [PMID: 27069510 PMCID: PMC4827180 DOI: 10.1186/s13098-016-0146-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 03/31/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Distal symmetric polyneuropathy (DSPN) is the most common complication of type 2 diabetes mellitus (T2DM) and the most common form of peripheral neuropathy. DSPN increases the risk of foot ulceration up to seven-fold, and is a significant risk factor in more than 60 % of the amputations of the lower limbs in patients with T2DM. The aims of our study were to evaluate the difference in the density of intraepidermal nerve fibers (IENF) in patients with respectively without DSPN, to evaluate the strength of the relationship between the symptomatology of the DSPN and IENF density and to define a cutoff value of the IENF density for the diagnosis of DSPN. METHODS We enrolled, according to a consecutive, population-based method, 36 patients with T2DM admitted in our Clinic. For all patients, we measured HbA1c, lipid profile, body mass index and we assessed the presence and severity of DSPN using the evaluation of clinical symptoms, nerve conduction velocity and IENF density quantification. RESULTS The presence of neuropathy was significantly associated with a decreased density of IENF for both the proximal (11.6 vs. 14.9 fibers/mm; p = 0.014) and the distal biopsies (7.2 vs. 8.6 fibers/mm; p = 0.020). The optimal threshold value of IENF density (the point with the maximum sum of specificity and sensitivity), according to our model, was 10.1 fibers/mm. CONCLUSIONS Skin biopsy followed by IENF density quantification is a valid, reliable tool for the diagnosis of DSPN.
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Affiliation(s)
- Bogdan Timar
- />Department III – Functional Sciences, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu, 300041 Timisoara, Romania
| | - Simona Popescu
- />Department VII – Internal Medicine, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu, 300041 Timisoara, Romania
| | - Romulus Timar
- />Department VII – Internal Medicine, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu, 300041 Timisoara, Romania
| | - Flavia Baderca
- />Department II – Microscopic Morphology, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Bogdan Duica
- />Department X – Surgery, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Mihaela Vlad
- />Department VII – Internal Medicine, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu, 300041 Timisoara, Romania
| | - Codrina Levai
- />Legal Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Bogdan Balinisteanu
- />Department II – Microscopic Morphology, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Mihaela Simu
- />Department VIII – Neurosciences, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
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Karlsson P, Haroutounian S, Polydefkis M, Nyengaard JR, Jensen TS. Structural and functional characterization of nerve fibres in polyneuropathy and healthy subjects. Scand J Pain 2016; 10:28-35. [PMID: 28361768 DOI: 10.1016/j.sjpain.2015.08.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/14/2015] [Accepted: 08/22/2015] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Quantification of intraepidermal nerve fibre density (IENFD) is an important small fibre measure in distal symmetric polyneuropathies (DSP), but quantitative evaluation of additional structural and functional factors may help in elucidating the underlying mechanisms, and in improving the diagnostic accuracy in DSP. The literature reports a weak or moderate relationship between IENFD and spontaneous and evoked pain in neuropathies, but the relationship between functional and structural small fibre parameters in patients with DSP is unclear. The objectives of the current study, therefore, were to determine morphological and functional parameters related to small nerve fibres in subjects with distal symmetric polyneuropathy (DSP) and healthy controls, and to characterize the interplay among these parameters in these two groups. MATERIALS AND METHODS 17 patients with painful DSP (≥4 on 0-10 numerical rating scale) and with symptoms and signs of small fibre abnormality (with or without large fibre involvement) and 19 healthy control subjects underwent comprehensive functional and structural small fibre assessments that included quantitative sensory testing, response to 30min topical application of 10% capsaicin and analysis of skin biopsy samples taken from the distal leg (IENFD, epidermal and dermal nerve fibre length densities (eNFLD, dNFLD) using global spatial sampling and axonal swelling ratios (swellings/IENFD and swellings/NFLD)). RESULTS DSP patients had reduced sensitivity to cold (median -11.07°C vs. -2.60, P≤0.001) and heat (median 46.7 vs. 37.70, P≤0.001), diminished neurovascular (median 184 vs. 278 mean flux on laser Doppler, P=0.0003) and pain response to topical capsaicin (median 10 vs. 35 on 0-100 VAS, P=0.0002), and lower IENFD, eNFLD and dNFLD values combined with increased swelling ratios (all P<0.001) compared to healthy controls. The correlation between structural and functional parameters was poor in DSP patients, compared with healthy controls. In healthy controls eNFLD and dNFLD, IENFD and eNFLD, IENFD and dNFLD all correlated well with each other (r=0.81; P≤0.001, r=0.58; P=0.009, r=0.60; P=0.007, respectively). In DSP, on the other hand, only eNFLD and dNFLD showed significant correlation (r=0.53, P=0.03). A diagnostic approach of combined IENFD and eNFLD utilization increased DSP diagnostic sensitivity from 82.0% to 100% and specificity from 84.0% to 89.5%. CONCLUSIONS This study presents a rigorous comparison between functional and morphological parameters, including parameters such as eNFDL and dNFLD that have not been previously evaluated in this context. The correlation pattern between functional and structural small fibre parameters is different in patients with DSP when compared to healthy controls. The findings suggest a more direct relationship between structure and function of nerve fibres in healthy controls compared to DSP. Furthermore, the findings suggest that combining IENFD with measurement of NFLD improves the diagnostic sensitivity and specificity of DSP. IMPLICATIONS Combining small fibre parameters may improve the diagnostic accuracy of DSP.
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Affiliation(s)
- Páll Karlsson
- Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark
- Stereology and Electron Microscopy Laboratory and Centre for Stochastic Geometry and Advanced Bioimaging, Aarhus University Hospital, Aarhus, Denmark
| | - Simon Haroutounian
- Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Jens R Nyengaard
- Stereology and Electron Microscopy Laboratory and Centre for Stochastic Geometry and Advanced Bioimaging, Aarhus University Hospital, Aarhus, Denmark
| | - Troels S Jensen
- Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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Jørum E. Advancing methods for characterizing structure and functions of small nerve fibres in neuropathic conditions. Scand J Pain 2016; 10:54-56. [PMID: 28361772 DOI: 10.1016/j.sjpain.2015.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ellen Jørum
- Section of Clinical Neurophysiology, Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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115
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Lefaucheur JP, Wahab A, Planté-Bordeneuve V, Sène D, Ménard-Lefaucheur I, Rouie D, Tebbal D, Salhi H, Créange A, Zouari H, Ng Wing Tin S. Diagnosis of small fiber neuropathy: A comparative study of five neurophysiological tests. Neurophysiol Clin 2015; 45:445-55. [DOI: 10.1016/j.neucli.2015.09.012] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 09/13/2015] [Accepted: 09/14/2015] [Indexed: 01/13/2023] Open
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Yeo JH, Yoon SY, Kwon SK, Kim SJ, Lee JH, Beitz AJ, Roh DH. Repetitive Acupuncture Point Treatment with Diluted Bee Venom Relieves Mechanical Allodynia and Restores Intraepidermal Nerve Fiber Loss in Oxaliplatin-Induced Neuropathic Mice. THE JOURNAL OF PAIN 2015; 17:298-309. [PMID: 26604098 DOI: 10.1016/j.jpain.2015.10.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 10/21/2015] [Accepted: 10/24/2015] [Indexed: 01/11/2023]
Abstract
UNLABELLED The chemotherapeutic agent, oxaliplatin, produces a robust painful neuropathy that results in the loss of intraepidermal nerve fibers (IENFs). We have previously reported that an acupuncture point (acupoint) injection of diluted bee venom (DBV) produces a temporary antiallodynic effect in oxaliplatin-induced neuropathic mice. Herein we show a significant long-lasting antinociceptive effect of repetitive DBV acupoint treatment on oxaliplatin-induced mechanical allodynia and a significant reduction in the loss of IENFs. DBV (0.1 mg/kg, subcutaneous) was administered once a day for 18 days beginning on day 15 after oxaliplatin injection. Immunohistochemistry for IENF was performed on the glabrous skin of the hind paw footpad using the pan-neuronal marker, protein gene product 9.5. A temporary increase in mechanical threshold was observed 60 minutes after a single DBV injection into the Zusanli acupoint, and this effect was enhanced over time with repetitive DBV treatments. The basal mechanical threshold before daily DBV injection also increased from day 7 after DBV injections, and peaked at day 14 after DBV treatment. Moreover, the oxaliplatin-induced loss of IENFs was significantly reduced in mice treated repetitively with DBV. Repetitive pretreatment with the α-2 adrenoceptor antagonist, yohimbine, (5 mg/kg, subcutaneous) completely prevented the antiallodynic effects and the increase in IENFs observed in mice treated repetitively with DBV. PERSPECTIVE We showed that repetitive acupoint stimulation with DBV gradually and significantly reduced oxaliplatin-induced mechanical allodynia and restored the loss of IENFs in neuropathic mice via an α-2 adrenoceptor mechanism. Collectively, results of this study suggest that repetitive acupoint treatment with DBV can be a potential strategy for the management of chemotherapy-induced neuropathy.
