Pregnancy does not induce or worsen retinal and peripheral nerve dysfunction in insulin-dependent diabetic women

In order to verify whether pregnancy induces or worsens diabetic retinopathy or somatic and autonomic neuropathy, 16 insulin-dependent diabetic (IDDM) pregnant women, 14 age-matched nondiabetic pregnant women, and 12 IDDM nonpregnant women matched for age and disease duration were studied. Plasma glucose, HbA1c, and fructosamine were repeatedly assayed during pregnancy. Retinopathic and neuropathic endpoints were evaluated through ophthalmoscopy, electrophysiology of left peroneal and sural nerves (motor and sensory conduction velocities), and cardiovascular autonomic tests (deep breathing, cough test, lying-to-standing). In the IDDM pregnant women, evaluations were performed three times during pregnancy and 6 months after delivery. Good metabolic control was achieved during pregnancy. At baseline, nine IDDM pregnant women did not show signs of retinopathy, and seven had nonproliferative retinopathy. Only one patient showed worsening during pregnancy, but she improved after delivery. Motor conduction velocity, significantly lower in IDDM pregnant women, progressively improved, and, in the third trimester, was not significantly different from that of nondiabetic pregnant women. At baseline, none of the IDDM pregnant women had abnormal responses to cardiovascular autonomic tests. During pregnancy, the response to deep breathing appeared temporarily reduced in all pregnant women, possibly due to lowered ventilatory excursion at the end of pregnancy. In IDDM women with minimal or no retinopathy, and subclinical or no peripheral neuropathy, pregnancy does not appear to induce or worsen these complications.

A multicenter study on the prevalence of diabetic neuropathy in Italy. Italian Diabetic Neuropathy Committee

OBJECTIVE

The prevalence of neuropathy, a common complication of diabetes, was determined in diabetic patients recruited from 109 outpatient diabetes clinics in Italy.

RESEARCH DESIGN AND METHODS

Neuropathy was diagnosed using the Diabetic Neuropathy Index (DNI), a standardized examination developed for use in the outpatient setting. A total of 8,757 diabetic patients were studied, 51.2% men and 48.8% women, with average and median ages of 56 and 58 years, respectively.

RESULTS

Of the 8,757 patients, 32.3% had neuropathy, defined as a positive score of > 2 points on the DNI. A total of 2,033 (49.6% men and 50.4% women) were administered the Diabetic Neuropathy Score (DNS), the second component of the screening program, by a neurologist. This component consists of a quantitative neurological examination and nerve conduction studies that together provide a summated score. A total of 335 patients (16.5%) were not neuropathic, and 395 (19.4%) had borderline, 453 (22.3%) mild, 592 (29.1%) moderate, and 258 (12.7%) severe neuropathy. The concordance between a positive score on the DNI and a DNS indicating neuropathy was 83.5%. The severity of neuropathy increased with both age and disease duration. Of patients with neuropathy, 64.1% had an average age between 58 and 59 years with a disease duration between 12.4 +/- 8.4 years (mild neuropathy) and 15.6 +/- 9.7 years (severe neuropathy).

CONCLUSIONS

Neuropathy is a common complication of diabetes and, in this study, was present in 32.3% of all patients. An increased awareness of the high prevalence of neuropathy can lead to early therapeutic intervention and possible prevention of later neuropathic complications, such as infection and foot ulcers.

Conduction studies as prognostic parameters in the natural history of diabetic neuropathy: a long-term follow-up of 114 patients

