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Marwaha B. Role of Tau protein in long COVID and potential therapeutic targets. Front Cell Infect Microbiol 2023; 13:1280600. [PMID: 37953801 PMCID: PMC10634420 DOI: 10.3389/fcimb.2023.1280600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 10/06/2023] [Indexed: 11/14/2023] Open
Abstract
Introduction Long COVID is an emerging public health burden and has been defined as a syndrome with common symptoms of fatigue, shortness of breath, cognitive dysfunction, and others impacting day-to-day life, fluctuating or relapsing over, occurring for at least two months in patients with a history of probable or confirmed SARS CoV-2 infection; usually three months from the onset of illness and cannot be explained by an alternate diagnosis. The actual prevalence of long-term COVID-19 is unknown, but it is believed that more than 17 million patients in Europe may have suffered from it during pandemic. Pathophysiology Currently, there is limited understanding of the pathophysiology of this syndrome, and multiple hypotheses have been proposed. Our literature review has shown studies reporting tau deposits in tissue samples of the brain from autopsies of COVID-19 patients compared to the control group, and the in-vitro human brain organoid model has shown aberrant phosphorylation of tau protein in response to SARS-CoV-2 infection. Tauopathies, a group of neurodegenerative disorders with the salient features of tau deposits, can manifest different symptoms based on the anatomical region of brain involvement and have been shown to affect the peripheral nervous system as well and explained even in rat model studies. Long COVID has more than 203 symptoms, with predominant symptoms of fatigue, dyspnea, and cognitive dysfunction, which tauopathy-induced CNS and peripheral nervous system dysfunction can explain. There have been no studies up till now to reveal the pathophysiology of long COVID. Based on our literature review, aberrant tau phosphorylation is a promising hypothesis that can be explored in future studies. Therapeutic approaches for tauopathies have multidimensional aspects, including targeting post-translational modifications, tau aggregation, and tau clearance through the autophagy process with the help of lysosomes, which can be potential targets for developing therapeutic interventions for the long COVID. In addition, future studies can attempt to find the tau proteins in CSF and use those as biomarkers for the long COVID.
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Affiliation(s)
- Bharat Marwaha
- Department of Cardiology, Adena Health System, Chillicothe, OH, United States
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2
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Lefaucheur JP. The value of electrochemical skin conductance measurement by Sudoscan® for assessing autonomic dysfunction in peripheral neuropathies beyond diabetes. Neurophysiol Clin 2023; 53:102859. [PMID: 36966705 DOI: 10.1016/j.neucli.2023.102859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/28/2023] Open
Abstract
The diagnosis and follow-up of peripheral neuropathies involving small-diameter nerve fibers require specific examinations beyond conventional nerve conduction studies which only concern large-diameter nerve fibers. Among these tests, some are dedicated to the investigation of cutaneous innervation by the autonomic nervous system, mainly by unmyelinated sympathetic C fibers. To this end, various laboratory tests have been proposed, but the measurement of electrochemical skin conductance (ESC) by Sudoscan® is increasingly becoming the most widely used technique, because it allows a quick and simple assessment of the sudomotor function of the limb extremities. This technique is based on the principles of reverse iontophoresis and chronoamperometry and since its introduction in 2010, has been the source of nearly 200 publications. In the clinical field, most of these publications concern the evaluation of diabetic polyneuropathy, for which the value of Sudoscan® no longer needs to be demonstrated. However, there is also evidence for a role for Sudoscan® in the testing of the autonomic nervous system in various peripheral neuropathies of other origins or diseases primarily affecting the central nervous system. In this article, a comprehensive review of the literature on the clinical value of Sudoscan® outside of diabetes is presented, detailing ESC changes in neuropathies associated with various clinical conditions, such as hereditary amyloidosis or other genetic pathologies, chemotherapy neurotoxicity, dysimmune or infectious disorders, fibromyalgia, parkinsonism or other neurodegenerative diseases.
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Abstract
Diabetes polyneuropathy is an important complication of diabetes polyneuropathy, and its notable sequelae of foot ulceration, autonomic dysfunction, and neuropathic pain are associated with significant morbidity and mortality. Despite the major impact on quality of life and health economic costs, it remains underdiagnosed until late in its natural history, and there is lack of any intervention that can reverse its clinical progress. Assessment of small fiber neuropathy (SFN) in diabetes offers an opportunity to detect abnormalities at an early stage so that both interventional studies and preventative measures can be enacted to prevent progression to the devastating complications of foot ulceration and cardiac dysautonomic death. Over the last two decades, significant advances have been made in understanding the pathophysiology of diabetes neuropathy and its assessment. In this review, we discuss limitations of the screening methods recommended in current clinical guidelines which are based on large nerve fiber assessments. Thereafter, we discuss in detail the various methods currently available to assess small fiber structure and function and examine their individual strength and limitations. Finally, we discuss the reasons why despite the considerable body of evidence available, legislators and global experts have yet to incorporate the assessment of SFN as routine clinical surveillance in diabetes management. We hope that these insights will stimulate further discussion and be instrumental in the early adoption of these methods so as to reduce the burden of complications arising due to diabetes polyneuropathy.
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Affiliation(s)
- Sanjeev Sharma
- Diabetes Trails unit, Ipswich Hospital
(ESNEFT), Ipswich, UK
| | - Prashanth Vas
- Department of Diabetes, Kings College
Hospital, London, UK
| | - Gerry Rayman
- Diabetes Trails unit, Ipswich Hospital
(ESNEFT), Ipswich, UK
- Gerry Rayman, MD, Diabetes Trials Unit,
Department of Diabetes & Endocrinology, Ipswich Hospital, ESNEFT, Heath
Road, Ipswich, Suffolk IP4 5RH, UK.