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Affiliation(s)
- Ji-Hee Yeo
- Department of Oral Physiology and Research Center for Tooth and Periodontal Tissue Regeneration, School of Dentistry, Kyung Hee University, Seoul, Republic of Korea
| | - Seo-Yeon Yoon
- Department of Brain and Cognitive Sciences College of Natural Sciences, Dental Research Institute and Department of Neurobiology and Physiology, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Soon-Keun Kwon
- Department of Oral Physiology and Research Center for Tooth and Periodontal Tissue Regeneration, School of Dentistry, Kyung Hee University, Seoul, Republic of Korea
| | - Sol-Ji Kim
- Department of Oral Physiology and Research Center for Tooth and Periodontal Tissue Regeneration, School of Dentistry, Kyung Hee University, Seoul, Republic of Korea
| | - Jang-Hern Lee
- Department of Veterinary Physiology, College of Veterinary Medicine, Seoul National University, Seoul, Republic of Korea
| | - Alvin J Beitz
- Department of Veterinary and Biomedical Sciences, College of Veterinary Medicine, University of Minnesota, St Paul, Minnesota
| | - Dae-Hyun Roh
- Department of Oral Physiology and Research Center for Tooth and Periodontal Tissue Regeneration, School of Dentistry, Kyung Hee University, Seoul, Republic of Korea.
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Lin MT, Lee LJH, Chao CC, Hsieh ST. Quality of life in polyneuropathy: association with biomarkers of small fiber impairment. Health Qual Life Outcomes 2015; 13:169. [PMID: 26467421 PMCID: PMC4607005 DOI: 10.1186/s12955-015-0363-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 10/05/2015] [Indexed: 02/06/2023] Open
Abstract
Background Polyneuropathy presumably lowers quality of life (QoL). However, there is a lack of systematic studies that assess QoL changes and biomarkers of polyneuropathy as determinants of QoL. We aimed to investigate the relationship between every specific aspect of QoL and the clinical parameters used to assess the impairment of motor, sensory (large and small fibers), and autonomic nerves in polyneuropathy. Methods Polyneuropathy patients were recruited from September 2013 to March 2014; QoL was assessed using (1) the WHO Quality of Life-BREF (WHOQoL), (2) the European Quality of Life-5 Dimensions, and (3) the Brief Pain Inventory Short Form. Neuropathy examinations included nerve conduction studies, autonomic function tests, quantitative sensory testing (QST), and intraepidermal nerve fiber (IENF) density assessment of skin biopsies. Results There were 61 polyneuropathy patients (male/female = 38/23, mean age 58.14 ± 12.95 years). Patients had a lower QoL than age-and gender-matched controls in the physical and psychological domains of the WHOQoL. Among the biomarkers for different nerve fiber categories, only the small fiber neuropathy assessments were significantly related to all domains of the WHOQoL. In contrast, the parameters of the large fiber neuropathy were independent of QoL. Patients with abnormal temperature thresholds and a lower IENF density had lower WHOQoL scores compared to patients with normal thresholds and IENF densities. Warm threshold of the foot in QST was linearly correlated with all domains of the WHOQoL. Conclusions QoL scores were reduced in polyneuropathy, and biomarkers of small fiber neuropathy, i.e., warm threshold and IENF density were discriminating predictors of QoL. Electronic supplementary material The online version of this article (doi:10.1186/s12955-015-0363-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Meng-Ting Lin
- School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Lukas Jyuhn-Hsiarn Lee
- Department of Neurology, National Taiwan University Hospital, 7 Chung-Shan S Road, Taipei, 10002, Taiwan. .,National Institute of Environmental Medicine Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, 35053, Taiwan.
| | - Chi-Chao Chao
- Department of Neurology, National Taiwan University Hospital, 7 Chung-Shan S Road, Taipei, 10002, Taiwan.
| | - Sung-Tsang Hsieh
- Department of Neurology, National Taiwan University Hospital, 7 Chung-Shan S Road, Taipei, 10002, Taiwan. .,Department of Anatomy and Cell Biology, National Taiwan University College of Medicine, Taipei, 10051, Taiwan. .,Graduate Institute of Brain and Mind Sciences, National Taiwan University College of Medicine, Taipei, 10051, Taiwan.
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118
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Nisar MU, Asad A, Waqas A, Ali N, Nisar A, Qayyum MA, Maryam H, Javaid M, Jamil M. Association of Diabetic Neuropathy with Duration of Type 2 Diabetes and Glycemic Control. Cureus 2015; 7:e302. [PMID: 26430576 PMCID: PMC4571902 DOI: 10.7759/cureus.302] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Introduction: Diabetes mellitus is associated with severe microvascular and macrovascular complications with major implications for public health. Diabetic neuropathy is a very problematic complication of diabetes mellitus. It is associated with severe morbidity, mortality, and a huge economic burden. The present study was designed with two aims: 1) to analyze the association of diabetic neuropathy with the glycemic index (levels of fasting blood glucose, random blood glucose, and Hb1Ac) in patients with Type 2 diabetes, and 2) to analyze the association of diabetic neuropathy with time passed since the diagnosis of diabetes. Methods: This case-control study was undertaken between June 2013 and February 2015 in the Armed Forces Institute of Rehabilitation Medicine (AFIRM), Rawalpindi, Pakistan. Type 2 diabetics with an age range of 30-60 years were recruited from outpatient departments of AFIRM, Rawalpindi. Data were collected and recorded on a form with four sections recording the following: 1) demographics of patients and number of years passed since diagnosis of diabetes; 2) clinical examination for touch, pressure, power, pain, vibration, and ankle reflex; 3) nerve conduction studies for motor components of the common peroneal nerve and tibial nerve and the sensory component of median nerve and sural nerve; 4) glycemic index, including fasting blood glucose levels (BSF), random blood glucose (BSR) levels, and HbA1c levels. Data were analyzed in SPSS v. 20. Chi-square and phi statistics and logistic regression analysis were run to analyze associations between diabetic neuropathy and time passed since diagnosis of diabetes and glycemic index. Results: In total, 152 patients were recruited. One-half of those patients had neuropathy (76 patients) and the other half (76 patients) had normal nerve function. The mean (standard deviation [SD]) duration of diabetes was nine years (6.76), BSF levels 7.98 mmol/l (2.18), BSR 9.5 mmol/l (3.19), and HbA1c 6.5% (2.18). Logistic regression analysis predicted 87.5% of the model correctly. Duration since the diagnosis of diabetes and HbA1c levels were significantly associated with the diagnosis of neuropathy in diabetics. Conclusion: The presence of diabetic neuropathy was significantly associated with HbA1c levels and the duration of diabetes.
