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Mooshage CM, Schimpfle L, Kender Z, Tsilingiris D, Aziz-Safaie T, Hohmann A, Szendroedi J, Nawroth P, Sturm V, Heiland S, Bendszus M, Kopf S, Kurz FT, Jende JME. Association of Small Fiber Function with Microvascular Perfusion of Peripheral Nerves in Patients with Type 2 Diabetes : Study using Quantitative Sensory Testing and Magnetic Resonance Neurography. Clin Neuroradiol 2024; 34:55-66. [PMID: 37548682 PMCID: PMC10881621 DOI: 10.1007/s00062-023-01328-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/19/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION/AIMS Diabetic small fiber neuropathy (SFN) is caused by damage to thinly myelinated A‑fibers (δ) and unmyelinated C‑fibers. This study aimed to assess associations between quantitative sensory testing (QST) and parameters of peripheral nerve perfusion obtained from dynamic contrast enhanced (DCE) magnetic resonance neurography (MRN) in type 2 diabetes patients with and without SFN. METHODS A total of 18 patients with type 2 diabetes (T2D, 8 with SFN, 10 without SFN) and 10 healthy controls (HC) took part in this cross-sectional single-center study and underwent QST of the right leg and DCE-MRN of the right thigh with subsequent calculation of the sciatic nerve constant of capillary permeability (Ktrans), extravascular extracellular volume fraction (Ve), and plasma volume fraction (Vp). RESULTS The Ktrans (HC 0.031 min-1 ± 0.009, T2D 0.043 min-1 ± 0.015; p = 0.033) and Ve (HC 1.2% ± 1.5, T2D: 4.1% ± 5.1; p = 0.027) were lower in T2D patients compared to controls. In T2D patients, compound z‑scores of thermal and mechanical detection correlated with Ktrans (r = 0.73; p = 0.001, and r = 0.57; p = 0.018, respectively) and Ve (r = 0.67; p = 0.002, and r = 0.69; p = 0.003, respectively). Compound z‑scores of thermal pain and Vp (r = -0.57; p = 0.015) correlated negatively. DISCUSSION The findings suggest that parameters of peripheral nerve microcirculation are related to different symptoms in SFN: A reduced capillary permeability may result in a loss of function related to insufficient nutritional supply, whereas increased capillary permeability may be accompanied by painful symptoms related to a gain of function.
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Affiliation(s)
- Christoph M Mooshage
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Lukas Schimpfle
- Department of Endocrinology, Diabetology and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center of Diabetes Research, associated partner in the DZD, Munich-Neuherberg, Germany
- Institute for Diabetes and Cancer (IDC), Helmholtz Diabetes Center, Helmholtz Center, Munich, Neuherberg, Munich, Germany
| | - Zoltan Kender
- German Center of Diabetes Research, associated partner in the DZD, Munich-Neuherberg, Germany
- Institute for Diabetes and Cancer (IDC), Helmholtz Diabetes Center, Helmholtz Center, Munich, Neuherberg, Munich, Germany
| | - Dimitrios Tsilingiris
- Department of Endocrinology, Diabetology and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Taraneh Aziz-Safaie
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Anja Hohmann
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Julia Szendroedi
- Department of Endocrinology, Diabetology and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center of Diabetes Research, associated partner in the DZD, Munich-Neuherberg, Germany
- Joint Heidelberg-IDC Translational Diabetes Program, Inner Medicine 1, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Nawroth
- Department of Endocrinology, Diabetology and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center of Diabetes Research, associated partner in the DZD, Munich-Neuherberg, Germany
- Joint Heidelberg-IDC Translational Diabetes Program, Inner Medicine 1, Heidelberg University Hospital, Heidelberg, Germany
| | - Volker Sturm
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Department of Neuroradiology, Division of Experimental Radiology, Heidelberg, Germany
| | - Sabine Heiland
- Department of Neuroradiology, Division of Experimental Radiology, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Stefan Kopf
- Department of Endocrinology, Diabetology and Clinical Chemistry (Internal Medicine 1), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Center of Diabetes Research, associated partner in the DZD, Munich-Neuherberg, Germany
- Institute for Diabetes and Cancer (IDC), Helmholtz Diabetes Center, Helmholtz Center, Munich, Neuherberg, Munich, Germany
| | - Felix T Kurz
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- German Cancer Research Center, Heidelberg, Germany
| | - Johann M E Jende
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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Arnold T, Johnston CS. An examination of relationships between vitamin B12 status and functional measures of peripheral neuropathy in young adult vegetarians. Front Nutr 2023; 10:1304134. [PMID: 38174111 PMCID: PMC10764020 DOI: 10.3389/fnut.2023.1304134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024] Open