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4
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Oh TJ, Song Y, Jang HC, Choi SH. SUDOSCAN in Combination with the Michigan Neuropathy Screening Instrument Is an Effective Tool for Screening Diabetic Peripheral Neuropathy. Diabetes Metab J 2022; 46:319-326. [PMID: 34525791 PMCID: PMC8987688 DOI: 10.4093/dmj.2021.0014] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/13/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Screening for diabetic peripheral neuropathy (DPN) is important to prevent severe foot complication, but the detection rate of DPN is unsatisfactory. We investigated whether SUDOSCAN combined with Michigan Neuropathy Screening Instrument (MNSI) could be an effective tool for screening for DPN in people with type 2 diabetes mellitus (T2DM) in clinical practice. METHODS We analysed the data for 144 people with T2DM without other cause of neuropathy. The presence of DPN was confirmed according to the Toronto Consensus criteria. Electrochemical skin conductance (ESC) of the feet was assessed using SUDOSCAN. We compared the discrimination power of following methods, MNSI only vs. SUDOSCAN only vs. MNSI plus SUDOSCAN vs. MNSI plus 10-g monofilament test. RESULTS Confirmed DPN was detected in 27.8% of the participants. The optimal cut-off value of feet ESC to distinguish DPN was 56 μS. We made the DPN screening scores using the corresponding odds ratios for MNSI-Questionnaire, MNSI-Physical Examination, SUDOSCAN, and 10-g monofilament test. For distinguishing the presence of DPN, the MNSI plus SUDOSCAN model showed higher areas under the receiver operating characteristic curve (AUC) than MNSI only model (0.717 vs. 0.638, P=0.011), and SUDOSCAN only model or MNSI plus 10-g monofilament test showed comparable AUC with MNSI only model. CONCLUSION The screening model for DPN that includes both MNSI and SUDOSCAN can detect DPN with acceptable discrimination power and it may be useful in Korean patients with T2DM.
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Affiliation(s)
- Tae Jung Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yoojung Song
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hak Chul Jang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung Hee Choi
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Corresponding author: Sung Hee Choi https://orcid.org/0000-0003-0740-8116 Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea E-mail:
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Sheen YJ, Sheu WHH, Wang HC, Chen JP, Sun YH, Chen HM. Assessment of diabetic small-fiber neuropathy by using short-wave infrared hyperspectral imaging. JOURNAL OF BIOPHOTONICS 2022; 15:e202100220. [PMID: 34766729 DOI: 10.1002/jbio.202100220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 09/02/2021] [Accepted: 11/05/2021] [Indexed: 06/13/2023]
Abstract
Among patients with type 2 diabetes mellitus (T2DM), the association between hyperspectral imaging (HSI) examination and diabetic neuropathy (DN) is ascertained using HSI of the feet using four types of spectral difference measurements. DN was evaluated by traditional Michigan Neuropathy Screening Instrument (MNSI), evaluation of painful neuropathy (ID-Pain, DN4) and sudomotor function by measuring electrochemical skin conductance (ESC). Of the 120 T2DM patients and 20 healthy adults enrolled, T2DM patients are categorized into normal sudomotor (ESC >60 μS) and sudomotor dysfunction (ESC ≤ 60 μS) groups. Spectral difference analyses reveal significant intergroup differences, whereas traditional examinations cannot distinguish between the two groups. HSI waveform reflectance gradually increases with disease severity, at 1400 to 1600 nm. The area under the curve (AUC) of receiver operating characteristic (ROC) analysis for abnormal ESC is ≥0.8 for all four HSI methods. HSI could be an objective, sensitive, rapid, noninvasive and remote approach to identify early small-fiber DN.
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Affiliation(s)
- Yi-Jing Sheen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Wayne Huey-Herng Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Institute of Medical Technology, College of Life Science, National Chung-Hsing University, Taichung, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Hsin-Che Wang
- Research and Development Department, ISUZU Optics, Hsinchu, Taiwan
- Center for Quantitative Imaging in Medicine (CQUIM), Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jun-Peng Chen
- Biostatistics Task Force, Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Hsuan Sun
- Center for Quantitative Imaging in Medicine (CQUIM), Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsian-Min Chen
- Center for Quantitative Imaging in Medicine (CQUIM), Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Biomedical Engineering, Hung Kuang University, Taichung, Taiwan
- Department of Computer Science & Information Engineering, National United University, Miaoli, Taiwan
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Zhao Y, Bao JJ, Ye LF, Zhou L. Consistency Analysis Between SUDOSCAN Examinations and Electromyography Results in Patients with Diabetes. Diabetes Metab Syndr Obes 2022; 15:3397-3402. [PMID: 36345491 PMCID: PMC9636856 DOI: 10.2147/dmso.s384881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To evaluate the consistency between SUDOSCAN examinations and electromyography (EMG) results in patients with diabetes. METHODS A total of 326 patients with diabetes (201 males and 125 females) who were hospitalized in the endocrinology ward of the Affiliated Hospital of Nanjing University of Chinese Medicine (Jiangsu Province Hospital of Chinese Medicine) from June 2020 to February 2021 were selected as participants. All the patients were tested using a SUDOSCAN conductance analyzer for electrical skin conductivities and EMG for nerve conduction. The differences and consistencies between the results of the two examinations were analyzed. McNemar's test was used to analyze the differences between the results, and Cohen's kappa test was utilized to test the consistencies. RESULTS A total of 174 patients had abnormal SUDOSCAN results, and 152 patients had normal SUDOSCAN results. The EMG results of 299 patients were abnormal, and the EMG results of 27 patients were normal. The McNemar test result was P = 0.000, and the differences between the results of the SUDOSCAN and EMG examinations were statistically significant (P < 0.01). No significant consistency was found between the SUDOSCAN and EMG results, meaning that the consistency between the two examination results was not statistically significant (P = 0.868, P > 0.05). The difference between the results was statistically significant (P < 0.05), and the consistency was poor (kappa = 0.005). CONCLUSION Differences existed between the SUDOSCAN examination and EMG results, and the results of the two examination methods were inconsistent, indicating that SUDOSCAN examinations cannot replace EMG examinations for DSPN.