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Affiliation(s)
- Muhammad Umer Nisar
- Final year MBBS Student, Yusra Medical & Dental College Near Kahuta Morr, GT Road, P.O Humak, Islamabad
| | - Ambreen Asad
- Associate Professor, Dept. of Physiology, Yusra Medical & Dental College Near Kahuta Morr, GT Road, P.O Humak, Islamabad
| | - Ahmed Waqas
- Final year MBBS Student, CMH Lahore Medical College and Institute of Dentistry, Shami Road, Lahore Cantt
| | - Nazia Ali
- Fourth year MBBS Student, Yusra Medical & Dental College Near Kahuta Morr, GT Road, P.O Humak, Islamabad
| | - Anam Nisar
- Wah Medical College, , POF Hospital Wah Cantt. Pakistan
| | - Mohsin A Qayyum
- Fourth year MBBS Student , Yusra Medical & Dental College Near Kahuta Morr, GT Road, P.O Humak, Islamabad
| | - Hafsa Maryam
- Fourth year MBBS, Yusra Medical & Dental College Near Kahuta Morr, GT Road, P.O Humak, Islamabad
| | - Mohsin Javaid
- Fourth year MBBS Student, Yusra Medical & Dental College Near Kahuta Morr, GT Road, P.O Humak, Islamabad
| | - Mohsin Jamil
- Fourth year MBBS Student, Yusra Medical & Dental College Near Kahuta Morr, GT Road, P.O Humak, Islamabad
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Chao CC, Huang CM, Chiang HH, Luo KR, Kan HW, Yang NCC, Chiang H, Lin WM, Lai SM, Lee MJ, Shun CT, Hsieh ST. Sudomotor innervation in transthyretin amyloid neuropathy: Pathology and functional correlates. Ann Neurol 2015; 78:272-83. [PMID: 25973863 PMCID: PMC5034810 DOI: 10.1002/ana.24438] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 04/25/2015] [Accepted: 05/10/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Autonomic neuropathy is a major component of familial amyloid polyneuropathy (FAP) due to mutated transthyretin, with sudomotor failure as a common manifestation. This study aimed to investigate the pathology and clinical significance of sudomotor denervation. METHODS Skin biopsies were performed on the distal leg of FAP patients with a follow-up duration of 3.8 ± 1.6 years. Sudomotor innervation was stained with 2 markers: protein gene product 9.5 (PGP 9.5), a general neuronal marker, and vasoactive intestinal peptide (VIP), a sudomotor nerve functional marker, followed by quantitation according to sweat gland innervation index (SGII) for PGP 9.5 (SGIIPGP 9.5) and VIP (SGIIVIP). RESULTS There were 28 patients (25 men) with Ala97Ser transthyretin and late onset (59.9 ± 6.0 years) disabling neuropathy. Autonomic symptoms were present in 22 patients (78.6%) at the time of skin biopsy. The SGIIPGP 9.5 and SGIIVIP of FAP patients were significantly lower than those of age- and gender-matched controls. The reduction of SGIIVIP was more severe than that of SGIIPGP 9.5 (p = 0.002). Patients with orthostatic hypotension or absent sympathetic skin response at palms were associated with lower SGIIPGP 9.5 (p = 0.019 and 0.002, respectively). SGIIPGP 9.5 was negatively correlated with the disability grade at the time of skin biopsy (p = 0.004), and was positively correlated with the interval from the time of skin biopsy to the time of wheelchair usage (p = 0.029). INTERPRETATION This study documented the pathological evidence of sudomotor denervation in FAP. SGIIPGP 9.5 was functionally correlated with autonomic symptoms, autonomic tests, ambulation status, and progression of disability.
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Affiliation(s)
- Chi-Chao Chao
- Department of Neurology, National Taiwan University Hospital
| | - Cho-Min Huang
- Department of Anatomy and Cell Biology, National Taiwan University College of Medicine
| | - Hao-Hua Chiang
- Department of Anatomy and Cell Biology, National Taiwan University College of Medicine
| | - Kai-Ren Luo
- Department of Anatomy and Cell Biology, National Taiwan University College of Medicine
| | - Hung-Wei Kan
- Department of Anatomy and Cell Biology, National Taiwan University College of Medicine
| | - Naomi Chu-Chiao Yang
- Department of Anatomy and Cell Biology, National Taiwan University College of Medicine
| | - Hao Chiang
- Department of Anatomy and Cell Biology, National Taiwan University College of Medicine
| | - Whei-Min Lin
- Department of Anatomy and Cell Biology, National Taiwan University College of Medicine
| | - Shu-Mei Lai
- Department of Anatomy and Cell Biology, National Taiwan University College of Medicine
| | - Ming-Jen Lee
- Department of Neurology, National Taiwan University Hospital
| | - Chia-Tung Shun
- Department of Pathology, National Taiwan University Hospital
- Department of Forensic Medicine
| | - Sung-Tsang Hsieh
- Department of Neurology, National Taiwan University Hospital
- Department of Anatomy and Cell Biology, National Taiwan University College of Medicine
- Graduate Institute of Brain and Mind Sciences
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
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McCormick KG, Scorletti E, Bhatia L, Calder PC, Griffin MJ, Clough GF, Byrne CD. Impact of high dose n-3 polyunsaturated fatty acid treatment on measures of microvascular function and vibration perception in non-alcoholic fatty liver disease: results from the randomised WELCOME trial. Diabetologia 2015; 58:1916-25. [PMID: 26021488 DOI: 10.1007/s00125-015-3628-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 04/29/2015] [Indexed: 12/20/2022]
Abstract
AIMS/HYPOTHESIS The effect of n-3 fatty acid treatment on vibration perception thresholds (VPTs) and cutaneous microvascular reactivity is not known. We tested whether: (1) a 15-18 month treatment with high dose (4 g/day) docosahexaenoic (DHA) plus eicosapentaenoic (EPA) acid improved VPT and microvascular reactivity in patients with non-alcoholic fatty liver disease; and (2) there are associations between VPT, microvascular reactivity and metabolic variables. METHODS In the completed single centre, randomised, parallel group, placebo controlled Wessex Evaluation of fatty Liver and Cardiovascular markers in non-alcoholic fatty liver disease with OMacor thErapy (WELCOME) trial, we tested the effect of DHA+EPA on VPT at 125 Hz (big toe) and the cutaneous hyperaemic response (forearm) to arterial occlusion (ratio of maximum to resting blood flux [MF/RF]). Allocation and dispensing was carried out by an independent research pharmacist; all participants and research team members were blinded to group assignment. RESULTS In all, 51 and 49 patients were randomised to placebo and DHA+EPA, respectively (mean age 51.4 years). Of these, 32 had type 2 diabetes. Forty-six (placebo) and 47 (DHA+EPA) patients completed the study; there were no important adverse (or unexpected) effects or side effects. In multivariable-adjusted regression models (intention-to-treat analyses), DHA+EPA treatment was associated with an increase in VPT (β coefficient 1.49 [95% CI 0.04, 2.94], p = 0.04). For VPT, the adjusted mean differences (95% CIs) in the placebo and DHA+EPA treatment groups were -0.725 (-1.71, 0.25) and 0.767 (-0.21, 1.75) m/s(2), respectively. With DHA+EPA treatment, there was no change in MF/RF (β coefficient 0.07 [95% CI -0.56, 0.70], p = 0.84), the adjusted mean differences (95% CIs) in the placebo and DHA+EPA treatment groups were -0.549 (-1.03, -0.07) and -0.295 (-0.77, 0.18) respectively. VPT was independently associated with age (β coefficient 0.019 [95% CI 0.010, 0.029], p < 0.0001) and MF/RF (β coefficient -0.074 [95% CI -0.132, -0.016], p = 0.013), but not with diabetes (p = 0.38). CONCLUSIONS/INTERPRETATION High dose n-3 fatty acid treatment did not improve measures of microvascular function or vibration perception. Ageing and microvascular reactivity are associated with a measure of peripheral nerve function. TRIAL REGISTRATION ClinicalTrials.gov NCT00760513. FUNDING The study was funded by the National Institute for Health Research UK and Diabetes UK.