Abstract
Introduction Prevalence rates for vitamin B12 deficiency in U.S. adult vegetarians may exceed 30%, which is concerning given the role for this vitamin in numerous nervous system functions, including the synthesis of myelin sheaths. Defective myelin synthesis and repair are directly linked to peripheral neuropathy; yet, few investigations have examined how physical indicators of peripheral neuropathy (e.g., hand dexterity, vibration sensitivity and balance) are impacted in individuals adhering to vegetarian diets. This feasibility research explored the relationships between peripheral neuropathy and vitamin B12 status using a cross-sectional study design. In addition, a small pilot trial was conducted for limited-efficacy testing of vitamin B12 supplementation for reducing peripheral neuropathy. Methods Healthy, able-bodied adults (n = 38; 19-40 years of age) reported exclusive adherence to a vegetarian or vegan diet for 3 years. Peripheral neuropathy was measured using a force plate for assessing balance, and a vibration sensitivity tester and pegboard tests to assess hand dexterity. Serum vitamin B12 and folate were measured using standard radioimmunoassay techniques. Results Twenty-six percent of the sample displayed deficient or marginal vitamin B12 status (serum vitamin B12 <221 pmol/L). Participants with adequate vitamin B12 status scored 10% higher on the Purdue pegboard assembly test and 20% higher on the left hand adjusted functional dexterity test in comparison to participants with marginal-to-deficient vitamin B12 status (p < 0.05). Discussion These data provide preliminary evidence that peripheral neuropathy can be detected in individuals with marginal-to-deficient vitamin B12 status.
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Affiliation(s)
| | - Carol S. Johnston
- Nutrition Program, College of Health Solutions, Arizona State University, Phoenix, AZ, United States
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Kafaie J, Al Balushi A, Kim M, Pestronk A. Clinical and Laboratory Profiles of Idiopathic Small Fiber Neuropathy in Children: Case Series. J Clin Neuromuscul Dis 2017; 19:31-37. [PMID: 28827487 DOI: 10.1097/cnd.0000000000000178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The role of autoimmune mechanisms in idiopathic small fiber neuropathy (SFN) is not completely understood. Serum IgM binding to trisulfated disaccharide IdoA2S-GlcNS-6S (TS-HDS) and IgG to fibroblast growth factor receptor 3 were associated with sensory motor polyneuropathies and sensory neuronopathy among others. In this retrospective case review, we describe the clinical and laboratory findings of idiopathic SFN in a small cohort of pediatric patients. Eight children were diagnosed with SFN clinically and confirmed by reduced epidermal nerve fiber density. No involvement of large fibers was confirmed by clinical examination and electrophysiological tests. Possible triggering factors were infectious mononucleosis in 4 patients and human papilloma virus vaccination in 1 patient. Tilt table test was positive in 1 patient, and clinical autonomic dysfunctions were noted in 6 patients. Five patients had positive IgM against TS-HDS, 3 of whom had lower extremity predominant paresthesia. In conclusion, a high proportion of patients with idiopathic SFN in our cohort had a positive IgM TS-HDS antibody.
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Affiliation(s)
- Jafar Kafaie
- *Department of Neurology, Saint Louis University School of Medicine, Louis, MO; and †Department of Neurology, Washington University School of Medicine, St. Louis, MO
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Routine use of punch biopsy to diagnose small fiber neuropathy in fibromyalgia patients. Clin Rheumatol 2014; 34:413-7. [PMID: 25535201 PMCID: PMC4348533 DOI: 10.1007/s10067-014-2850-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 12/07/2014] [Indexed: 11/25/2022]
Abstract
Fibromyalgia is a clinical syndrome that currently does not have any specific pathological finding to aid in diagnosis. Therefore, fibromyalgia is most likely a heterogeneous group of diseases with similar symptoms. Identifying and understanding the pathological basis of fibromyalgia will allow physicians to better categorize patients, increasing prospective treatment options, and improving potential therapeutic endeavors. Recent work has demonstrated that approximately 50 % of patients diagnosed with fibromyalgia have damage to their small unmyelinated nerve fibers. A skin punch biopsy is a sensitive and specific diagnostic test for this damage as a reduction in nerve fiber density allows for the diagnosis of small fiber neuropathy. Small fiber neuropathy is a disease with symptoms similar to fibromyalgia, but it often has a definable etiology. Identifying small fiber neuropathy and its underlying cause in fibromyalgia patients provides them with a succinct diagnosis, increases treatment options, and facilitates more specific studies for future therapeutics.