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Affiliation(s)
- Yue Zhao
- Department of Endocrinology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing City, Jiangsu Province, 210029, People’s Republic of China
| | - Jin-Jing Bao
- Department of Endocrinology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing City, Jiangsu Province, 210029, People’s Republic of China
| | - Li-Fang Ye
- Department of Endocrinology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing City, Jiangsu Province, 210029, People’s Republic of China
| | - Lei Zhou
- Department of Endocrinology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing City, Jiangsu Province, 210029, People’s Republic of China
- Correspondence: Lei Zhou, Department of Endocrinology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, No. 155 of Han Zhong Road, Qing Huai District, Nanjing City, Jiangsu Province, 210029, People’s Republic of China, Tel +86 13851989209, Email
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Bönhof GJ, Herder C, Ziegler D. Diagnostic Tools, Biomarkers, and Treatments in Diabetic polyneuropathy and Cardiovascular Autonomic Neuropathy. Curr Diabetes Rev 2022; 18:e120421192781. [PMID: 33845748 DOI: 10.2174/1573399817666210412123740] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/24/2021] [Accepted: 03/02/2021] [Indexed: 11/22/2022]
Abstract
The various manifestations of diabetic neuropathy, including distal symmetric sensorimotor polyneuropathy (DSPN) and cardiovascular autonomic neuropathy (CAN), are among the most prevalent chronic complications of diabetes. Major clinical complications of diabetic neuropathies, such as neuropathic pain, chronic foot ulcers, and orthostatic hypotension, are associated with considerable morbidity, increased mortality, and diminished quality of life. Despite the substantial individual and socioeconomic burden, the strategies to diagnose and treat diabetic neuropathies remain insufficient. This review provides an overview of the current clinical aspects and recent advances in exploring local and systemic biomarkers of both DSPN and CAN assessed in human studies (such as biomarkers of inflammation and oxidative stress) for better understanding of the underlying pathophysiology and for improving early detection. Current therapeutic options for DSPN are (I) causal treatment, including lifestyle modification, optimal glycemic control, and multifactorial risk intervention, (II) pharmacotherapy derived from pathogenetic concepts, and (III) analgesic treatment against neuropathic pain. Recent advances in each category are discussed, including non-pharmacological approaches, such as electrical stimulation. Finally, the current therapeutic options for cardiovascular autonomic complications are provided. These insights should contribute to a broader understanding of the various manifestations of diabetic neuropathies from both the research and clinical perspectives.
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Affiliation(s)
- Gidon J Bönhof
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Christian Herder
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
| | - Dan Ziegler
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
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8
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Mahfouz FM, Park SB, Li T, Timmins HC, Horvath LG, Harrison M, Grimison P, King T, Goldstein D, Mizrahi D. Association of electrochemical skin conductance with neuropathy in chemotherapy-treated patients. Clin Auton Res 2022; 32:497-506. [PMID: 36129622 PMCID: PMC9719444 DOI: 10.1007/s10286-022-00895-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/06/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE Chemotherapy-induced peripheral neuropathy (CIPN) is an adverse event of cancer treatment that can affect sensory, motor, or autonomic nerves. Assessment of autonomic neuropathy is challenging, with limited available tools. Accordingly, it is not routinely assessed in chemotherapy-treated patients. In this study, we aimed to examine whether electrochemical skin conductance (ESC) via Sudoscan, a potential measure of autonomic function, associates with subjective and objective measures of CIPN severity and autonomic neuropathy. METHODS A cross-sectional assessment of patients who completed neurotoxic chemotherapy 3-24 months prior was undertaken using CIPN patient-reported outcomes (EORTC-QLQ-CIPN20), clinically graded scale (NCI-CTCAE), neurological examination score (TNSc), autonomic outcome measure (SAS), and Sudoscan. Differences in CIPN severity between participants with or without ESC dysfunction were investigated. Linear regression analyses were used to identify whether ESC values could predict CIPN severity. RESULTS A total of 130 participants were assessed, with 93 participants classified with CIPN according to the clinically graded scale (NCI-CTCAE/grade ≥ 1), while 49% demonstrated hands or feet ESC dysfunction (n = 46). Participants with ESC dysfunction did not significantly differ from those with no dysfunction on multiple CIPN severity measures (clinical-grade, patient-report, neurological examination), and no differences on the autonomic outcome measure (SAS) (all p > 0.0063). Linear regression analyses showed that CIPN could not be predicted by ESC values. CONCLUSIONS The inability of ESC values via Sudoscan to predict clinically-graded and patient-reported CIPN or autonomic dysfunction questions its clinical utility for chemotherapy-treated patients. The understanding of autonomic neuropathy with chemotherapy treatment remains limited and must be addressed to improve quality of life in cancer survivors.
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Affiliation(s)
- Fawaz Mayez Mahfouz
- grid.1013.30000 0004 1936 834XBrain and Mind Centre, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2050 Australia
| | - Susanna B. Park
- grid.1013.30000 0004 1936 834XBrain and Mind Centre, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2050 Australia
| | - Tiffany Li
- grid.1013.30000 0004 1936 834XBrain and Mind Centre, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2050 Australia
| | - Hannah C. Timmins
- grid.1013.30000 0004 1936 834XBrain and Mind Centre, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2050 Australia
| | - Lisa G. Horvath
- grid.419783.0Chris O’Brien Lifehouse, Camperdown, NSW 2050 Australia ,grid.1013.30000 0004 1936 834XSydney Medical School, The University of Sydney, Camperdown, NSW 2050 Australia ,grid.413249.90000 0004 0385 0051Royal Prince Alfred Hospital, Camperdown, NSW 2050 Australia
| | - Michelle Harrison