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Affiliation(s)
- Keith G McCormick
- Human Development and Health Academic Unit, Faculty of Medicine, University Hospital Southampton, MP887, IDS Building, Tremona Road, Southampton, SO166YD, UK
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Körei AE, Istenes I, Papanas N, Kempler P. Small-Fiber Neuropathy: A Diabetic Microvascular Complication of Special Clinical, Diagnostic, and Prognostic Importance. Angiology 2015; 67:49-57. [PMID: 25957257 DOI: 10.1177/0003319715583595] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Damage of small nerve fibers may lead to a large variety of clinical symptoms. Small-fiber neuropathy underlies the symptoms of painful diabetic neuropathy, which may decrease quality of life. It also contributes to the poor prognosis of diabetic neuropathy because it plays a key role in the pathogenesis of foot ulceration and autonomic neuropathy. Impairment of small nerve fibers is considered the earliest alteration in the course of diabetic neuropathy. Therefore, assessment of functional and morphological abnormalities of small nerve fibers may enable timely diagnosis. The definition, symptoms, and clinical significance of small-fiber neuropathy are considered in the present review. An apparently more complex interaction between small-fiber impairment and microcirculation is extensively discussed. Diagnostic modalities include morphometric and functional methods. Corneal confocal microscopy and punch skin biopsy are considered gold standards, but noninvasive functional tests are also diagnostically useful. However, in routine clinical practice, small-fiber neuropathy is diagnosed by its typical clinical presentation. Finally, prompt treatment should be initiated following diagnosis.
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Affiliation(s)
- A E Körei
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - I Istenes
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - N Papanas
- Second Department of Internal Medicine, Outpatient Clinic of the Diabetic Foot, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - P Kempler
- First Department of Medicine, Semmelweis University, Budapest, Hungary
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Schreiber AK, Nones CFM, Reis RC, Chichorro JG, Cunha JM. Diabetic neuropathic pain: Physiopathology and treatment. World J Diabetes 2015; 6:432-444. [PMID: 25897354 PMCID: PMC4398900 DOI: 10.4239/wjd.v6.i3.432] [Citation(s) in RCA: 233] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 11/26/2014] [Accepted: 02/09/2015] [Indexed: 02/05/2023] Open
Abstract
Diabetic neuropathy is a common complication of both type 1 and type 2 diabetes, which affects over 90% of the diabetic patients. Although pain is one of the main symptoms of diabetic neuropathy, its pathophysiological mechanisms are not yet fully known. It is widely accepted that the toxic effects of hyperglycemia play an important role in the development of this complication, but several other hypotheses have been postulated. The management of diabetic neuropathic pain consists basically in excluding other causes of painful peripheral neuropathy, improving glycemic control as a prophylactic therapy and using medications to alleviate pain. First line drugs for pain relief include anticonvulsants, such as pregabalin and gabapentin and antidepressants, especially those that act to inhibit the reuptake of serotonin and noradrenaline. In addition, there is experimental and clinical evidence that opioids can be helpful in pain control, mainly if associated with first line drugs. Other agents, including for topical application, such as capsaicin cream and lidocaine patches, have also been proposed to be useful as adjuvants in the control of diabetic neuropathic pain, but the clinical evidence is insufficient to support their use. In conclusion, a better understanding of the mechanisms underlying diabetic neuropathic pain will contribute to the search of new therapies, but also to the improvement of the guidelines to optimize pain control with the drugs currently available.
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Chiang MC, Tseng MT, Pan CL, Chao CC, Hsieh ST. Progress in the treatment of small fiber peripheral neuropathy. Expert Rev Neurother 2015; 15:305-13. [PMID: 25664678 DOI: 10.1586/14737175.2015.1013097] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Small fiber neuropathy is a syndrome of diverse disease etiology because of multiple pathophysiologic mechanisms with major presentations of neuropathic pain and autonomic symptoms. Over the past decade, there has been substantial progress in the treatments for neuropathic pain, dysautonomia and disease-modifying strategy. In particular, anticonvulsants and antidepressants alleviate neuropathic pain based on randomized clinical trials.
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Affiliation(s)
- Ming-Chang Chiang
- Department of Biomedical Engineering, National Yang-Ming University, Taipei, Taiwan
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[Diabetic neuropathy: do not only consider distal symmetrical neuropathy]. DER NERVENARZT 2015; 86:161-6. [PMID: 25604836 DOI: 10.1007/s00115-014-4127-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Diabetic neuropathy is a common complication of diabetes mellitus. The length-dependent symmetrical sensorimotor type of neuropathy is the most prevalent form of diabetic neuropathy but other forms of diabetic neuropathy also need to be kept in mind. Their differential diagnosis is often more challenging but implicates specific forms of treatment other than improvement of metabolic control. AIM OF THE STUDY This article gives an overview of the less frequent forms of diabetic neuropathy and discusses their impact, diagnostic and therapeutic implications. RESULTS Autonomic diabetic neuropathy, diabetic small fiber neuropathy and less frequent forms of diabetic neuropathy, such as diabetic radiculoplexopathy, diabetic neuropathy of cranial nerves, therapy-induced neuropathy and alternative causes of peripheral neuropathy in patients with diabetes are described. DISCUSSION Diagnosis of less frequent subtypes of diabetic neuropathy and differentiation towards alternative causes of peripheral neuropathy are often difficult in daily medical routine. Diagnostic clues are helpful in identifying rarer forms of diabetic neuropathy, thus enabling more specific treatment.
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Katsuda Y, Sasase T, Tadaki H, Mera Y, Motohashi Y, Kemmochi Y, Toyoda K, Kakimoto K, Kume S, Ohta T. Contribution of hyperglycemia on diabetic complications in obese type 2 diabetic SDT fatty rats: effects of SGLT inhibitor phlorizin. Exp Anim 2015; 64:161-9. [PMID: 25736710 PMCID: PMC4427731 DOI: 10.1538/expanim.14-0084] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The spontaneously diabetic torii (SDT) fatty rat is a new model of type 2 diabetes
showing overt obesity, hyperglycemia and hyperlipidemia. With early onset of diabetes
mellitus, diabetic microvascular complications, including nephropathy, peripheral
neuropathy and retinopathy, are observed at young ages. In the present study, blood
glucose levels of female SDT fatty rats were controlled with phlorizin, a non-selective
SGLT inhibitor, to examine whether and how these complications are caused by
hyperglycemia. Phlorizin treatment adequately controlled plasma glucose levels during the
experiment. At 29 weeks of age, urinary albumin excretion considerably increased in SDT
fatty rats. Glomerulosclerosis and tubular pathological findings also indicate diabetic
nephropathy. These renal parameters tended to decrease with phlorizin; however, effects
were partial. Sciatic nerve conduction velocities were significantly delayed in SDT fatty
rats compared with Sprague-Dawley (SD) rats. Intraepidermal nerve fiber density, an
indicator of subclinical small nerve fiber neuropathy, significantly decreased in SDT
fatty rats. Retinal dysfunction (prolongation of peak latency for oscillatory potential in
electroretinograms) and histopathological eye abnormalities, including retinal folding and
mature cataracts were also observed. Both nerve and eye disorders were prevented with
phlorizin. These findings indicate that severe hyperglycemia mainly causes diabetic
complications in SDT fatty rats. However, other factors, such as hyperlipidemia and
hypertension, may affect diabetic nephropathy. These characteristics of diabetic
complications will become helpful in evaluating new drugs for diabetic complications using
SDT fatty rats.
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Affiliation(s)
- Yoshiaki Katsuda
- Biological/Pharmacological Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., 1-1 Murasaki-cho, Takatsuki, Osaka 569-1125, Japan
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126
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Karlsson P, Nyengaard JR, Polydefkis M, Jensen TS. Structural and functional assessment of skin nerve fibres in small-fibre pathology. Eur J Pain 2014; 19:1059-70. [PMID: 25546653 DOI: 10.1002/ejp.645] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2014] [Indexed: 01/19/2023]
Abstract
Damage to nociceptor nerve fibres may give rise to peripheral neuropathies, some of which are pain free and some are painful. A hallmark of many peripheral neuropathies is the loss of small nerve fibres in the epidermis, a condition called small-fibre neuropathy (SFN) when it is predominantly the small nerve fibres that are damaged. Historically, SFN has been very difficult to diagnose as clinical examination and nerve conduction studies mainly detect large nerve fibres, and quantitative sensory testing is not sensitive enough to detect small changes in small nerve fibres. However, taking a 3-mm punch skin biopsy from the distal leg and quantification of the nerve fibre density has proven to be a useful method to diagnose SFN. However, the correlation between the nerve fibre loss and other test results varies greatly. Recent studies have shown that it is possible not only to extract information about the nerve fibre density from the biopsies but also to get an estimation of the nerve fibre length density using stereology, quantify sweat gland innervation and detect morphological changes such as axonal swelling, all of which may be additional parameters indicating diseased small fibres relating to symptoms reported by the patients. In this review, we focus on available tests to assess structure and function of the small nerve fibres, and summarize recent advances that have provided new possibilities to more specifically relate structural findings with symptoms and function in patients with SFN.
