Diabetic truncal polyneuropathy

Truncal sensory polyneuropathy in light-chain amyloidosis

We describe a case of truncal sensory polyneuropathy in a patient with light-chain amyloidosis. We highlight the clinical signs and differential diagnoses related to the presentation.

Stem Cell Therapy in Diabetic Polyneuropathy: Recent Advancements and Future Directions

Diabetic polyneuropathy (DPN) is the most frequent, although neglected, complication of long-term diabetes. Nearly 30% of hospitalized and 20% of community-dwelling patients with diabetes suffer from DPN; the incidence rate is approximately 2% annually. To date, there has been no curable therapy for DPN. Under these circumstances, cell therapy may be a vital candidate for the treatment of DPN. The epidemiology, classification, and treatment options for DPN are disclosed in the current review. Cell-based therapies using bone marrow-derived cells, embryonic stem cells, pluripotent stem cells, endothelial progenitor cells, mesenchymal stem cells, or dental pulp stem cells are our primary concern, which may be a useful treatment option to ease or to stop the progression of DPN. The importance of cryotherapies for treating DPN has been observed in several studies. These findings may help for the future researchers to establish more focused, accurate, effective, alternative, and safe therapy to reduce DPN. Cell-based therapy might be a permanent solution in the treatment and management of diabetes-induced neuropathy.

High-fat diet induced discrepant peripheral and central nervous systems insulin resistance in APPswe/PS1dE9 and wild-type C57BL/6J mice

This study was designed to examine whether AD pathological phenotype in APPswe/PS1dE9 (APP/PS1) mice exposed to continuous high-fat diet predispose these murine models to metabolic dysfunction and neuropathological impairments. One-month old male APP/PS1 and C57BL/6J mice were provided with 60% high-fat diet for 6.5 months. After dietary intervention, metabolic phenotyping, cognitive behaviors, AD-related brain pathological changes and insulin signaling were compared. high fat diet induced hyperglycemia, hypercholesterolemia, and aggravated inflammatory stress in both APP/PS1 and C57BL/6J mice. Compared with C57BL/6J control mice, APP/PS1 mice showed lower glucose transporter protein expression in liver, muscle, and brain. High-fat diet caused a decrease of glucose transporter protein expression in muscle and liver but increased cortical glucose transporter protein expression in APP/PS1 mice. High-fat diet-fed APP/PS1 mice demonstrated decreased cognitive function, as well as elevated cortical soluble amyloid-β levels and APP protein expression. Decrease in cortical IR, p-IR protein expression and p-GSK3β/GSK3β ratio were observed in high-fat diet-fed APP/PS1 mice. High-fat diet caused discrepant peripheral and central nervous system metabolic phenotype in APP/PS1 and C57BL/6J mice. AD pathological phenotype might accelerate metabolic changes and cognitive impairment in APP/PS1 mice treated with HFD.

The 2017 Banting Memorial Lecture The diabetic lower limb - a forty year journey: from clinical observation to clinical science

A series of clinical research projects conducted over the past 40 years, all of which were informed by clinical observation or discussions with people with diabetes and staff colleagues are described in this review. A study of necrobiosis lipoidica diabeticorum confirmed that this rare skin complication occurs predominantly in young women with Type 1 diabetes and other microvascular complications. Biopsies of necrobiotic lesions showed destruction of superficial nerve fibres by inflammatory tissue, which likely causes the sensory loss in lesions that is pathognomonic of the condition. The development of corneal confocal microscopy as a new non-invasive surrogate marker of peripheral neuropathy in diabetes is described next and several small studies of the use of this new technique in clinical research are reported. The influence of blood glucose instability on the genesis of neuropathic pain is then explained, with results suggesting that the stability of glycaemic control may be more important than the level of control achieved. Lastly, in neuropathy, studies of gustatory sweating are discussed, including the observation that sweating in the head and neck region is more common in people with end-stage diabetic nephropathy than in those with neuropathy. The disappearance of gustatory sweating after renal transplantation suggests a metabolic cause and for those with troublesome sweating, use of the anticholinergic, anti-muscarinic, topical cream glycopyrrolate is confirmed in a randomized control trial. In the area of diabetic foot research, distended dorsal foot veins were observed to be a clinical sign of sympathetic autonomic neuropathy: raised venous Po₂ and Doppler abnormalities of blood flow are highly suggestive of arteriovenous shunting. A series of studies of the abnormalities of pressures and loads under the neuropathic diabetic foot are described: high dynamic plantar pressures are highly predictive of subsequent ulceration in the neuropathic foot. Lastly, a number of recent studies on unsteadiness and gait abnormalities when climbing and descending stairs are described. It is hoped that the art of clinical observation survives in the highly technological 21st century.