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Zotova EG, Arezzo JC. NON-INVASIVE EVALUATION OF NERVE CONDUCTION IN SMALL DIAMETER FIBERS IN THE RAT. PHYSIOLOGY JOURNAL 2013; 2013:254789. [PMID: 23580940 PMCID: PMC3620683 DOI: 10.1155/2013/254789] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A novel non-invasive technique was applied to measure velocity within slow conducting axons in the distal extreme of the sciatic nerve (i.e., digital nerve) in a rat model. The technique is based on the extraction of rectified multiple unit activity (MUA) from in vivo whole nerve compound responses. This method reliably identifies compound action potentials in thinly myelinated fibers conducting at a range of 9-18 m/s (Aδ axons), as well as in a subgroup of unmylinated C fibers conducting at approximately 1-2 m/s. The sensitivity of the method to C-fiber conduction was confirmed by the progressive decrement of the responses in the 1-2 m/s range over a 20-day period following the topical application of capsaicin (ANOVA p<0.03). Increasing the frequency of applied repetitive stimulation over a range of 0.75 Hz to 6.0 Hz produced slowing of conduction and a significant decrease in the magnitude of the compound C-fiber response (ANOVA p<0.01). This technique offers a unique opportunity for the non-invasive, repeatable, and quantitative assessment of velocity in the subsets of Aδ and C fibers in parallel with evaluation of fast nerve conduction.
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Affiliation(s)
- Elena G. Zotova
- Department of Neurology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Joseph C. Arezzo
- Department of Neurology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
- Department of Neuroscience, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
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Zaproudina N, Airaksinen O, Närhi M. Are the infrared thermography findings skin temperature-dependent? a study on neck pain patients. Skin Res Technol 2012; 19:e537-44. [PMID: 23020845 DOI: 10.1111/srt.12007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Skin temperature (Tsk) disorders have been proposed as sign of impaired innervation in several conditions, but the influence of different factors on the infrared thermography (IRT) findings remains unclear. METHODS The relations between the Tsk and δT (side-to-side temperature difference) values, and influence of age, gender, anthropometric characteristics and pain intensity on those values were analysed in non-specific neck pain (NP) patients (n = 91) using mixed model analysis. IRT findings were also compared in subgroups of NP patients: with cold (CHNPP, n = 21) or warm hands (WHNPP, n = 56) and healthy controls, with cold (CHC, n = 11) or warm hands (WHC, n = 19). Also, the stability of δT values in CHNPP was examined. RESULTS Only the area of measurement and the actual Tsk influenced the δT values. CHNPP demonstrated higher δT values in distal parts, compared with WHNPP and controls, but those values vanished when their hands turned warm. δT values in CHNPP were related to the pain intensity. The findings of WHNPP and WHC did not differ. CONCLUSION Our results suggest that the δT values as signs of impaired Tsk regulation are dynamic and better detectable in cold skin. The results underline the need of caution in interpretation of IRT findings.
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Affiliation(s)
- Nina Zaproudina
- Institute of Biomedicine, University of Eastern Finland, Kuopio, Finland.
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Wöpking S, Scherens A, Haussleiter IS, Richter H, Schüning J, Klauenberg S, Maier C. Significant difference between three observers in the assessment of intraepidermal nerve fiber density in skin biopsy. BMC Neurol 2009; 9:13. [PMID: 19335896 PMCID: PMC2672925 DOI: 10.1186/1471-2377-9-13] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Accepted: 03/31/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The determination of Intraepidermal Nerve Fiber Density (IENFD) in skin biopsy is a useful method for the evaluation of different types of peripheral neuropathies. To allow a reliable use of the method it is necessary to determine interobserver reliability. Previous studies dealing with this topic used limited suitable statistical methods. METHODS In the present study three observers determined the IENFD and estimated the staining quality of the basement membrane for an adequate quantity of 120 skin biopsies (stained with indirect immunofluorescence technique) from 68 patients. More adequate statistical methods like intraclass correlation coefficient and Bland Altman Plot were chosen to estimate interobserver reliability. RESULTS We found an unexpected significant difference in IENFD between the observers (p < 0.05) and so the results of this study are not in line with the high interobserver reliability reported before (intraclass correlation coefficient: 0.73). The Bland Altmann Plot showed a variance growing with rising mean. The difference in IENFD between the observers and the resulting low interobserver reliability is likely caused by different interpretations of the standard counting rules. There was no significant difference in IENFD between observers for biopsies with a well-defined basement membrane. Thus skin biopsies with an inexactly defined basement membrane should not be used diagnostically for the determination of IENFD. CONCLUSION These results emphasise that standardisation of the method is extremely important and at least two observers should analyse skin biopsies with critical IENFD near the cut-off values.