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Affiliation(s)
- P Karlsson
- Danish Pain Research Center and Stereology & EM Laboratory, Aarhus University Hospital, Denmark.,Stereology and Electron Microscopy Laboratory and Centre for Stochastic Geometry and Advanced Bioimaging, Aarhus University Hospital, Denmark
| | - J R Nyengaard
- Stereology and Electron Microscopy Laboratory and Centre for Stochastic Geometry and Advanced Bioimaging, Aarhus University Hospital, Denmark
| | - M Polydefkis
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - T S Jensen
- Danish Pain Research Center and Stereology & EM Laboratory, Aarhus University Hospital, Denmark.,Department of Neurology, Aarhus University Hospital, Denmark
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127
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Park SY, Kim YA, Hong YH, Moon MK, Koo BK, Kim TW. Up-regulation of the receptor for advanced glycation end products in the skin biopsy specimens of patients with severe diabetic neuropathy. J Clin Neurol 2014; 10:334-41. [PMID: 25324883 PMCID: PMC4198715 DOI: 10.3988/jcn.2014.10.4.334] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 02/17/2014] [Accepted: 02/17/2014] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND PURPOSE The receptor for advanced glycation end products (RAGE) may contribute to the development of diabetic neuropathy. To assess its relevance in humans, this study examined the expression of RAGE in the skin biopsy samples of patients with diabetes mellitus, and investigated its correlation with intraepidermal nerve-fiber density (IENFD) and clinical measures of neuropathy severity. METHODS Forty-four patients who either had type 2 diabetes or were prediabetes underwent clinical evaluation and a 3-mm skin punch biopsy. The clinical severity of their neuropathy was assessed using the Michigan Diabetic Neuropathy Score. IENFD was measured along with immunohistochemical staining for RAGE in 29 skin biopsy samples. The expression of RAGE was also quantified by real-time reverse-transcription PCR in the remaining 15 patients. RESULTS RAGE was localized mostly in the dermal and subcutaneous vascular endothelia. The staining was more intense in patients with a lower IENFD (p=0.004). The quantity of RAGE mRNA was significantly higher in patients with severe neuropathy than in those with no or mild neuropathy (p=0.003). The up-regulation of RAGE was related to dyslipidemia and diabetic nephropathy. There was a trend toward decreased sural nerve action-potential amplitude and slowed peroneal motor-nerve conduction with increasing RAGE expression. CONCLUSIONS The findings of this study demonstrate up-regulation of RAGE in skin biopsy samples from patients with diabetic neuropathy, supporting a pathogenic role of RAGE in the development of diabetic neuropathy.
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Affiliation(s)
- Su-Yeon Park
- Department of Neurology, Korea Cancer Center Hospital, Seoul, Korea
| | - Young-A Kim
- Department of Pathology, Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon-Ho Hong
- Department of Neurology, Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Min-Kyong Moon
- Department of Endocrinology and Metabolism, Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Bo-Kyeong Koo
- Department of Endocrinology and Metabolism, Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Wan Kim
- Department of Ophthalmology, Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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128
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Alsunousi S, Marrif HI. Diabetic neuropathy and the sensory apparatus "meissner corpuscle and merkel cells". Front Neuroanat 2014; 8:79. [PMID: 25177276 PMCID: PMC4132297 DOI: 10.3389/fnana.2014.00079] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 07/22/2014] [Indexed: 01/30/2023] Open
Affiliation(s)
- Salma Alsunousi
- Department of Histology, Faculty of Medicine, Benghazi University Benghazi, Libya
| | - Husnia I Marrif
- Department of Pharmaceutical Sciences, Princess Noura University Riyadh, Saudi Arabia
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129
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Kodaira M, Inui K, Kakigi R. Evaluation of nociceptive Aδ- and C-fiber dysfunction with lidocaine using intraepidermal electrical stimulation. Clin Neurophysiol 2014; 125:1870-7. [DOI: 10.1016/j.clinph.2014.01.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/16/2014] [Accepted: 01/18/2014] [Indexed: 10/25/2022]
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130
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El-Abassi R, Singhal D, England JD. Fabry's disease. J Neurol Sci 2014; 344:5-19. [DOI: 10.1016/j.jns.2014.06.029] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 06/12/2014] [Accepted: 06/14/2014] [Indexed: 10/25/2022]
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131
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Abstract
Neuropathy is the most common complication of diabetes. As a consequence of longstanding hyperglycemia, a downstream metabolic cascade leads to peripheral nerve injury through an increased flux of the polyol pathway, enhanced advanced glycation end‐products formation, excessive release of cytokines, activation of protein kinase C and exaggerated oxidative stress, as well as other confounding factors. Although these metabolic aberrations are deemed as the main stream for the pathogenesis of diabetic microvascular complications, organ‐specific histological and biochemical characteristics constitute distinct mechanistic processes of neuropathy different from retinopathy or nephropathy. Extremely long axons originating in the small neuronal body are vulnerable on the most distal side as a result of malnutritional axonal support or environmental insults. Sparse vascular supply with impaired autoregulation is likely to cause hypoxic damage in the nerve. Such dual influences exerted by long‐term hyperglycemia are critical for peripheral nerve damage, resulting in distal‐predominant nerve fiber degeneration. More recently, cellular factors derived from the bone marrow also appear to have a strong impact on the development of peripheral nerve pathology. As evident from such complicated processes, inhibition of single metabolic factors might not be sufficient for the treatment of neuropathy, but a combination of several inhibitors might be a promising approach to overcome this serious disorder. (J Diabetes Invest, doi: 10.1111/j.2040‐1124.2010.00070.x, 2010)
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Affiliation(s)
| | | | - Kazuhiro Sugimoto
- Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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132
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Thaisetthawatkul P, Fernandes Filho JA, Herrmann DN. Autonomic evaluation is independent of somatic evaluation for small fiber neuropathy. J Neurol Sci 2014; 344:51-4. [PMID: 24972819 DOI: 10.1016/j.jns.2014.06.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 06/07/2014] [Accepted: 06/11/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND The relationship between the autonomic reflex screening test (ARS) and measures of sensory function and structure (quantitative sensory testing (QST) and intraepidermal nerve fiber density (IENFD)) remains uncertain in patients with distal small fiber neuropathy (SFN). The aim of this study was to evaluate the correlations among a range of autonomic (quantitative sudomotor axon reflex test (QSART), cardiovagal and cardio adrenergic tests and the composite autonomic severity score (CASS)) and somatic sensory measures (QST of vibration, cooling and heat-pain thresholds and IENFD). METHOD 122 patients with clinically suspected sensory neuropathy without motor weakness and with normal nerve conduction studies underwent blinded autonomic reflex screening test (ARS), quantitative sensory testing (QST) and skin biopsy (IENFD) for diagnosis of SFN. The relationship between autonomic and somatic sensory measures was assessed. RESULTS There was no association between autonomic function measures (QSART volume, CASS_QSART, CASS_vagal, CASS_adrenergic or total CASS) and small fiber sensory measures (IENFD, cooling or heat-pain thresholds). Weak correlations were noted among some modalities of QST (vibration and cooling thresholds) and IENFD. DISCUSSION Autonomic and sensory outcomes are independent (complementary) measures of distal SFN, and should where feasible be used concurrently in the evaluation of SFN.