- grid.419783.0Chris O’Brien Lifehouse, Camperdown, NSW 2050 Australia ,grid.415994.40000 0004 0527 9653Department of Medical Oncology, Liverpool Hospital, Liverpool, NSW 2170 Australia
| | - Peter Grimison
- grid.419783.0Chris O’Brien Lifehouse, Camperdown, NSW 2050 Australia ,grid.1013.30000 0004 1936 834XSydney Medical School, The University of Sydney, Camperdown, NSW 2050 Australia
| | - Tracy King
- grid.1013.30000 0004 1936 834XCancer Nursing Research Unit, The University of Sydney, Camperdown, NSW 2050 Australia ,grid.413249.90000 0004 0385 0051Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, NSW 2050 Australia
| | - David Goldstein
- grid.1005.40000 0004 4902 0432Prince of Wales Clinical School, Faculty of Medicine and Health, UNSW Sydney, Randwick, NSW 2031 Australia ,grid.415193.bDepartment of Medical Oncology, Prince of Wales Hospital, Randwick, NSW 2031 Australia
| | - David Mizrahi
- grid.1005.40000 0004 4902 0432Prince of Wales Clinical School, Faculty of Medicine and Health, UNSW Sydney, Randwick, NSW 2031 Australia ,grid.1013.30000 0004 1936 834XThe Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Camperdown, NSW 2050 Australia
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Le TL, Galmiche L, Levy J, Suwannarat P, Hellebrekers DM, Morarach K, Boismoreau F, Theunissen TE, Lefebvre M, Pelet A, Martinovic J, Gelot A, Guimiot F, Calleroz A, Gitiaux C, Hully M, Goulet O, Chardot C, Drunat S, Capri Y, Bole-Feysot C, Nitschké P, Whalen S, Mouthon L, Babcock HE, Hofstra R, de Coo IF, Tabet AC, Molina TJ, Keren B, Brooks A, Smeets HJ, Marklund U, Gordon CT, Lyonnet S, Amiel J, Bondurand N. Dysregulation of the NRG1/ERBB pathway causes a developmental disorder with gastrointestinal dysmotility in humans. J Clin Invest 2021; 131:145837. [PMID: 33497358 DOI: 10.1172/jci145837] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/14/2021] [Indexed: 02/06/2023] Open
Abstract
Hirschsprung disease (HSCR) is the most frequent developmental anomaly of the enteric nervous system, with an incidence of 1 in 5000 live births. Chronic intestinal pseudo-obstruction (CIPO) is less frequent and classified as neurogenic or myogenic. Isolated HSCR has an oligogenic inheritance with RET as the major disease-causing gene, while CIPO is genetically heterogeneous, caused by mutations in smooth muscle-specific genes. Here, we describe a series of patients with developmental disorders including gastrointestinal dysmotility, and investigate the underlying molecular bases. Trio-exome sequencing led to the identification of biallelic variants in ERBB3 and ERBB2 in 8 individuals variably associating HSCR, CIPO, peripheral neuropathy, and arthrogryposis. Thorough gut histology revealed aganglionosis, hypoganglionosis, and intestinal smooth muscle abnormalities. The cell type-specific ErbB3 and ErbB2 function was further analyzed in mouse single-cell RNA sequencing data and in a conditional ErbB3-deficient mouse model, revealing a primary role for ERBB3 in enteric progenitors. The consequences of the identified variants were evaluated using quantitative real-time PCR (RT-qPCR) on patient-derived fibroblasts or immunoblot assays on Neuro-2a cells overexpressing WT or mutant proteins, revealing either decreased expression or altered phosphorylation of the mutant receptors. Our results demonstrate that dysregulation of ERBB3 or ERBB2 leads to a broad spectrum of developmental anomalies, including intestinal dysmotility.
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Affiliation(s)
- Thuy-Linh Le
- Laboratory of Embryology and Genetics of Human Malformation, Imagine Institute, INSERM UMR 1163, Université de Paris, Paris, France
| | - Louise Galmiche
- INSERM UMR 1235, TENS, The Enteric Nervous System in Gut and Brain Diseases, IMAD, University of Nantes, Nantes, France.,Pathology Department, Assistance Publique Hôpitaux de Paris (AP-HP), Necker-Enfants Malades Hospital, Paris, France
| | - Jonathan Levy
- Genetics Department, Robert Debré Hospital, AP-HP, Paris, France.,Université de Paris, NeuroDiderot, INSERM UMR 1141, Paris, France
| | - Pim Suwannarat
- Department of Genetics, Mid-Atlantic Permanente Medical Group, Suitland, Maryland, USA
| | - Debby Mei Hellebrekers
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, Netherlands
| | - Khomgrit Morarach
- Division of Molecular Neurobiology, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Franck Boismoreau
- Institut de Biologie de l'ENS (IBENS), INSERM, CNRS, École Normale Supérieure, PSL Research University, Paris, France
| | - Tom Ej Theunissen
- Department of Genetics and Cell Biology, Maastricht University, Maastricht, Netherlands
| | - Mathilde Lefebvre
- Fetal Pathology Unit, Armand Trousseau Hospital, AP-HP, Paris, France
| | - Anna Pelet
- Laboratory of Embryology and Genetics of Human Malformation, Imagine Institute, INSERM UMR 1163, Université de Paris, Paris, France
| | - Jelena Martinovic
- Fetal Pathology Unit, Antoine Béclère Hospital, AP-HP, Paris-Saclay University, Clamart, France
| | - Antoinette Gelot
- Neuropathology, Pathology Department, Armand Trousseau Hospital, AP-HP, Paris, France.,Aix-Marseille University, INMED INSERM UMR1249, Campus de Luminy, Marseille, France
| | - Fabien Guimiot
- Université de Paris, NeuroDiderot, INSERM UMR 1141, Paris, France.,Fetal Pathology Unit, Robert Debré Hospital, AP-HP, Paris, France
| | - Amanda Calleroz
- Pathology and Laboratory Medicine Division, Children's National Hospital, Washington DC, USA
| | - Cyril Gitiaux
- Department of Pediatric Clinical Neurophysiology, Necker-Enfants Malades Hospital, AP-HP, Université de Paris, Paris, France
| | - Marie Hully
- Department of Pediatric Neurology and Rehabilitation, Necker-Enfants Malades Hospital, AP-HP, Université de Paris, Paris, France
| | - Olivier Goulet
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - Christophe Chardot
- Department of Pediatric Surgery, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - Severine Drunat
- Genetics Department, Robert Debré Hospital, AP-HP, Paris, France.,Université de Paris, NeuroDiderot, INSERM UMR 1141, Paris, France
| | - Yline Capri
- Genetics Department, Robert Debré Hospital, AP-HP, Paris, France
| | - Christine Bole-Feysot
- Genomics Core Facility, Imagine Institute-Structure Federative de Recherche Necker, INSERM UMR 1163 and INSERM US24/CNRS UMS 3633, Université de Paris, Paris, France
| | | | - Sandra Whalen
- Clinical Genetics Unit and Reference Center, Anomalies du Développement et Syndromes Malformatifs, AP-HP, Sorbonne University, Armand Trousseau Hospital, Paris, France
| | - Linda Mouthon
- Department of Genetics, La Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Holly E Babcock
- Children's National Hospital, Rare Disease Institute, Washington, DC, USA
| | - Robert Hofstra