Length-dependent truncal Aδ-fiber dysfunction in hereditary transthyretin amyloidosis: An intra-epidermal electrical stimulation study

OBJECTIVE

To elucidate Aδ-fiber dysfunction at the trunk in patients with hereditary transthyretin (ATTRm) amyloidosis using intra-epidermal electrical stimulation (IES).

METHODS

In 16 patients with ATTRm amyloidosis and 18 healthy subjects, sensory thresholds using IES and cooling detection thresholds using the Computer-Aided Sensory Evaluation (CASE IV) system, were assessed to investigate Aδ-fiber functions at the Th10 level of the anterior, lateral, and posterior trunk. Furthermore, evoked potentials (EPs) following electrical stimulation using IES at the anterior and posterior trunk were evaluated.

RESULTS

In patients with ATTRm amyloidosis, both IES and CASE IV sensory thresholds tended to be higher at the anterior trunk than at the lateral and posterior trunks. The amplitudes of EPs following electrical stimulation at the anterior trunk were lower than those at the posterior trunk. Aδ-fiber dysfunction at the anterior trunk was conspicuous in patients with more intense polyneuropathy at the limbs. In healthy subjects, there were no differences in both sensory thresholds and EP amplitudes among any examination sites. Sensory thresholds with IES and CASE IV were correlated.

CONCLUSIONS

Evaluation using IES demonstrated length-dependent Aδ-fiber dysfunction at the trunk in patients with ATTRm amyloidosis.

SIGNIFICANCE

IES may be a useful clinical tool for investigating Aδ-fiber dysfunction at various parts of the body in patients with neuropathy.

Insulin receptor in the brain: Mechanisms of activation and the role in the CNS pathology and treatment

While the insulin receptor (IR) was found in the CNS decades ago, the brain was long considered to be an insulin-insensitive organ. This view is currently revisited, given emerging evidence of critical roles of IR-mediated signaling in development, neuroprotection, metabolism, and plasticity in the brain. These diverse cellular and physiological IR activities are distinct from metabolic IR functions in peripheral tissues, thus highlighting region specificity of IR properties. This particularly concerns the fact that two IR isoforms, A and B, are predominantly expressed in either the brain or peripheral tissues, respectively, and neurons express exclusively IR-A. Intriguingly, in comparison with IR-B, IR-A displays high binding affinity and is also activated by low concentrations of insulin-like growth factor-2 (IGF-2), a regulator of neuronal plasticity, whose dysregulation is associated with neuropathologic processes. Deficiencies in IR activation, insulin availability, and downstream IR-related mechanisms may result in aberrant IR-mediated functions and, subsequently, a broad range of brain disorders, including neurodevelopmental syndromes, neoplasms, neurodegenerative conditions, and depression. Here, we discuss findings on the brain-specific features of IR-mediated signaling with focus on mechanisms of primary receptor activation and their roles in the neuropathology. We aimed to uncover the remaining gaps in current knowledge on IR physiology and highlight new therapies targeting IR, such as IR sensitizers.