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Affiliation(s)
| | - J Americo Fernandes Filho
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA; Neurology Section, VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - David N Herrmann
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
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133
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Reduced intraepidermal nerve fiber density in patients with chronic ischemic pain in peripheral arterial disease. Pain 2014; 155:1784-1792. [PMID: 24931568 DOI: 10.1016/j.pain.2014.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 06/04/2014] [Accepted: 06/06/2014] [Indexed: 11/22/2022]
Abstract
Chronic ischemic pain in peripheral arterial disease (PAD) is a leading cause of pain in the lower extremities. A neuropathic component of chronic ischemic pain has been shown independent of coexisting diabetes. We aimed to identify a morphological correlate potentially associated with pain and sensory deficits in PAD. Forty patients with symptomatic PAD (Fontaine stages II-IV), 20 with intermittent claudication (CI), and 20 with critical limb ischemia (CLI) were enrolled; 12 volunteers served as healthy controls. All patients were examined using pain scales and questionnaires. All study participants underwent quantitative sensory testing (QST) at the distal calf and skin punch biopsy at the distal leg for determination of intraepidermal nerve fiber density (IENFD). Additionally, S100 beta serum levels were measured as a potential marker for ischemic nerve damage. Neuropathic pain questionnaires revealed slightly higher scores and more pronounced pain-induced disability in CLI patients compared to CI patients. QST showed elevated thermal and mechanical detection pain thresholds as well as dynamic mechanical allodynia, particularly in patients with advanced disease. IENFD was reduced in PAD compared to controls (P<0.05), more pronounced in the CLI subgroup (CLI: 1.3 ± 0.5 fibers/mm, CI: 2.9 ± 0.5 fibers/mm, controls: 5.3 ± 0.6 fibers/mm). In particular, increased mechanical and heat pain thresholds negatively correlated with lower IENFD. Mean S100 beta levels were in the normal range but were higher in advanced disease. Patients with chronic ischemic pain had a reduced IENFD associated with impaired sensory functions. These findings support the concept of a neuropathic component in ischemic pain.
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134
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Sensory correlates of pain in peripheral neuropathies. Clin Neurophysiol 2014; 125:1048-58. [DOI: 10.1016/j.clinph.2013.09.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 08/26/2013] [Accepted: 09/30/2013] [Indexed: 01/04/2023]
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135
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Biegstraaten M, Linthorst GE, van Schaik IN, Hollak CEM. Fabry disease: a rare cause of neuropathic pain. Curr Pain Headache Rep 2014; 17:365. [PMID: 23996721 DOI: 10.1007/s11916-013-0365-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Fabry disease is characterized by burning or shooting pains in hands and feet, which have a severe impact on the quality of life of patients. It is therefore of importance that Fabry patients receive adequate diagnosis, counseling, treatment and follow up. This review describes neuropathic pain in classical Fabry disease with the aim to help clinicians to recognize Fabry patients among patients presenting with chronic extremity pain. The diagnostic dilemmas in patients with neuropathic pain and a non-classical disease course are discussed, together with the available diagnostic modalities, pain medication options and the effect of enzyme replacement therapy on small fiber neuropathy.
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Affiliation(s)
- Marieke Biegstraaten
- Department of Internal Medicine, div Endocrinology and Metabolism, Academic Medical Center, Amsterdam, The Netherlands.
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136
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Herrmann DN. Noninvasive and minimally invasive detection and monitoring of peripheral neuropathies. Expert Rev Neurother 2014; 8:1807-16. [DOI: 10.1586/14737175.8.12.1807] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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137
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Lee-Kubli CA, Mixcoatl-Zecuatl T, Jolivalt CG, Calcutt NA. Animal models of diabetes-induced neuropathic pain. Curr Top Behav Neurosci 2014; 20:147-70. [PMID: 24510303 DOI: 10.1007/7854_2014_280] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Neuropathy will afflict over half of the approximately 350 million people worldwide who currently suffer from diabetes and around one-third of diabetic patients with neuropathy will suffer from painful symptoms that may be spontaneous or stimulus evoked. Diabetes can be induced in rats or mice by genetic, dietary, or chemical means, and there are a variety of well-characterized models of diabetic neuropathy that replicate either type 1 or type 2 diabetes. Diabetic rodents display aspects of sensorimotor dysfunction such as stimulus-evoked allodynia and hyperalgesia that are widely used to model painful neuropathy. This allows investigation of pathogenic mechanisms and development of potential therapeutic interventions that may alleviate established pain or prevent onset of pain.
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138
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Clinical and diagnostic features of small fiber damage in diabetic polyneuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2014; 126:275-90. [DOI: 10.1016/b978-0-444-53480-4.00019-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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139
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Xu L, Tang D, Guan M, Xie C, Xue Y. Effect of high-fat diet on peripheral neuropathy in C57BL/6 mice. Int J Endocrinol 2014; 2014:305205. [PMID: 25404943 PMCID: PMC4227356 DOI: 10.1155/2014/305205] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Revised: 09/17/2014] [Accepted: 09/26/2014] [Indexed: 11/17/2022] Open
Abstract
Objective. Dyslipidemia may contribute to the development of peripheral neuropathy, even in prediabetics; however, few studies have evaluated vascular dysfunction and oxidative stress in patients with peripheral neuropathy. Methods. Using high-fat diet- (HFD-) induced prediabetic C57BL/6 mice, we assessed motor and sensory nerve conduction velocity (NCV) using a BIOPAC System and thermal algesia with a Plantar Test (Hargreaves' method) Analgesia Meter. Intraepidermal nerve fiber density and mean dendrite length were tested following standard protocols. Vascular endothelial growth factor-A (VEGF-A) and 12/15-lipoxygenase (12/15-LOX) were evaluated by immunohistochemistry and Western blot, respectively. Results. HFD-fed mice showed deficits in motor and sensory NCV, thermal hyperalgesia, reduced mean dendrite length, and VEGF-A expression in the plantar skin and increased 12/15-LOX in the sciatic nerve (P < 0.05 compared with controls). Conclusion. HFD may cause large myelinated nerve and small sensory nerve fiber damage, thus leading to neuropathy. The mean dendrite length may be a more sensitive marker for early detection of peripheral neuropathy. Reduced blood supply to the nerves and increased oxidative stress may contribute to the development and severity of peripheral neuropathy.
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Affiliation(s)
- Lingling Xu
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Dou Tang
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Meiping Guan
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Cuihua Xie
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yaoming Xue
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
- *Yaoming Xue:
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140
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Abstract
As ensheathing and secretory cells, Schwann cells are a ubiquitous and vital component of the endoneurial microenvironment of peripheral nerves. The interdependence of axons and their ensheathing Schwann cells predisposes each to the impact of injury in the other. Further, the dependence of the blood-nerve interface on trophic support from Schwann cells during development, adulthood, and after injury suggests these glial cells promote the structural and functional integrity of nerve trunks. Here, the developmental origin, injury-induced changes, and mature myelinating and nonmyelinating phenotypes of Schwann cells are reviewed prior to a description of nerve fiber pathology and consideration of pathogenic mechanisms in human and experimental diabetic neuropathy. A fundamental role for aldose-reductase-containing Schwann cells in the pathogenesis of diabetic neuropathy, as well as the interrelationship of pathogenic mechanisms, is indicated by the sensitivity of hyperglycemia-induced biochemical alterations, such as polyol pathway flux, formation of reactive oxygen species, generation of advanced glycosylation end products (AGEs) and deficient neurotrophic support, to blocking polyol pathway flux.
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Affiliation(s)
- Andrew P Mizisin
- Department of Pathology, School of Medicine, University of California San Diego, La Jolla, CA, USA.
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141
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Abstract
The skin is innervated by small sensory and autonomic fibers. In the epidermis, sensory fibers are present as unmyelinated C fibers that terminate as free nerve endings. The determination of epidermal nerve fiber (ENF) density using the immunohistochemical method is a powerful tool that provides insight into a population of nerve fibers that is prominently altered in small fiber neuropathy. The superficial location of epidermal nerve fibers allows repeated sampling of these nerves in a relatively noninvasive fashion, and in sites that cannot be assessed through conventional electrodiagnostic techniques. These features have allowed investigators to diagnose diabetic neuropathy earlier in the course of disease. ENF density holds promise as a biomarker for neuropathic pain and is a sensitive indicator of neuropathic progression. Finally, the ability to injure these fibers in a standardized fashion has led to novel measures of human axonal regeneration that may provide a more sensitive ruler by which to assess promising regenerative compounds in clinical trials.