In order to evaluate the clinical and prognostic role of common neurophysiological parameters, we examined 114 patients selected from a population of 2500 diabetics, observed in the period 1973-1986. The follow-up lasted 9 to 16 years (mean = 10). For prognostic purposes the patients were divided into 3 groups according to the motor conduction velocity (MCV) of the peroneal nerve: A) 47 cases with normal MCV (more than 44 m/s); B) 38 cases with mild neuropathy (MCV between 44 and 39 m/s); C) 29 cases with severe neuropathy (MCV less than 39 m/s). The natural history was evaluated on the basis of the following parameters: neurological symptom score (NSS), neurological disability score (NDS), patient's self-evaluation (PE) and neurologist's evaluation (ME). At the initial examination, there was a significant correlation between MCV and NDS/ME. At the final examination, MCV was reduced to groups A and B, unchanged in group C. NSS, NDS, PE and ME were worsened, but a significant correlation was found only between MCV and NDS: neuropathic groups (B and C) showed a more severe evolution than the normal group (A). In conclusion, a) MCV is progressively reduced as diabetes evolves, but--once it has reached a plateau--it stabilizes; b) MCV only has a prognostic value when it is considered together with clinical neurological signs.

Ataxia-teleangectasia: neurophysiological studies in 8 patients

Eight patients affected by Ataxia-Teleangectasia (AT) were studied with a set of neurophysiological tests. The study was done two times between 2 and 10 years. The most characteristic feature was a severe involvement of the posterior spinal cord: it was associated with a moderate peripheral neuropathy as well as a severe peripheral neuropathy. These data could indicate that the dying back phenomena are not the only pathogenetic basis of the spinal cord degeneration in this disease.

Striated anal sphincter electromyography in idiopathic fecal incontinence

PURPOSE

This study was designed to determine the importance of innervation of striated anal sphincters, one of the most important structures in idiopathic fecal incontinence.

METHODS

Forty-three idiopathic, fecally incontinent patients (40 women and 3 men; mean age, 57.2 +/- 11 (range, 33-77) years) underwent anorectal manometry and sphincteric electromyography. On the basis of electromyographic findings, patients were subdivided into three groups: Group A consisted of 21 patients with normal electromyography; Group B consisted of 14 patients with moderate denervation; Group C consisted of 8 patients with severe denervation. Manometric results from the patients were compared with those from 15 healthy subjects (8 women and 7 men; mean age, 35 +/- 12 (range, 15-55) years).

RESULTS

Incontinent patients had a shorter anal canal (P = 0.005), and anal canal pressure was lower at rest (P < 0.001), at contraction (P < 0.001), and at coughing (P < 0.001); rectal distention and rectal compliance were reduced (maximum tolerated volume, P < 0.003; compliance at 200 ml, P = 0.03; at 250, P < 0.005; at 300 ml, P = 0.03). No statistically significant differences were found between the manometric results of the three different groups of patients. A statistically significant linear correlation was reached by comparing the clinical severity of fecal incontinence with age (P = 0.02) and some other manometric parameters: the pressure of the anal canal at rest (P < 0.001) and at contraction (P < 0.01); rectal compliance at 50 ml (P = 0.03), 100 ml (P = 0.004), and 150 ml (P = 0.004).

CONCLUSION

Clinical severity of fecal incontinence is correlated with some manometric parameters. Severity of denervation of the anal striated sphincters does not appear to influence severity of fecal incontinence.

Posterior interosseous nerve neuropathy. Clinical and electromyographical aspects

A clinical-EMGraphic examination was carried out in 37 patients with posterior interosseous nerve neuropathy: 5 cases had a traumatic origin, 4 iatrogenic, and 28 non-traumatic. One of the non-traumatic cases had a lipoma, and another had chondroma. In the other cases, nerve entrapment at the level of the arcade of Frohse could be presumed. Acute or chronic onset of the deficit was probably due to repeated pronation-supination hand movements. A motor deficit in finger extension together with a radial deviation of the wrist, was typical. Surprisingly about 50% of the non-traumatic cases showed some sensory disturbance at the forearm, wrist or hand. EMG examination was useful to establish the entity and topography of the deficit. Follow-up was carried out in 27 cases (3 traumatic, 2 iatrogenic and 22 non-traumatic). Even if spontaneous recovery is possible, though infrequent, in non-traumatic cases with marked deficit surgery gave the most satisfactory results, especially when onset had been acute and operation was performed within nine months of onset.

