OBJECTIVE Diabetic peripheral neuropathy (DPN) has hitherto been considered a disease of the peripheral nervous system only, with central nervous system (CNS) involvement largely overlooked. The aim of this study was to investigate any differences in brain structure in subjects with DPN. RESEARCH DESIGN AND METHODS Thirty-six subjects with type 1 diabetes (No DPN [ n = 18], Painful DPN [ n = 9], Painless DPN [ n = 9]) underwent neurophysiological assessment to quantify the severity of DPN. All subjects, including 18 healthy volunteers (HVs), underwent volumetric brain magnetic resonance imaging at 3 Tesla. RESULTS Adjusted peripheral gray matter volume was statistically significantly lower in subjects with painless and painful DPN (mean 599.6 mL [SEM 9.8 mL] and 585.4 mL [10.0 mL], respectively) compared with those with No DPN (626.5 mL [5.7 mL]) and HVs (639.9 mL [7.2 mL]; ANCOVA, P = 0.001). The difference in adjusted peripheral gray matter volume between subjects with No DPN and HVs, and those with Painful DPN and Painless DPN was not statistically significant ( P = 0.16 and 0.30, respectively). Voxel-based morphometry analyses revealed greater localized volume loss in the primary somatosensory cortex, supramarginal gyrus, and cingulate cortex (corrected P CONCLUSIONS This is the first study to focus on structural changes in the brain associated with DPN. Our findings suggest increased peripheral gray matter volume loss, localized to regions involved with somatosensory perception in subjects with DPN. This may have important implications for the long-term prognosis of DPN.

https://care.diabetesjournals.org/content/diacare/37/6/1681.full.pdf

Magnetic Resonance Neuroimaging Study of Brain Structural Differences in Diabetic Peripheral Neuropathy

Diabetic distal symmetrical peripheral polyneuropathy (DSP) results in decreased somatosensory cortical gray matter volume, indicating that the disease process may produce morphological changes in the brains of those affected. However, no study has examined whether changes in brain volume alter the functional organization of the somatosensory cortex and how this relates to the various painful DSP clinical phenotypes. In this case-controlled, multimodal brain MRI study of 44 carefully phenotyped subjects, we found significant anatomical and functional changes in the somatosensory cortex. Subjects with painful DSP insensate have the lowest somatosensory cortical thickness, with expansion of the area representing pain in the lower limb to include face and lip regions. Furthermore, there was a significant relationship between anatomical and functional changes within the somatosensory cortex and severity of the peripheral neuropathy. These data suggest a dynamic plasticity of the brain in DSP driven by the neuropathic process. It demonstrates, for the first time in our knowledge, a pathophysiological relationship between a clinically painful DSP phenotype and alterations in the somatosensory cortex.

/pdf/structural-and-functional-abnormalities-of-the-primary-sez5rgjovh.pdf

Structural and Functional Abnormalities of the Primary Somatosensory Cortex in Diabetic Peripheral Neuropathy: A Multimodal MRI Study

Objective: Although a clear link between diabetic peripheral neuropathy (DPN) and autonomic neuropathy is recognized, the relationship of autonomic neuropathy with subtypes of DPN is less clear This study aimed to investigate the relationship of autonomic neuropathy with painless and painful DPN
Research design and methods: Eighty subjects (20 healthy volunteers, 20 with no DPN, 20 with painful DPN, 20 with painless DPN) underwent detailed neurophysiological investigations (including conventional autonomic function tests [AFTs]) and spectral analysis of short-term heart rate variability (HRV), which assesses sympathovagal modulation of the heart rate Various frequency-domain (including low frequency [LF], high frequency [HF], and total power [TP]) and time-domain (standard deviation of all normal-to-normal R-R intervals [SDNN] and root mean square of successive differences [RMSSD]) parameters were assessed
Results: HRV analysis revealed significant differences across the groups in LF, HF, TP, SDNN, and RMSSD (ANOVA P < 0001) Subgroup analysis showed that compared with painless DPN, painful DPN had significantly lower HF (359 ± 108 [means ± SD] vs 267 ± 156), TP (573 ± 128 vs 479 ± 151), and SDNN (291 ± 065 vs 162 ± 35), P < 005 No significant differences were seen between painless DPN and painful DPN using an AFT
Conclusions: This study shows that painful DPN is associated with significantly greater autonomic dysfunction than painless DPN These changes are only detected using spectral analysis of HRV (a simple test based on a 5-min electrocardiogram recording), suggesting that it is a more sensitive tool to detect autonomic dysfunction, which is still under-detected in people with diabetes The greater autonomic dysfunction seen in painful DPN may reflect more predominant small fiber involvement and adds to the growing evidence of its role in the pathophysiology of painful DPN

Painful Diabetic Neuropathy Is AssociatedWith Greater Autonomic Dysfunction ThanPainless Diabetic Neuropathy