Pure T7 sensory level as an isolated manifestation of Guillain-Barré syndrome

INTRODUCTION

Truncal sensory level (TSL) is a localizing sign for spinal cord pathology. However, in rare instances, lesions higher up in the spinothalamic tract can cause TSL.

CASE REPORT

A 26-year-old woman presented with numbness from waist down with a T7 TSL on examination with negative spine magnetic resonance imaging. Later, the patient developed the full picture of Guillain-Barré syndrome confirmed with electrophysiological testing.

CONCLUSION

TSL can localize to the nerve roots and can be an early manifestation of Guillain-Barré syndrome.

Diabetic neuropathy part 2: proximal and asymmetric phenotypes

Diabetic neuropathies consist of a variety of syndromes resulting from different types of damage to peripheral or cranial nerves. Although distal symmetric polyneuropathy is the most common type of diabetic neuropathy, many other subtypes have been defined since the 1800s, including proximal diabetic, truncal, cranial, median, and ulnar neuropathies. Various theories have been proposed for the pathogenesis of these neuropathies. The treatment of most requires tight and stable glycemic control. Spontaneous recovery is seen in most of these conditions with diabetic control. Immunotherapies have been tried in some of these conditions however are controversial.

Diabetic neuropathy part 1: overview and symmetric phenotypes

Diabetes is the most common cause of neuropathy in United States and neuropathies are the most common complication of diabetes mellitus, affecting up to 50% of patients with type 1 and type 2 diabetes mellitus. Symptoms usually include numbness, tingling, pain, and weakness. Dizziness with postural changes can be seen with autonomic neuropathy. Metabolic, vascular, and immune theories have been proposed for the pathogenesis of diabetic neuropathy. Axonal damage and segmental demyelination can be seen with diabetic neuropathies. Management of diabetic neuropathy should begin at the initial diagnosis of diabetes and mainly requires tight and stable glycemic control.

Curcumin modulates dopaminergic receptor, CREB and phospholipase C gene expression in the cerebral cortex and cerebellum of streptozotocin induced diabetic rats

Curcumin, an active principle component in rhizome of Curcuma longa, has proved its merit for diabetes through its anti-oxidative and anti-inflammatory properties. This study aims at evaluating the effect of curcumin in modulating the altered dopaminergic receptors, CREB and phospholipase C in the cerebral cortex and cerebellum of STZ induced diabetic rats. Radioreceptor binding assays and gene expression was done in the cerebral cortex and cerebellum of male Wistar rats using specific ligands and probes. Total dopaminergic receptor binding parameter, B_max showed an increase in cerebral cortex and decrease in the cerebellum of diabetic rats. Gene expression studies using real time PCR showed an increased expression of dopamine D1 and D2 receptor in the cerebral cortex of diabetic rats. In cerebellum dopamine D1 receptor was down regulated and D2 receptor showed an up regulation. Transcription factor CREB and phospholipase C showed a significant down regulation in cerebral cortex and cerebellum of diabetic rats. We report that curcumin supplementation reduces diabetes induced alteration of dopamine D1, D2 receptors, transcription factor CREB and phospholipase C to near control. Our results indicate that curcumin has a potential to regulate diabetes induced malfunctions of dopaminergic signalling, CREB and Phospholipase C expression in cerebral cortex and cerebellum and thereby improving the cognitive and emotional functions associated with these regions. Furthermore, in line with these studies an interaction between curcumin and dopaminergic receptors, CREB and phospholipase C is suggested, which attenuates the cortical and cerebellar dysfunction in diabetes. These results suggest that curcumin holds promise as an agent to prevent or treat CNS complications in diabetes.

Neuroprotective role of curcumin in the cerebellum of streptozotocin-induced diabetic rats

AIMS

Chronic hyperglycaemia in diabetes involves a direct neuronal damage caused by intracellular glucose which leads to altered neurotransmitter functions and reduced motor activity. The present study investigated the effect of curcumin in the functional regulation of muscarinic and alpha7 nicotinic acetylcholine receptors, insulin receptors, acetylcholine esterase and Glut3 in the cerebellum of streptozotocin (STZ)-induced diabetic rats.