Contribution of electromyography to the diagnosis, treatment and prognosis of cervical disc disease: a study of 114 patients

The aim of this study is to verify whether EMG has the same diagnostic and prognostic capacity in cervical root syndrome as it does in lumbo-sacral syndromes. Our population includes 114 patients affected by a cervico-brachialgia with EMG denervation provoked by cervical disc disease. 26 patients were submitted to a myelography confirming the discal origin of the syndrome: there were 3 cases of disc protrusion and 23 cases of cervical spondylosis. The agreement between EMG and myelographical data was significant in 20 cases (76.9%). There were no significant differences of evolution between operated and non-operated cases. EMG failed to provide prognostic criteria as it does in lumbo-sacral syndromes: it must hence be concluded that all patients presenting cervico-brachialgia and EMG signs of denervation should in any case be admitted to the hospital for exploratory examination. In this context, the particular role of EMG is to establish the degree of the muscular impairment, the number of roots involved, the duration of the syndrome and--recently--the identification of the intervertebral space to be explored by spinal CT.

Somato-sensory evoked potentials in diabetes type I

Twenty-nine young patients with insulin dependent diabetes were studied. Clinical findings, metabolic profile, and neurophysiological data were correlated. Nerve conduction velocity (NCV) and Somato-sensory Evoked Potential (SEPs) were recorded stimulating the median nerve and the posterior tibial nerve bilaterally. High incidence of distal neuropathy was present in our cases plus a significant alteration of the plexus conduction, at the level of brachial plexus and of the cauda. We conclude that even in young diabetic patients the damage can be multifocal, and SEP technique could contribute to a more accurate study of neurological complication in the diabetic disease.

Radiation-induced brachial plexopathy: clinical and electromyographical (EMG) considerations in 13 cases

The purpose of this study was to determine the clinical and electromyographical characteristics of the initial picture, and the subsequent course of the radiation-induced brachial plexopathy. The AA. studied 13 females affected by infiltrating carcinoma of the breast, who underwent a radical mastectomy with removal of the axillary cavity, followed by radiotherapy (total dose was 50 Gy per cycle). The symptom-free interval between the end of radiotherapy and the appearance of symptoms varied considerably (from one month to 15 years). The initial clinical picture presented pain (5 cases), paresthesia (6 cases) and motor deficit (8 cases). EMG examination showed a pluriradicular denervation in 10 cases (with a very frequent damage of the lower roots of the plexus) and a monoradicular denervation in 3 cases. In 6 cases it was possible to carry out a follow-up with repeated tests for 3-17 years after radiotherapy. The role of the EMG in the diagnosis and prognosis of this plexopathy is then discussed.

Sensory, motor, and autonomic neuropathy in patients with multiple symmetric lipomatosis

Clinical evaluation of 33 male patients affected by multiple symmetric lipomatosis has revealed a previously unreported high prevalence of somatic and autonomic neuropathies. In 84% of the patients, clinical examination revealed signs or symptoms of neural disturbances, ranging from a vibratory sensory loss to severely incapacitating trophic ulcers or Charcot's arthropathy. Electrodiagnostic investigations demonstrated a significant reduction of motor and sensory conduction velocity in the peroneal and sural nerves. Morphometric studies of nerve and muscle biopsies from five patients with multiple symmetric lipomatosis revealed a significant reduction in myelinated fiber density (4435 +/- 593 fibers/mm2 in MSL vs 7660 +/- 800 in controls; p less than 0.05), a selective reduction in the large fibers of 7 to 10 micron in diameter, and signs of chronic denervation-reinnervation processes. Bedside tests for autonomic neuropathy were abnormal in 15 of 20 patients studied. Metabolic studies in these patients confirmed a significant increase in plasma high-density lipoprotein fractions consistent with the diagnosis of hyperalphalipoproteinemia, and a significant reduction in plasma low-density lipoprotein fractions (hypobetalipoproteinemia) associated with a marked enhancement of lipoprotein lipase activity in adipose tissue. Thus, a metabolic factor has to be considered in the pathogenesis of MSL neuropathy.