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Affiliation(s)
- Sigrid Wöpking
- Department of Pain Management, Ruhr-University Bochum, BG-Kliniken Bergmannsheil, Bürkle-de-la-Camp-Platz 1, D-44789 Bochum, Germany.
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Khodorova A, Montmayeur JP, Strichartz G. Endothelin receptors and pain. THE JOURNAL OF PAIN 2009; 10:4-28. [PMID: 19111868 DOI: 10.1016/j.jpain.2008.09.009] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Revised: 09/08/2008] [Accepted: 09/30/2008] [Indexed: 12/11/2022]
Abstract
UNLABELLED The endogenous endothelin (ET) peptides participate in a remarkable variety of pain-relatedprocesses. Pain that is elevated by inflammation, by skin incision, by cancer, during a Sickle Cell Disease crisis and by treatments that mimic neuropathic and inflammatory pain and are all reduced by local administration of antagonists of endothelin receptors. Many effects of endogenously released endothelin are simulated by acute, local subcutaneous administration of endothelin, which at very high concentrations causes pain and at lower concentrations sensitizes the nocifensive reactions to mechanical, thermal and chemical stimuli. PERSPECTIVE In this paper we review the biochemistry, second messenger pathways and hetero-receptor coupling that are activated by ET receptors, the cellular physiological responses to ET receptor activation, and the contribution to pain of such mechanisms occurring in the periphery and the CNS. Our goal is to frame the subject of endothelin and pain for a broad readership, and to present the generally accepted as well as the disputed concepts, including important unanswered questions.
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Affiliation(s)
- Alla Khodorova
- Department of Anesthesiology, Perioperative and Pain Medicine, Pain Research Center, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115-6110, USA
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Devigili G, Tugnoli V, Penza P, Camozzi F, Lombardi R, Melli G, Broglio L, Granieri E, Lauria G. The diagnostic criteria for small fibre neuropathy: from symptoms to neuropathology. Brain 2008; 131:1912-25. [PMID: 18524793 PMCID: PMC2442424 DOI: 10.1093/brain/awn093] [Citation(s) in RCA: 523] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Small fibre neuropathy (SFN), a condition dominated by neuropathic pain, is frequently encountered in clinical practise either as prevalent manifestation of more diffuse neuropathy or distinct nosologic entity. Aetiology of SFN includes pre-diabetes status and immune-mediated diseases, though it remains frequently unknown. Due to their physiologic characteristics, small nerve fibres cannot be investigated by routine electrophysiological tests, making the diagnosis particularly difficult. Quantitative sensory testing (QST) to assess the psychophysical thresholds for cold and warm sensations and skin biopsy with quantification of somatic intraepidermal nerve fibres (IENF) have been used to determine the damage to small nerve fibres. Nevertheless, the diagnostic criteria for SFN have not been defined yet and a 'gold standard' for clinical practise and research is not available. We screened 486 patients referred to our institutions and collected 124 patients with sensory neuropathy. Among them, we identified 67 patients with pure SFN using a new diagnostic 'gold standard', based on the presence of at least two abnormal results at clinical, QST and skin biopsy examination. The diagnosis of SFN was achieved by abnormal clinical and skin biopsy findings in 43.3% of patients, abnormal skin biopsy and QST findings in 37.3% of patients, abnormal clinical and QST findings in 11.9% of patients, whereas 7.5% patients had abnormal results at all the examinations. Skin biopsy showed a diagnostic efficiency of 88.4%, clinical examination of 54.6% and QST of 46.9%. Receiver operating characteristic curve analysis confirmed the significantly higher performance of skin biopsy comparing with QST. However, we found a significant inverse correlation between IENF density and both cold and warm thresholds at the leg. Clinical examination revealed pinprick and thermal hypoesthesia in about 50% patients, and signs of peripheral vascular autonomic dysfunction in about 70% of patients. Spontaneous pain dominated the clinical picture in most SFN patients. Neuropathic pain intensity was more severe in patients with SFN than in patients with large or mixed fibre neuropathy, but there was no significant correlation with IENF density. The aetiology of SFN was initially unknown in 41.8% of patients and at 2-year follow-up a potential cause could be determined in 25% of them. Over the same period, 13% of SFN patients showed the involvement of large nerve fibres, whereas in 45.6% of them the clinical picture did not change. Spontaneous remission of neuropathic pain occurred in 10.9% of SFN patients, while it worsened in 30.4% of them.
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