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, Netherlands
| | - Irenaeus Fm de Coo
- Department of Toxicogenomics, Unit Clinical Genomics, Maastricht University, MHeNs School for Mental Health and Neuroscience, Maastricht, Netherlands
| | - Anne-Claude Tabet
- Genetics Department, Robert Debré Hospital, AP-HP, Paris, France.,Human Genetics and Cognitive Functions, Institut Pasteur, UMR3571 CNRS, Université de Paris, Paris, France
| | - Thierry J Molina
- Pathology Department, Assistance Publique Hôpitaux de Paris (AP-HP), Necker-Enfants Malades Hospital, Paris, France.,Université de Paris, Imagine Institute, Laboratory of Molecular Mechanisms of Hematological Disorders and Therapeutic Implications, INSERM UMR 1163, Paris, France
| | - Boris Keren
- Department of Genetics, La Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Alice Brooks
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, Netherlands
| | - Hubert Jm Smeets
- Department of Toxicogenomics, Unit Clinical Genomics, Maastricht University, MHeNs School for Mental Health and Neuroscience, Maastricht, Netherlands
| | - Ulrika Marklund
- Division of Molecular Neurobiology, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Christopher T Gordon
- Laboratory of Embryology and Genetics of Human Malformation, Imagine Institute, INSERM UMR 1163, Université de Paris, Paris, France
| | - Stanislas Lyonnet
- Laboratory of Embryology and Genetics of Human Malformation, Imagine Institute, INSERM UMR 1163, Université de Paris, Paris, France.,Fédération de Génétique, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - Jeanne Amiel
- Laboratory of Embryology and Genetics of Human Malformation, Imagine Institute, INSERM UMR 1163, Université de Paris, Paris, France.,Fédération de Génétique, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - Nadège Bondurand
- Laboratory of Embryology and Genetics of Human Malformation, Imagine Institute, INSERM UMR 1163, Université de Paris, Paris, France
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Joseph P, Arevalo C, Oliveira RKF, Faria-Urbina M, Felsenstein D, Oaklander AL, Systrom DM. Insights From Invasive Cardiopulmonary Exercise Testing of Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Chest 2021; 160:642-651. [PMID: 33577778 DOI: 10.1016/j.chest.2021.01.082] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/22/2021] [Accepted: 01/29/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) affects tens of millions worldwide; the causes of exertional intolerance are poorly understood. The ME/CFS label overlaps with postural orthostatic tachycardia (POTS) and fibromyalgia, and objective evidence of small fiber neuropathy (SFN) is reported in approximately 50% of POTS and fibromyalgia patients. RESEARCH QUESTION Can invasive cardiopulmonary exercise testing (iCPET) and PGP9.5-immunolabeled lower-leg skin biopsies inform the pathophysiology of ME/CFS exertional intolerance and potential relationships with SFN? STUDY DESIGN AND METHODS We analyzed 1,516 upright invasive iCPETs performed to investigate exertional intolerance. After excluding patients with intrinsic heart or lung disease and selecting those with right atrial pressures (RAP) <6.5 mm Hg, results from 160 patients meeting ME/CFS criteria who had skin biopsy test results were compared with 36 control subjects. Rest-to-peak changes in cardiac output (Qc) were compared with oxygen uptake (Qc/VO2 slope) to identify participants with low, normal, or high pulmonary blood flow by Qc/VO2 tertiles. RESULTS During exercise, the 160 ME/CFS patients averaged lower RAP (1.9 ± 2 vs 8.3 ± 1.5; P < .0001) and peak VO2 (80% ± 21% vs 101.4% ± 17%; P < .0001) than control subjects. The low-flow tertile had lower peak Qc than the normal and high-flow tertiles (88.4% ± 19% vs 99.5% ± 23.8% vs 99.9% ± 19.5% predicted; P < .01). In contrast, systemic oxygen extraction was impaired in high-flow vs low- and normal-flow participants (0.74% ± 0.1% vs 0.88 ± 0.11 vs 0.86 ± 0.1; P < .0001) in association with peripheral left-to-right shunting. Among the 160 ME/CFS patient biopsies, 31% were consistent with SFN (epidermal innervation ≤5.0% of predicted; P < .0001). Denervation severity did not correlate with exertional measures. INTERPRETATION These results identify two types of peripheral neurovascular dysregulation that are biologically plausible contributors to ME/CFS exertional intolerance-depressed Qc from impaired venous return, and impaired peripheral oxygen extraction. In patients with small-fiber pathology, neuropathic dysregulation causing microvascular dilation may limit exertion by shunting oxygenated blood from capillary beds and reducing cardiac return.
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Affiliation(s)
- Phillip Joseph
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale-New Haven Hospital, Yale University, New Haven, CT.
| | - Carlo Arevalo
- Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Rudolf K F Oliveira
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Mariana Faria-Urbina
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Donna Felsenstein
- Infectious Diseases Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, Boston, MA; Department of Pathology (Neuropathology), Massachusetts General Hospital, Boston, MA
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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11
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Pérez-Concha T, Tijero B, Acera M, Fernández T, Gabilondo I, Gómez-Esteban JC. Usefulness of thermography in the diagnosis and classification of complex regional pain syndrome. Neurologia 2020; 38:S0213-4853(20)30337-6. [PMID: 33342641 DOI: 10.1016/j.nrl.2020.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/08/2020] [Accepted: 10/18/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION We propose a protocol for study of complex regional pain syndrome (CRPS) based on a battery of quantitative measures (skin thermography, electrochemical skin conductance and sensory thresholds) and apply such protocol to 5 representative cases of CRPS. PATIENTS AND METHODS 5 CPRS cases (2 women/3 men) that met the Budapest criteria for the diagnosis of CRPS. RESULTS All patients showed spontaneous pain and allodynia. Two cases correspond to a stage I, in both the resting basal temperature was increased in the affected limb. Three cases reflect more advanced stages with a decrease in resting temperature and a delay in the recovery of the temperature when compared to contralateral limb. DISCUSSION These non-invasive quantitative functional tests not only improve the diagnostic accuracy of CRPS but also, they help us to stratify and understand the pathological processes of the disease.