Influence of continuous subcutaneous insulin infusion (CSII) treatment on diabetic somatic and autonomic neuropathy

Near-normal plasma daily glucose profile was induced by Continuous Subcutaneous Insulin Infusion (CSII) treatment in order to evaluate its influence on diabetic somatic and autonomic neuropathy. Twelve insulin-dependent diabetic subjects with somatic neuropathy were studied before and after a short term CSII treatment of 10 days. Four out of these subjects, all affected by autonomic neuropathy, were followed for 1 yr with controls every four months. Metabolic equilibrium was monitored by mean daily plasma glucose (MPDG) profile and by Glycosylated Hemoglobin (GHb) evaluation. Somatic neuropathy was studied assessing conduction velocity at peroneal motor (PMCV) nerve, ulnar motor (UMCV), ulnar sensory (USCV) and sural sensory (SSCV) nerves. Autonomic neuropathy was assessed by means of a battery of five cardiovascular autonomic tests: Valsalva Manoeuvre (VR), Deep Breathing (DB), Lying-to-Standing (LS), Sustained HandGrip (SHG) and Postural Hypotension (PH). Short-term CSII treatment induced a near normalization of metabolic parameters, a significant improvement in VR (p less than 0.05) and DB (p less than 0.01) values, but no changes in NCV. The prolongation of CSII treatment in 4 subjects induced a significant (p less than 0.05) improvement in VR, DB and LS values and in PMCV and UMCV after 4 months. This improvement did not increase with the longer CSII treatment (1 yr).(ABSTRACT TRUNCATED AT 250 WORDS)

Impaired auditory brainstem-evoked responses in insulin-dependent diabetic subjects

Auditory brainstem-evoked responses (ABR) were recorded from the scalp of 30 normoacoustic insulin-dependent diabetic subjects, aged between 15 and 41 yr (29 +/- 7 yr). Three different stimulus repetition rates (11, 37, and 87 cps) were used. The results were compared with those obtained from 20 age- and sex-matched, normoacoustic control subjects. In diabetic patients, metabolic control (mean daily plasma glucose, glycosylated hemoglobin) and the presence of retinopathy, nephropathy, and somatic neuropathy were also investigated. The latencies (ms) of ABR waves were significantly impaired in diabetic subjects as compared with normals. Peripheral transmission time (wave I) and central transmission time (waves I-V) were also significantly delayed in diabetic subjects. Moreover, by increasing stimulus repetition rates, a significant increase in waves I-V shift was observed in diabetic patients. ABR impairment was not related to glucose balance, to the duration of diabetes, or to the presence of the diabetic retinopathy, nephropathy, and somatic neuropathy. In conclusion, diabetic neuropathy is characterized not only by somatic and autonomic nerve dysfunctions, but also by the early involvement of the central nervous system (CNS). ABR recording can represent a useful, noninvasive, simple procedure to detect both acoustic nerve and CNS damage.

Biochemical and electrophysiological study of subjects with a history of past lead exposure

The effects of lead on porphyrin metabolism and peripheral nervous system were studied in a group of 38 subjects who had not been exposed for a period of time, ranging from 3 to 27 years. The mean values for blood lead (PbB), chelated lead(PbUEDTA), and free erythrocyte protoporphyrin (FEP) were found to be significantly higher in the subjects with past lead exposure than in controls. In all cases the neurological examination was negative. The mean values for maximum motor conduction velocity (MMCV) and conduction velocity of the slower fibers (CVSF) of the ulnar and peroneal nerves were found to be significantly lower in the subjects with past lead exposure than in the control group of 23 subjects standardized for age. Signs of partial denervation were present in four cases, with two presenting a decrease of the motor conduction velocity (MCV) as well. No correlation was found between electrophysiological findings and biochemical indicators of dose and effect. The length of exposure showed a significant negative correlation only with the MMCV of the ulnar nerve. A significant difference from controls standardized for age was observed only in subjects with exposure of more than 6 months for all the electromyographic (EMG) parameters. It does not appear that the EMG findings could depend upon modest lead deposits still present in the organism; they should rather give evidence to the permanent effect of alterations that occurred during the prolonged exposure to lead.