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Affiliation(s)
- Gigi Ebenezer
- Cutaneous Nerve Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael Polydefkis
- Cutaneous Nerve Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins Bayview EMG Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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142
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Dyck PJ, Herrmann DN, Staff NP, Dyck PJB. Assessing decreased sensation and increased sensory phenomena in diabetic polyneuropathies. Diabetes 2013; 62:3677-86. [PMID: 24158999 PMCID: PMC3806590 DOI: 10.2337/db13-0352] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 07/25/2013] [Indexed: 12/14/2022]
Abstract
Loss of sensation and increased sensory phenomena are major expressions of varieties of diabetic polyneuropathies needing improved assessments for clinical and research purposes. We provide a neurobiological explanation for the apparent paradox between decreased sensation and increased sensory phenomena. Strongly endorsed is the use of the 10-g monofilaments for screening of feet to detect sensation loss, with the goal of improving diabetic management and prevention of foot ulcers and neurogenic arthropathy. We describe improved methods to assess for the kind, severity, and distribution of both large- and small-fiber sensory loss and which approaches and techniques may be useful for conducting therapeutic trials. The abnormality of attributes of nerve conduction may be used to validate the dysfunction of large sensory fibers. The abnormality of epidermal nerve fibers/1 mm may be used as a surrogate measure of small-fiber sensory loss but appear not to correlate closely with severity of pain. Increased sensory phenomena are recognized by the characteristic words patients use to describe them and by the severity and persistence of these symptoms. Tests of tactile and thermal hyperalgesia are additional markers of neural hyperactivity that are useful for diagnosis and disease management.
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Affiliation(s)
- Peter J. Dyck
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - David N. Herrmann
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
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143
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Han D. Retrogression of Nervous Fibers According to the Age of Patients with Diabetes Mellitus (DM). J Phys Ther Sci 2013; 25:1063-6. [PMID: 24259916 PMCID: PMC3818766 DOI: 10.1589/jpts.25.1063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 04/11/2013] [Indexed: 11/24/2022] Open
Abstract
[Purpose] This study was performed to discover the possible onset time of diabetic
neuropathy by age of diabetic patients, and to provide the knowledge necessary for
preventing or managing diabetic neuropathy. [Subjects] The subjects of this study were
outpatients who visited D Hospital Department of Neurology with complaints of significant
neuropathic symptoms including dullness, numbness and paraesthesia. [Methods] Stimulations
of 5 Hz, 250 Hz and 2,000 Hz were generated with a Neurometer CPT (Neurotron Inc.,
Baltimore, MD, USA) and delivered selectively to C fibers, A-delta fibers and A-beta
fibers. The intensity of the stimulations of 5 Hz, 250 Hz and 2,000 Hz was incrementally
increased as much as 0.01 mA. [Result] The results of this experiment show that the period
of retrogression of nervous fibers was different significantly according to the age of
patients with diabetes mellitus. Especially, in the case of individuals in their 50's, Aβ,
Aδ, and C fibers in both the right and left lower limbs significantly changed within a
period of 2 months. In the case of individuals in their 60's, Aβ and C fibers of the right
lower limb meaningfully changed 2 months after the onset of the disease, and Aβ, Aδ, and C
fibers of the left lower limb also significantly changed within a period of 2 months.
[Conclusion] We discovered that patients suffering from DM especially in their 50's or
60's should be thoroughly followed for their condition, right from the onset of DM, in
order to prevent the retrogression of nervous fibers.
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Affiliation(s)
- Dongwook Han
- Department of Physical Therapy, College of Medical and Life Science, Silla University
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144
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Cheng HT, Dauch JR, Porzio MT, Yanik BM, Hsieh W, Smith AG, Singleton JR, Feldman EL. Increased axonal regeneration and swellings in intraepidermal nerve fibers characterize painful phenotypes of diabetic neuropathy. THE JOURNAL OF PAIN 2013; 14:941-7. [PMID: 23685187 PMCID: PMC3994562 DOI: 10.1016/j.jpain.2013.03.005] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 01/23/2013] [Accepted: 03/11/2013] [Indexed: 01/25/2023]
Abstract
UNLABELLED We examined changes in intraepidermal nerve fibers (IENFs) to differentiate patients with diabetic neuropathy (DN) and diabetic neuropathic pain (DN-P) from those with DN without pain (DN-NOP). Punch skin biopsies were collected from the proximal thigh (PT) and distal leg (DL) of normal subjects, patients with type 2 diabetes without evidence of DN (DM), or DN-P and DN-NOP patients. Protein gene product 9.5-positive (PGP+) immunohistochemistry was used to quantify total IENF, and growth-associated protein 43 (GAP43) for regenerating IENF. Compared to normal subjects and patients with type 2 diabetes without evidence of DN, both DN-P and DN-NOP have reduced PGP+ IENF densities in DL and PT. Although GAP43+ IENF densities were also reduced in DL for both DN-P and DN-NOP, the GAP43+ IENF densities in PT of DN-P remained at the control levels. Higher GAP43/PGP ratios were detected in DN-P compared to DN-NOP in the DL and PT. In parallel, increased numbers of axonal swellings per PGP+ fiber (axonal swelling/PGP) were detected in DN-P compared to normal subjects, patients with type 2 diabetes without evidence of DN, and DN-NOP in the DL. These axonal swellings were positive for tropomyosin-receptor-kinase A and substance P, suggesting that they are associated with nociception. PERSPECTIVE Among patients with DN, the ratios of GAP43/PGP and axonal swelling/PGP are likely to differentiate painful from painless phenotypes.
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Affiliation(s)
- Hsinlin T Cheng
- Department of Neurology, University of Michigan Medical Center, Ann Arbor, Michigan 48109-2200, USA.
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145
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Sène D, Cacoub P, Authier FJ, Haroche J, Créange A, Saadoun D, Amoura Z, Guillausseau PJ, Lefaucheur JP. Sjögren Syndrome-Associated Small Fiber Neuropathy: Characterization From a Prospective Series of 40 Cases. Medicine (Baltimore) 2013; 92:e10-e18. [PMID: 23982054 PMCID: PMC4553978 DOI: 10.1097/md.0000000000000005] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We conducted the current study to analyze the clinical, immunologic, and neurophysiologic features of primary Sjögren syndrome (pSS)-associated sensory small fiber neuropathies (SFNs). Forty consecutive pSS patients with SFN were included. SFN was defined by the presence of suggestive sensory painful symptoms with normal nerve conduction studies and abnormal neurophysiologic tests for small nerve fibers or a low intraepidermal nerve fiber density at skin biopsy. Included patients were compared to 100 pSS patients without peripheral neuropathy.SFN patients were mainly female (92.5%). Age at pSS diagnosis was 55.3 ± 13.1 years, and at SFN diagnosis, 58.9 ± 11.8 years, with a median time to SFN diagnosis after symptom onset of 3.4 years. Clinical symptoms included burning pains (90%), numbness (87.5%), tingling (82.5%), pins and needles (72.5%), electric discharges (70%), and allodynia (55%). Dysautonomia included vasomotor symptoms (66%) and hyperhidrosis (47%). Abnormal neurophysiologic tests included laser evoked potentials (97.5%), thermal quantitative sensory testing (67.5%), and sympathetic skin reflex (40%). A skin biopsy revealed low intraepidermal nerve fiber density in 76% of the 17 tested patients.Compared to the 100 pSS patients without peripheral neuropathy, the 40 pSS-SFN patients were older at pSS diagnosis (55.3 ± 13.1 vs. 49.5 ± 14.9 yr; p = 0.03), and more often had xerostomia (97.5% vs. 81%; p = 0.01) and arthralgia (82.5% vs. 65.0%; p = 0.04). Immunologically, they were characterized by a lower prevalence of serum B-cell activation markers, that is, antinuclear antibodies (65% vs. 85%; p = 0.01), anti-SSA (42.5% vs. 71%; p = 0.002), and anti-SSB (17.5% vs. 39%; p = 0.017); rheumatoid factor (32.5% vs. 66%; p = 0.0005); and hypergammaglobulinemia (35% vs. 62%; p = 0.005).In conclusion, we report the main features of SFN in patients with pSS, the first such study to our knowledge. Our results show that patients with pSS-associated SFN are characterized by an older age at pSS diagnosis and a distinctive immunologic profile hallmarked by a lower frequency of serum B-cell activation markers.