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Affiliation(s)
- T Pérez-Concha
- Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain; Neurology Department, Cruces University Hospital, Barakaldo, Bizkaia, Spain.
| | - B Tijero
- Autonomic Center (NeuroTek), San Juan de Dios Hospital, Santurtzi, Spain; Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain; Neurology Department, Cruces University Hospital, Barakaldo, Bizkaia, Spain; Department of Neuroscience, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - M Acera
- Autonomic Center (NeuroTek), San Juan de Dios Hospital, Santurtzi, Spain; Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain
| | - T Fernández
- Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain; Neurology Department, Cruces University Hospital, Barakaldo, Bizkaia, Spain; Department of Neuroscience, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - I Gabilondo
- Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain; Neurology Department, Cruces University Hospital, Barakaldo, Bizkaia, Spain; Ikerbasque: The Basque Foundation for Science, Bilbao, Spain
| | - J C Gómez-Esteban
- Autonomic Center (NeuroTek), San Juan de Dios Hospital, Santurtzi, Spain; Neurodegenerative Diseases Group, Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain; Neurology Department, Cruces University Hospital, Barakaldo, Bizkaia, Spain; Department of Neuroscience, University of the Basque Country (UPV/EHU), Leioa, Spain.
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12
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Electrodiagnostic Testing of Small Fiber Neuropathies: A Review of Existing Guidelines. J Clin Neurophysiol 2020; 37:288-293. [PMID: 33151659 DOI: 10.1097/wnp.0000000000000681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This article reviews the literature on neurophysiological techniques for the diagnosis of small fiber neuropathy. The review is focused on clinical approach to suspected small fiber neuropathy, letting aside techniques whose clinical applicability is doubtful. We include, however, the special techniques required to examine C and Aδ fibers, which cannot be evaluated directly with conventional neurophysiological methods. The most relevant publications are summarized and recommendations for the clinical assessment of small fiber neuropathy are provided.
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13
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The Role of Electrochemical Skin Conductance as a Screening Test of Cardiovascular Autonomic Neuropathy in Patients with Parkinson's Disease. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17217751. [PMID: 33114002 PMCID: PMC7660297 DOI: 10.3390/ijerph17217751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/15/2020] [Accepted: 10/19/2020] [Indexed: 12/14/2022]
Abstract
Autonomic disorders have been recognized as an important non-motor feature in Parkinson's disease (PD). However, there is a paucity of information on the presence and severity of cardiovascular autonomic neuropathy (CAN) among different motor phenotypes. The aims of this study were to examine the feasibility of electrochemical skin conductance (ESC) measured by Sudoscan as a screening service for CAN in patients with PD and investigate the severity of CAN among different motor phenotypes. Design: This was a cross-sectional observational study that enrolled 63 patients with PD. Patients were divided into three phenotypes, postural instability/gait difficulty (PIGD), tremor-dominant (TD), and akinetic-rigid (AR), according to their motor symptoms. Cardiovascular autonomic function was measured, and the presence and severity of CAN was determined according to the composite autonomic scoring scale (CASS). Functional scores were measured by the Hoehn and Yahr (HY) stage and the Unified Parkinson's Disease Rating Scale (UPDRS). The median HY stage was 2.0 [1.5, 3.0]. Median UPDRS total score was 23.0 (17.5, 30.5), 10.0 (6.0, 11.0) and 14.0 (6.3, 23.8) in groups of PIGD, TD and AR, respectively (p = 0.001). Mean CASS was 1.7 ± 1.3, 0.6 ± 0.4, and 1.8 ± 1.5 in groups of PIGD, TD and AR, respectively (p = 0.204). Although the ESC was not strongly associated with the cardiovascular autonomic parameters, the CAN risk score provided by Sudoscan significantly correlated with parameters of cardiovascular autonomic function, including heart rate response to deep breathing (HR_DB), Valsalva ratio (VR), and baroreflex sensitivity (BRS). By receiver-operating characteristic (ROC) analysis, if a patient's CAN risk score is higher than 33.5 (%), it is recommended to be aware of the presence of CAN even in PD patients who are asymptomatic. The area under ROC curve was 0.704. Based on our results, CAN risk score may be used for screening of CAN in patients with PD before resorting to the more sophisticated and specific, but ultimately more time-consuming, complete autonomic function testing.
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14
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Porubcin MG, Novak P. Diagnostic Accuracy of Electrochemical Skin Conductance in the Detection of Sudomotor Fiber Loss. Front Neurol 2020; 11:273. [PMID: 32425871 PMCID: PMC7212463 DOI: 10.3389/fneur.2020.00273] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 03/24/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Small fiber neuropathy (SFN) is a common health problem. SFN is associated with loss of small fibers, either sensory, autonomic or both. Reduced autonomic sudomotor sweat gland nerve fiber density (SGNFD) and sensory epidermal nerve fiber density (ENFD) can be seen in SFN. Electrochemical skin conductance (ESC) is a non-invasive test for measurement of sudomotor function. This study evaluated the diagnostic accuracy of ESC to detect abnormal SGNFD and ENFD. Methods: This was a retrospective blinded study of participants referred for evaluation of SFN. The primary outcome measure was the specificity and sensitivity of ESC to diagnose loss of small fibers using SGNFD and ENFD as reference tests. The secondary outcome measures were the correlation between ESC and neuropathy severity, pain, and autonomic clinical scales. Results: Two hundred ten patients were enrolled in the study, age (mean ± sd) 45.5 ± 16.1 years, men/women = 52/158. ESC adjusted for weight (ESC/kg) was reduced in subjects with abnormally low SGNFD (normal/abnormal, ESC/kg = 1.19 ± 0.31/0.94 ± 0.37 μS/kg, p < 0.0001) and abnormally low ENFD (normal/abnormal ESC/kg 1.20 ± 0.37/1.04 ± 0.33 μS/kg, p < 0.0011). ESC/kg correlated with SGNFD (ρ = 0.39, p < 0.0001) and ENFD (ρ = 0.47, p < 0.0001). ESC/kg did not correlate with symptom scales. ESC/kg had 64% sensitivity and 77% specificity (ROC 0.73, p = 0.0001) to predict abnormal SGNFD and 69% sensitivity and 55% specificity (ROC 0.63, p = 0.0017) to predict abnormal ENFD. In comparison, SGNFD had 50.1% sensitivity and 85.1% specificity to predict abnormal ENFD (ROC 0.69, p = 0.0001). Conclusion: ESC/kg has modest accuracy to detect SGNFD loss. ESC may be a useful test in characterization of small fiber neuropathy.