Ganglioside treatment in diabetic peripheral neuropathy: a multicenter trial

Ganglioside treatment was evaluated with a multicenter, randomized, double-blind, controlled, cross-over vs placebo trial in 140 insulin-treated diabetic subjects with peripheral neuropathy. The patients entered the study when they showed an impairment in at least two of the electroneurographic parameters, and were assigned to two protocols according to the presence and severity of their neurological symptoms. Ninety-seven diabetic subjects with no or mild symptoms were assigned to protocol I, whereas 43 symptomatic patients were assigned to protocol II. the treatment periods lasted 6 weeks with an intermediate washout period of 4 weeks. The treatment consisted in the daily i.m. administration of 20 mg gangliosides or of placebo. Electroneurographic parameters were recorded at the beginning and at the end of each treatment period, whereas clinical and metabolic data (mean daily plasma glucose, glycosuria and glycosylated hemoglobin) were evaluated every three weeks in protocol I and every two weeks in protocol II. No change in the metabolic parameters was observed throughout the trial period. However, the treatment induced a statistically significant improvement of paresthesias (protocol II) and of some electrophysiological parameters; in particular, ganglioside treatment improved MCV of peroneal nerve (p less than 0.03) in patients of protocol I, MCV o ulnar nerve (p less than 0.002) and SCV of median nerve (p less than 0.06) in patients of protocol II. Furthermore, 22 subjects of protocol II showed a 'drug preference' while 10 preferred placebo and 9 had no preference. In conclusion, ganglioside treatment seems to have a positive effect on diabetic peripheral neuropathy, improving both some symptoms and some electrophysiological parameters.

Chronic peripheral neuropathy in workers with previous exposure to carbon disulphide

Two groups of viscose rayon production workers were examined 10 years after discontinuation of exposure to CS2. Group A comprised 20 subjects exposed to high CS2 concentrations and group B 13 subjects with lower exposure. Clinical findings and the measurements of nerve conduction velocity of the slow fibres in the peripheral nerves were evaluated. Twelve subjects had both clinical and electromyographic evidence of neuropathy and 10 showed a diminution in motor conduction velocity. A relationship between the degrees of exposure to CS2 and prevalence of polyneuropathy was found. On re-examining 12 subjects with neuropathy who had been examined four years before no significant electromyographic improvement was observed. These findings are consistent with a permanent axonal neuropathy caused by carbon disulphide.

Cervical rib syndrome: a neurosurgical experience with a series of 38 cases

A series of 38 patients with thoracic outlet syndrome caused by a cervical rib is reviewed after a postoperative follow-up period of 3 to 24 years. The outcome of the operation (anterior scalenotomy and partial to subtotal removal of the cervical rib) is not considered wholly satisfactory; three causes for this were identified: excessive duration of symptoms (mean almost 6 years), insufficient patient work-up and inadequacy of the incomplete removal of the cervical rib. In the presence of a cervical rib, other possible causes of compression of the neurovascular supply to the upper limb should always be considered.

Motor conduction velocity (MCV) in insulin-dependent and non-insulin-dependent diabetics with and without clinical peripheral neuropathy

Motor nerve conduction velocity (MCV) was determined in the external sciatic popliteus nerve in 83 subjects (46 males and 37 females), 33 with insulin-dependent and 50 with noninsulin-dependent diabetes, with or without clinical signs of diabetic neuropathy. Duration of known diabetes ranged from one month to 32 years. No difference was observed in MCV between insulin-dependent and non-insulin-dependent diabetics. MCV was inversely correlated (p < 0,05) with age, but not with the duration of the disease or with metabolic control. Duration and metabolic control were related to the appearance of clinical signs of peripheral neuropathy.