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Affiliation(s)
- Damien Sène
- From the Service de Médecine Interne 2, AP-HP, Hôpital Lariboisière, Université Paris Diderot-Paris 7, Paris (D. Sène, PJG); Service de Médecine Interne 2, AP-HP, Hôpital Pitié-Salpêtrière, Paris, Université, Pierre et Marie Curie-Paris 6, Paris (PC, JH, D. Saadoun, ZA); Centre de Référence des Maladies Neuromusculaire Garches-Necker-Mondor-Hendaye, AP-HP, Hôpital Henri Mondor; INSERM U955, Equipe 10, Université Paris Est-Créteil, Créteil (FJA); and Service de Neurologie (AC) and Service de Physiologie-Explorations Fonctionnelles (JPL), APHP, Hôpital Henri Mondor,Créteil, Université Paris Est-Créteil, Créteil; France
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146
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Abstract
In this review of thermoregulatory function in health and disease, we review the basic mechanisms controlling skin blood flow of the hairy and glabrous skin and illustrate the major differences in blood flow to glabrous skin, which is, in essence, sympathetically mediated, while hairy skin is dependent upon neuropeptidergic signals, nitric oxide, and prostaglandin, among others. Laser Doppler methods of quantification of blood flow--in response to iontophoresis of acetylcholine or heat--and nociceptor-mediated blood flow have relatively uniformly demonstrated an impaired capacity to increase blood flow to the skin in diabetes and in its forerunners, prediabetes and the metabolic syndrome. This reduced capacity is likely to be a significant contributor to the development of foot ulcerations and amputations in diabetes, and means of increasing blood flow are clearly needed. Understanding the pathogenic mechanisms is likely to provide a means of identifying a valuable therapeutic target. Thermoregulatory control of sweating is intimately linked to the autonomic nervous system via sympathetic C fibers, and sweat glands are richly endowed with a neuropeptidergic innervation. Sweating disturbances are prevalent in diabetes and its precursors, and quantification of sweating may be useful as an index of diagnosis of somatic and, probably, autonomic dysfunction. Moreover, quantifying this disturbance in sweating by various methods may be useful in identifying the risk of progression from prediabetes to diabetes, as well as responses to therapeutic intervention. We now have the technological power to take advantage of this physiological arrangement to better understand, monitor, and treat disorders of small nerve fibers and the somatic and autonomic nervous system (ANS). Newer methods of sudomotor function testing are rapid, noninvasive, not technically demanding, and accessible to the outpatient clinic. Whether the potential applications are screening for diabetes, following poorly controlled diabetes subjects during alteration of their treatment regimen, or simply monitoring somatic and autonomic function throughout the course of treatment, sudorimetry can be an invaluable tool for today's clinicians.
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Affiliation(s)
- Aaron I Vinik
- Strelitz Diabetes Center for Endocrine and Metabolic Disorders, Eastern Virginia Medical School, Norfolk, VA 23510, USA.
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147
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Yardley JE, Stapleton JM, Sigal RJ, Kenny GP. Do heat events pose a greater health risk for individuals with type 2 diabetes? Diabetes Technol Ther 2013; 15:520-9. [PMID: 23530578 DOI: 10.1089/dia.2012.0324] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Chronic medical conditions such as type 2 diabetes may alter the body's normal response to heat. Evidence suggests that the local heat loss response of skin blood flow (SkBF) is affected by diabetes-related impairments in both endothelium-dependent and non-endothelium-dependent mechanisms, resulting in lower elevations in SkBF in response to a heat or pharmacological stimulus. Thermoregulatory sweating may also be diminished by type 2 diabetes, impairing the body's ability to transfer heat from its core to the environment. Diabetes-associated co-morbidities and the medications (particularly those affecting fluid balance) required to treat these conditions may exacerbate the risk of heat-related illness by decreasing SkBF and sweating further. Unfortunately, the majority of studies measure local heat loss responses in the hands and feet and lack measures of core temperature. Therefore, the impact of these impairments on whole-body heat loss remains unknown. This review addresses heat-related vulnerability in individuals with type 2 diabetes by examining the literature related to heat loss responses in this population. Type 2 diabetes, its associated co-morbidities, and the medications required in their treatment may cause dehydration, lower SkBF, and reduced sweating, which could consequently impair thermoregulation. This effect is most evident in individuals with poor blood glucose control. Although type 2 diabetes can be associated with impairments in SkBF and sweating, more physically active individuals requiring fewer medications and having good blood glucose control may be able to tolerate heat as well as those of similar age and body composition.
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Affiliation(s)
- Jane E Yardley
- Human and Environmental Physiology Research Unit, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
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148
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Chantelau EA, Wienemann T. Pressure pain perception in the diabetic Charcot foot: facts and hypotheses. Diabet Foot Ankle 2013; 4:20981. [PMID: 23705057 PMCID: PMC3661900 DOI: 10.3402/dfa.v4i0.20981] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 04/17/2013] [Accepted: 04/23/2013] [Indexed: 11/20/2022]
Abstract
Background Reduced traumatic and posttraumatic (nociceptive) pain is a key feature of diabetic neuropathy. Underlying condition is a gradual degeneration of endings of pain nerves (A-delta fibers and C-fibers), which operate as receivers of noxious stimuli (nociceptors). Hence, the absence of A-delta fiber mediated sharp pain (“first” pain), and of C-fiber mediated dull pain (“second” pain). However, patients with diabetic neuropathy and acute Charcot foot often experience deep dull aching in the Charcot foot while walking on it. Aim To create a unifying hypothesis on the kind of pain in an acute Charcot foot. Result Absence of punctuate (pinprick) pain perception at the sole of a Charcot foot, as was shown recently, likely corresponds to vanished intraepidermal A-delta fiber endings. C-fiber nociceptors are reduced, according to histopathology studies. Both types of fibers contribute to posttraumatic hyperalgesia at the skin level, as studies show. Their deficiencies likely impact on posttraumatic hyperalgesia at the skin level and, probably, also at the skeletal level. Conclusion It is hypothesised that deep dull aching in an acute diabetic Charcot foot may represent faulty posttraumatic hyperalgesia involving cutaneous and skeletal tissues.
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Affiliation(s)
- Ernst A Chantelau
- Diabetic Foot Clinic, Department of Endocrinology and Diabetes, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
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149
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Price R, Asenjo J, Christou N, Backman S, Schweinhardt P. The role of excess subcutaneous fat in pain and sensory sensitivity in obesity. Eur J Pain 2013; 17:1316-26. [DOI: 10.1002/j.1532-2149.2013.00315.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2013] [Indexed: 12/26/2022]
Affiliation(s)
| | | | - N.V. Christou
- McGill University Department of Surgery; Royal Victoria Hospital; Montreal; Canada
| | - S.B. Backman
- McGill University Department of Anesthesia; Royal Victoria Hospital; Montreal; Canada
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150
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Abstract
It is increasingly apparent that not only is a cure for the current worldwide diabetes epidemic required, but also for its major complications, affecting both small and large blood vessels. These complications occur in the majority of individuals with both type 1 and type 2 diabetes. Among the most prevalent microvascular complications are kidney disease, blindness, and amputations, with current therapies only slowing disease progression. Impaired kidney function, exhibited as a reduced glomerular filtration rate, is also a major risk factor for macrovascular complications, such as heart attacks and strokes. There have been a large number of new therapies tested in clinical trials for diabetic complications, with, in general, rather disappointing results. Indeed, it remains to be fully defined as to which pathways in diabetic complications are essentially protective rather than pathological, in terms of their effects on the underlying disease process. Furthermore, seemingly independent pathways are also showing significant interactions with each other to exacerbate pathology. Interestingly, some of these pathways may not only play key roles in complications but also in the development of diabetes per se. This review aims to comprehensively discuss the well validated, as well as putative mechanisms involved in the development of diabetic complications. In addition, new fields of research, which warrant further investigation as potential therapeutic targets of the future, will be highlighted.
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Affiliation(s)
- Josephine M Forbes
- Diabetes Division, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
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