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Affiliation(s)
- Michal G Porubcin
- Brigham and Women's Faulkner Hospital, Harvard Medical School, Boston, MA, United States
| | - Peter Novak
- Brigham and Women's Faulkner Hospital, Harvard Medical School, Boston, MA, United States
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Javed S, Hayat T, Menon L, Alam U, Malik RA. Diabetic peripheral neuropathy in people with type 2 diabetes: too little too late. Diabet Med 2020; 37:573-579. [PMID: 31797434 DOI: 10.1111/dme.14194] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2019] [Indexed: 12/12/2022]
Abstract
Diabetic peripheral neuropathy in people with type 2 diabetes is poorly managed because of its insidious onset, delayed diagnosis and more complex aetiology resulting from the contribution of not only hyperglycaemia, but also ageing, hyperlipidaemia, hypertension and obesity. Because there is no US Food and Drug Adminstration-approved disease-modifying therapy for diabetic peripheral neuropathy, the key to ameliorating it in type 2 diabetes has to be through earlier diagnosis and timely multi-factorial risk factor reduction. The management of painful diabetic peripheral neuropathy also requires a detailed appraisal of the choice of therapy, taking into account efficacy, patient wishes, comorbidities, side effect profile and potential for abuse.
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Affiliation(s)
- S Javed
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
| | - T Hayat
- Primary Health Care Corporation, Doha, Qatar
| | - L Menon
- Department of Medicine, Weill-Cornell Medicine-Qatar, Doha, Qatar
| | - U Alam
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - R A Malik
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
- Department of Medicine, Weill-Cornell Medicine-Qatar, Doha, Qatar
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16
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Malik RA. Diabetic neuropathy: A focus on small fibres. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3255. [PMID: 31828951 DOI: 10.1002/dmrr.3255] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/25/2019] [Indexed: 01/16/2023]
Abstract
Diabetic peripheral neuropathy (DPN) is diagnosed too late, which contrasts with our approach for diabetic retinopathy and nephropathy, where incipient disease is detected early enabling timely treatment. The 10-g monofilament and a foot exam are the commonly used methods for screening diabetic neuropathy, but this primarily identifies moderate to severe diabetic neuropathy. Small fibres are damaged early and are associated with the development of painful diabetic neuropathy, foot ulceration, and Charcot foot. Tests of small fibre damage include thermal thresholds, microneurography, evoked potentials, sudomotor function, laser Doppler flare, skin biopsy, and corneal confocal microscopy. Measures of small fibre damage and repair may be key to the assessment of efficacy in clinical trials of disease modifying therapies for diabetic neuropathy.
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Affiliation(s)
- Rayaz A Malik
- Department of Medicine, Weill-Cornell Medicine-Qatar, Doha, Qatar
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
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17
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D'Amato C, Greco C, Lombardo G, Frattina V, Campo M, Cefalo CMA, Izzo V, Lauro D, Spallone V. The diagnostic usefulness of the combined COMPASS 31 questionnaire and electrochemical skin conductance for diabetic cardiovascular autonomic neuropathy and diabetic polyneuropathy. J Peripher Nerv Syst 2020; 25:44-53. [PMID: 31985124 DOI: 10.1111/jns.12366] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 01/18/2020] [Accepted: 01/21/2020] [Indexed: 01/01/2023]
Abstract
The study investigated the diagnostic performance for diabetic cardiovascular autonomic neuropathy (CAN) and diabetic polyneuropathy (DPN) of the combined use of composite autonomic symptom score (COMPASS) 31, validated questionnaire for autonomic symptoms of CAN, and electrochemical skin conductance (ESC), proposed for detecting DPN and CAN. One-hundred and two participants with diabetes (age 57 ± 14 years, duration 17 ± 13 years) completed the COMPASS 31 before assessing cardiovascular reflex tests (CARTs), neuropathic symptoms, signs, vibratory perception threshold (VPT), thermal thresholds (TT), and ESC using Sudoscan. Two patterns were evaluated: (a) the combined abnormalities in both tests (COMPASS 31+ESC), and (b) the abnormality in COMPASS 31 and/or ESC (COMPASS 31 and/or ESC). CAN (≥1 abnormal CART) and confirmed CAN (≥2 abnormal CARTs) were present in 28.1% and 12.5%, DPN (two abnormalities among symptoms, signs, VPT, and TT) in 52%, abnormal COMPASS 31 (total weighted score >16.44) in 48% and abnormal ESC (hands ESC <50 μS and/or feet ESC <70 μS) in 47.4%. Both the patterns-COMPASS 31+ESC and COMPASS 31 and/or ESC-were associated with CAN and DPN (P < .01). COMPASS 31 and ESC reached a sensitivity of 75% and 83% for confirmed CAN, and a specificity of 65% and 67% for DPN. When combining the tests, the sensitivity for CAN rose by up to 100% for CAN and the specificity up to 89% for DPN. The combination of the tests can allow a stepwise screening strategy for CAN, by suggesting CAN absence with combined normality, and prompting to CARTs with combined abnormality.