Pulmonary hypertension, defined as mean pulmonary artery pressure (mPAP) greater than or equal to 25 mmHg, is a recognized complication of hepatic dysfunction with portal hypertension and is considered a relative contraindication to liver transplantation. To characterize pulmonary hemodynamic responses in OLT candidates without pre-existing primary pulmonary hypertension, 22 consecutive patients referred for OLT at the Stanford University Hospital underwent prospective right heart catheterization with pressure determinations at baseline and following infusion of 11 crystalloid over 10 min. In addition, EKG, chest X-ray and transthoracic echocardiograms were performed as a part of the routine evaluation. Eleven non-cirrhotic patients served as controls. At baseline, 1/22 (4.5%) OLT patients had pulmonary hypertension while 9/22 (41%) developed pulmonary hypertension following volume infusion (p < 0.0001). In contrast, 0/11 controls manifested elevated pulmonary pressures at baseline or following volume challenge. OLT candidates were found to have significant increases in mean pulmonary pressure and capillary wedge pressure (PCWP) compared to controls, suggesting intravascular volume overload or left ventricular dysfunction as potential causes. OLT candidates who manifested volume-dependent pulmonary hypertension (a) had a 2-fold higher baseline PCWP, (b) currently smoked, and (c) had previously undergone portosystemic shunts. Aggregate analysis of EKG, echo and CXR for determination of volume-mediated pulmonary hypertension revealed a sensitivity of 25%, specificity of 75% and a positive predictive value of 40%. Preoperative identification of patients with a predisposition to manifesting elevated pulmonary pressures in the context of rapid volume infusion offers the potential for improved risk stratification and optimized clinical management.

Volume-mediated pulmonary responses in liver transplant candidates.

Pulmonary hypertension is a potentially lethal complication of end-stage liver disease with a prevalence of 2%. In the setting of liver transplantation, the prevalence may be as high as 12%. Given the potential importance of this syndrome to the transplantation community, the purpose of this review is to summarize the current state of understanding of portopulmonary hypertension and to suggest potential management strategies for (1) liver transplant candidates with suspected pulmonary hypertension and (2) intraoperative pulmonary hypertension following liver allograft reperfusion.

Pulmonary hypertension: considerations in the liver transplant candidate

Introduction: In severely injured trauma patients primary permeability detects can commonly be observed. However,ongoing disturbances of permeability may possibly be initiated by inflammatory responses (e.g. sepsis). Therefore we investigated changes in lung microvascular permeability (LMVP), extravascular lung water (EVLW), hemodynamics and gas exchange in ventilator dependend traumatized ICU patients, focusing on the development of septic complications. Patients and methods: 31 artificially ventilated trauma patients (mean age: 35 yrs, ISS > 30) were investigated prospectively from the day of admission to the ICU for up to ten days. Time course of EVLW was measured by the thermal-dye dilution technique on a daily basis. At the same time, blood gas analysis and hemodynamic parameters (mean arterial pressure (MAP), cardiac index (Cl), pulmonary microvascular pressure (Pmv)] were obtained. Pmv was derived from pulmonary artery pressure (PAMP) and pulmonary wedge pressure (PCWP) using standard equation. LMVP was determined I. Immediately after admission and II 7 days after trauma by computerized gamma szintigraphy. Changes in LMVP are expressed as permeability index (LMVPI). According to their course of illness, patients were assigned to 2 groups: group A (septic) or to group B (non-septic). Results:(table) 16 patients developed septic complications (group A). In that.pationts, elevated LMVPI and Pmv values already immediately after trauma could be noticed in contrast to non septic patients (group B; 15 pat.) . However, in all patients (AB) late rises of LMVPI could be seen. Subsequent accumulation of EVLW only did occur in septic patients (B). These patients showed marked disturbances in gas-exchange and hemodynamics as well. Ike Time I Qav A e A e EVLW (mlikgBW) 7.8±0.7 7.2±0.7 10.5±0.9 5.2±0.4 LMVPI (%/h) 7.5±0.9 4.5±0.8 9.0±1.1 7.2±0.5 CI(Vm2) 4.8±0.4 4.1±0.5 5.6±0.6 4.0±0.6 MAP (mm Hg) 85.0±3.5 92.0±4.4 88.0±3.5 98.0±4.3 Pmv (mm Hg) 19.9±2.4 12.9±2.3 22.7±3.0 12.8±4.2 PaO^uF^ 209.0±23 351.0±43 235.0±30 343.0±36 Discussion and conclusions: Our results indicate, that disturbances of vascular permeability can be observed very early in all trauma patients. However, in patients, developing septic complications (A), a marked hemodynamic response could be seen as well as pronounced edema formation and disturbances in gas exchange. However, apart from that, in a late observation state (>7 days), inflammatory responses must be assumed even in patients clinically considered not to be septic (B).

/pdf/cardiovascular-assessment-i-irpdl8uusr.pdf

Cardiovascular assessment I

Right ejection fraction and maximum elasticity are sensitive measurements of right ventricular function during liver transplantation.

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Cardiovascular assessment I

Right ejection fraction and maximum elasticity are sensitive measurements of right ventricular function during liver transplantation.