[The repetitive stimulation test in the diagnosis of neuromuscular fatigue syndromes. Critical review of the results in 62 cases]

The usefulness of the method of the repetitive stimulation of the peripheral nerves has been widely accepted since the original observations of Desmedt on patients with Myasthenia Gravis, and this test is now routinely performed in many EMG laboratories. On the other hand the technical difficulties and the variability of the results in the various syndromes of neuromuscular fatigability have put some criticism on the value of the test as a routine examination. The AA. make a critical review of the clinical history and of the EMG pattern of 62 patients, who underwent one or more tests of repetitive stimulation during a period of four years, under the suspicion of Myasthenia Gravis or myasthenic syndrome. The AA. give full details of the employed technique and analyze the results either of the 27 cases with Myasthenia Gravis, either of the 15 cases of Myasthenia Gravis with ocular involvement, either of the 16 cases with myasthenic syndrome and of the 4 cases of psychogenic fatigability. The only typical changes of the motor response are its post-tetanic decrease in the not-treated cases of diffuse form of Myasthenia Gravis and its facilitation in the myasthenic syndromes associated with bronchial carcinoma.

Clinical-electroencephalographic correlations in measles: a long range study of 18 subjects

EEGs of 18 cases of measles (uncomplicated, with seizures, with encephalitides) were obtained through an underground cable connection between the Infections Diseases Department and the EEG unit. The varions EEG features of the disease have been studied during the evolution of the illness. An occasional EEG does not offer specific information on either the severity or the evolution of the disease. Marked EEG abnormalities appeared in the encephalitic group. The Authors emphasize the importance of serial prolonged EEG follow-up of measles in order to define precisely the stage and the evolution of the disease.

Effect of cerebral cortex gangliosides on the clinical and electromyographic evolution of "a frigore" facial paralysis. Apropos of 24 cases

Results obtained with gangliosides in cases of frigor facial paralysis were assessed in the light of the clinical and EMG pictures. It was found that early and continuous administration reduced the risk of failure (16% in treated and 66% in untreated subjects).

[Clinical and EMG study of botulism (case report) (author's transl)]

The Authors describe the clinical and electromyographic findings of a case of botulism with complete recovery. Therapy was based on anti-cholynesterasic drugs, on guanidine (at dosage of 30 mg/kg/day) and on antibotulinic serum. The neuromuscular transmission was assessed with the Desmedt's test: during the disease the EMG showed a tipical pattern of facilitation of motor units potentials during stimulation at 30 per second, becoming normal after recovery.

Paralysis of the deep branch of the radial nerve due of an entrapment neuropathy

The clinical and neurophysiological findings in two cases of spontaneous paralysis of the deep branch of the radial nerve are reported. The patients are sisters and the dominant hand was affected in both. One patient was submitted to surgical exploration, and 'entrapment neuropathy' was found to be the cause. After neurolysis the patient gained complete recovery. The usefulness of the EMG illustrated and stressed.

[EMG prognosis of facial palsy associated with herpes zoster oticus (Ramsay-Hunt's syndrome). A longitudinal study of 11 cases (author's transl]

Eleven patients with peripheral facial palsy associated with geniculate herpes zoster (Ramsay-Hunt's syndrome) have been followed-up clinically and electromyographically. Each patient was examined three times: within the first week, at the end of the third week and 3-4 months after the onset of symptoms. Only in three cases the facial palsy evolved satisfactorily, with an almost total recovery within three weeks. In eight cases the recovery was delayed and incomplete, with residual, and often severe, hemifacial spasm. This study confirms the rather poor prognosis of peripheral facial palsy in Ramsay-Hunt's syndrome. The importance of detecting even slight signs of herpetic eruption in any case of apparently "idiopathic" peripheral facial palsy is emphasized.

[Motor complications during Herpes zoster of the ophtalmic branch of the trigeminal nerve. Electromyographic study of 7 cases (author's transl)]

It has been recently shown that in addition to ganglia the nerve is involved during Herpes Zoster. Electromyographic investigations of the masseter muscle, were carried out on the side of the skin lesions in 7 cases of Herpes Zoster of the first trigeminal branch. In 4 cases there was a partial denervation, possibly due to a mononeuritis of the motor branch of the trigeminal nerve. It is probable that systematic electromyographic examinations may demonstrate a higher proportion of motor complications during Herpes Zoster than previously accepted.