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Affiliation(s)
- Cinzia D'Amato
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Carla Greco
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giorgio Lombardo
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Valentina Frattina
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Mariagrazia Campo
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Chiara M A Cefalo
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Valentina Izzo
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Davide Lauro
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Vincenza Spallone
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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18
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Oaklander AL, Nolano M. Scientific Advances in and Clinical Approaches to Small-Fiber Polyneuropathy: A Review. JAMA Neurol 2019; 76:1240-1251. [PMID: 31498378 PMCID: PMC10021074 DOI: 10.1001/jamaneurol.2019.2917] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Small-fiber polyneuropathy involves preferential damage to the thinly myelinated A-delta fibers, unmyelinated C sensory fibers, or autonomic or trophic fibers. Although this condition is common, most patients still remain undiagnosed and untreated because of lagging medical and public awareness of research advances. Chronic bilateral neuropathic pain, fatigue, and nausea are cardinal symptoms that can cause disability and dependence, including pain medication dependence. OBSERVATIONS Biomarker confirmation is recommended, given the nonspecificity of symptoms. The standard test involves measuring epidermal neurite density within a 3-mm protein gene product 9.5 (PGP9.5)-immunolabeled lower-leg skin biopsy. Biopsies and autonomic function testing confirm that small-fiber neuropathy not uncommonly affects otherwise healthy children and young adults, in whom it is often associated with inflammation or dysimmunity. A recent meta-analysis concluded that small-fiber neuropathy underlies 49% of illnesses labeled as fibromyalgia. Initially, patients with idiopathic small-fiber disorders should be screened by medical history and blood tests for potentially treatable causes, which are identifiable in one-third to one-half of patients. Then, secondary genetic testing is particularly important for familial and childhood cases. Treatable genetic causes include Fabry disease, transthyretin and primary systemic amyloidosis, hereditary sensory autonomic neuropathy-1, and ion-channel mutations. Immunohistopathologic evidence suggests that small-fiber dysfunction and denervation, especially of blood vessels, contributes to diverse symptoms, including postexertional malaise, postural orthostatic tachycardia, and functional gastrointestinal distress. Preliminary evidence implicates acute or chronic autoreactivity in some cases, particularly in female patients and otherwise healthy children and young adults. Different temporal patterns akin to Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy have been described; here, corticosteroids and immunoglobulins, which are often efficacious for inflammatory neuropathic conditions, are increasingly considered. CONCLUSIONS AND RELEVANCE Because small fibers normally grow throughout life, improving contributory conditions may permit regrowth, slow progression, and prevent permanent damage. The prognosis is often hopeful for improving quality of life and sometimes for abatement or resolution, particularly in the young and otherwise healthy individuals. Examples include diabetic, infectious, toxic, genetic, and inflammatory causes. The current standard of care requires prompt diagnosis and treatment, particularly in children and young adults, to restore life trajectory. Consensus diagnostic and tracking metrics should be established to facilitate treatment trials.
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Affiliation(s)
- Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Pathology (Neuropathology), Massachusetts General Hospital, Boston
| | - Maria Nolano
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University "Federico II" of Naples, Naples, Italy.,Skin Biopsy Laboratory, Department of Neurology, IRCCS, Istituti Clinici Scientifici Maugeri, SpA SB, Telese Terme, Italy
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19
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Timmins HC, Li T, Kiernan MC, Horvath LG, Goldstein D, Park SB. Quantification of Small Fiber Neuropathy in Chemotherapy-Treated Patients. THE JOURNAL OF PAIN 2019; 21:44-58. [PMID: 31325646 DOI: 10.1016/j.jpain.2019.06.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/05/2019] [Accepted: 06/24/2019] [Indexed: 02/07/2023]
Abstract
Chemotherapy-induced peripheral neuropathy (CIPN) is a major, dose-limiting side effect of treatment with neurotoxic cancer treatments which can result in long-term impairment. Deficits often reflect a large fiber polyneuropathy, however small fiber involvement resulting in neuropathic pain and autonomic dysfunction can occur. Quantification of both CIPN and small fiber neuropathy (SFN) remains a challenge. Accordingly, the prevalence and pathophysiology of small fiber neuropathy amongst cancer survivors remains poorly understood. This review will provide an overview of the clinical features of SFN associated with neurotoxic cancer treatments as well as a summary of current assessment tools for evaluating small fiber function, and their use in patients treated with neurotoxic chemotherapies. The continued development and utilization of novel measures quantifying small fiber involvement will help elucidate the pathophysiology underlying symptoms of CIPN and assist in informing treatment approaches. Accurately identifying subgroups of patients with neuropathic symptoms which may respond to existing pain medication may reduce the impact of CIPN and improve long-term quality of life as well as provide better categorization of patients for future clinical trials of neuroprotective and treatment strategies for CIPN. PERSPECTIVE: This review provides a critical analysis of SFN associated with neurotoxic cancer treatments and the assessment tools for evaluating small fiber dysfunction in cancer patients. Quantification of small fiber involvement in CIPN will assist in identifying subgroups of patients with neuropathic symptoms which may respond to existing pain medications.
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Affiliation(s)
- Hannah C Timmins
- Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Tiffany Li
- Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia; Royal Prince Alfred Hospital, Camperdown, Australia; Sydney Medical School, The University of Sydney, Australia
| | - Lisa G Horvath
- The Chris O'Brien Lifehouse, Camperdown, Australia; Royal Prince Alfred Hospital, Camperdown, Australia; Sydney Medical School, The University of Sydney, Australia
| | - David Goldstein
- Prince of Wales Clinical School, University of New South Wales, Kensington, Australia; Prince of Wales Hospital, Randwick, Australia
| | - Susanna B Park
- Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.
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20
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Conceição I, de Castro I, Castro J. Correlation between Sudoscan and COMPASS 31: assessment of autonomic dysfunction on hATTR V30M patients. Amyloid 2019; 26:23. [PMID: 31343356 DOI: 10.1080/13506129.2019.1582494] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Isabel Conceição
- a Department of Neurosciences, CHLN - Hospital Santa Maria , Lisbon , Portugal.,b IMM, Universidade de Lisboa , Lisbon , Portugal
| | - Isabel de Castro
- a Department of Neurosciences, CHLN - Hospital Santa Maria , Lisbon , Portugal.,b IMM, Universidade de Lisboa , Lisbon , Portugal
| | - José Castro
- a Department of Neurosciences, CHLN - Hospital Santa Maria , Lisbon , Portugal.,b IMM, Universidade de Lisboa , Lisbon , Portugal
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