MAIN METHODS

All studies were done in the cerebellum of male Wistar rats. Radioreceptor binding assays were done for total muscarinic, M(1) and M(3) receptors using specific ligands, and the gene expression was also studied using specific probes.

KEY FINDINGS

Our results showed an increased gene expression of acetylcholine esterase, Glut3, muscarinic M1, M3, alpha7 nicotinic acetylcholine and insulin receptors in the cerebellum of diabetic rats in comparison to control. Scatchard analysis of total muscarinic, M1 and M3 receptors showed an increased binding parameter, B(max) in diabetic rats compared to control. Curcumin and insulin inhibited diabetes-induced elevation in the gene expression of acetylcholine esterase, Glut3, insulin and cholinergic receptors in the cerebellum of diabetic rats.

SIGNIFICANCE

Our studies suggest that curcumin plays a vital role in regulating the activity of cholinergic and insulin receptors and mechanism of glucose transportation through Glut3, which results in normalizing the diabetes-mediated cerebellar disorders. Thus, curcumin has a significant role in a therapeutic application for the prevention or progression of diabetic complications in the cerebellum.

The spectrum of diabetic neuropathies

Diabetes mellitus is associated with many different neuropathic syndromes, ranging from a mild sensory disturbance as can be seen in a diabetic sensorimotor polyneuropathy, to the debilitating pain and weakness of a diabetic lumbosacral radiculoplexus neuropathy. The etiology of these syndromes has been studied extensively, and may vary among metabolic, compressive, and immunological bases for the different disorders, as well as mechanisms yet to be discovered. Many of these disorders of nerve appear to be separate conditions with different underlying mechanisms, and some are caused directly by diabetes mellitus, whereas others are associated with it but not caused by hyperglycemia. This article discusses a number of the more common disorders of nerve found with diabetes mellitus. It discusses the symmetrical neuropathies, particularly generalized diabetic polyneuropathy, and then the focal or asymmetrical types of diabetes-associated neuropathy.

Intercostal nerve mononeuropathy: study of 14 cases

This retrospective study describes 14 cases of intercostal nerve mononeuropathy (INM) found in 5,560 electromyography (EMG) exams performed between January 1991 and June 2004 in our University Hospital. Medical charts of all patients with history of thoracic pain and EMG diagnosis of intercostal mononeuropathy were reviewed. INM was detected in 14 patients; etiology was thoracic surgery in 6 (43%), post-herpetic neuropathy in 4 (28%), probable intercostal neuritis in 2 (14%), lung neoplasia in 1 (7%), and radiculopathy in 1 (7%). From this study, trauma and infection were the main etiologies in intercostal neuropathic pain development. Tricyclic antidepressants and anticonvulsants were the most common therapeutic drugs used.

[Abdominal neuropathy of motor expression of diabetic origin. Apropos of a case]

Authors report a case of diabetic truncal neuropathy presenting as a painful abdominal swelling. This entity, which frequently is probably under estimated, may mimic abdominal visceral pathology and patients may be subjected unnecessary to extensive diagnosis procedures.

Peripheral diabetic neuropathy

Diabetic neuropathy is a common complication of diabetes mellitus with significant morbidity and mortality. Hyperglycemia with its secondary metabolic, vascular, and enzymatic consequences is most likely to be the predominant cause. The clinical manifestations includes a wide range of somatic and autonomic syndromes. Painful diabetic neuropathy may require symptomatic treatment. The precise role of therapies such as continuous subcutaneous insulin therapy and aldose reductase inhibitors remains to be clarified.

Effect of diabetes on the enzymes of the cholinergic system of the rat brain

Choline acetyltransferase (ChAT) and acetylcholinesterase (AChE) activities were determined in several brain regions of normal and streptozotocin-induced diabetic rats. The diabetic rats exhibited significant increase in ChAT activity (p less than 0.05) in all brain regions studied except for the cortex and the midbrain. Meanwhile, the diabetes condition was associated with significant increase (p less than 0.05) in AChE activity of the bulbus olfactorius, medulla oblongata and cerebellum. These data suggest that uncontrolled diabetes is associated with significant alterations in the brain cholinergic systems.

Proximal sensory conduction in diabetic patients

A study of segmental conduction along the peripheral afferent pathway of the upper limbs was carried out in 44 diabetic patients and 44 controls. An abnormal proximal conduction (Erb-cervical) was observed in 9 patients (20.4%). A similar incidence of abnormalities appeared at the most distal segment (digit III-wrist). A significant relationship between the alterations of proximal conduction and the presence of clinical signs of diabetic polyneuropathy was found. A common pathogenic mechanism underlying both these disorders is suggested.

Diabetic neuropathies and pain

Many of the diabetic neuropathic syndromes are characterized by painful symptoms with a sensation of burning and associated with troublesome hyperaesthesia. It is important to distinguish between the acute and chronic forms of peripheral sensory neuropathy; while the former carries an excellent prognosis for symptomatic improvement within one year, the latter may cause persistent symptoms for many years. In contrast to the acute form, in which symptoms are particularly severe but abnormal neurological signs are minimal, patchy stocking and glove sensory loss together with peripheral small muscle wasting are often present in chronic sensorimotor neuropathy. Peripheral polyneuropathies are more common in patients with poor metabolic control, although recent evidence implicates blood glucose flux as a possible contributory factor to neuropathic pain. It is possible that blood glucose flux or altered peripheral blood flow leads to increased spontaneous activity in nociceptive afferent fibres which are present in the axonal sprouts that characterize small fibre neuropathy. In the diagnosis of the neuropathies, exclusion of other aetiological factors is of paramount importance as there is no specific diagnostic test for diabetic nerve damage. If there is no symptomatic improvement after a period of stable and optimal metabolic control together with simple analgesics, then the tricyclic drugs should be regarded as first line therapy. The rapid effect of these drugs suggests a peripheral rather than central mode of action.

Classification of peripheral neuropathy: the long and the short of it

Insights into how the nervous system functions have often sprung from knowledge of the localization of nervous system diseases. Indeed, the recent rebirth of behavioral neurology has been sparked by new insights into the topography of higher cortical functions. Yet, the localization of disease affecting the peripheral nervous system is simply assumed to be a by-product of the beginning course in gross anatomy! Indeed, the anatomic sophistication laid out by Sunderland and reflected in the daily practice of electromyography might cause doubt as to the need for further inquiry into the problem of localization of disease within peripheral nervous system. There are, however, numerous problems in clinical practice that do not yield to the traditional root-plexus-nerve analysis of localization.

Accumulation of midazolam after repeated dosage in patients receiving mechanical ventilation in an intensive care unit

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Diabetic thoracic polyradiculopathy presenting as abdominal swelling

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Electromyographic study of diabetic and alcoholic polyneuropathic patients treated with gangliosides

A double-blind, randomized electromyographic investigation was conducted of the effects of cerebral ganglioside treatment on patients suffering from diabetic or alcoholic polyneuropathy. Cerebral gangliosides (50 mg once a day) administered to 15 diabetic and to 15 alcoholic neuropathic patients for 40 days, facilitated the reappearance of sensory potentials and significantly increased the MAP amplitude in median, ulnar, and peroneal nerves. In relation to ganglioside treatment, there was no significant change in the conduction velocities or in the distal latencies of these nerves, nor was there a change in the duration of the MAPs. On the basis of these results, it is suggested that the cerebral gangliosides are capable of inducing an improvement in the excitability of nerve fibers and of facilitating the processes of reinnervation, probably by means of an enhancement of fiber sprouting.