The sural sensory/radial motor amplitude ratio for the diagnosis of peripheral neuropathy in type 2 diabetic patients.

BACKGROUND AND AIM: The diagnosis of peripheral diabetic neuropathy is based on clinical examination. Nerve conduction study (NCS) enables earlier diagnosis, but it is demanding and requires specialised personnel. In an attempt to simplify the procedure, this study aimed to identify a new electrophysiological index, which might correlate with results obtained on standardised NCS in patients with long-standing type 2 diabetes. PATIENTS AND METHODS: Medical records of type 2 diabetic patients evaluated for neuropathy by NCS were reviewed retrospectively. This analysis included 104 patients (50 men, 54 women) with a mean age of 67.1±5.5 years and mean diabetes duration of 13.1±2.7 years. NCS was performed on radial, ulnar, sural, and peroneal nerves. Neuropathy was defined as impaired NCS. Ratios of neurophysiological parameters from these nerves were calculated and each of them was compared with diagnosis of neuropathy. RESULTS: The sural sensory/radial motor amplitude ratio had the best combination of sensitivity (85%) and specificity (71%) for neuropathy. It also remained the strongest independent predictor of neuropathy in multivariate regression analysis: low levels of this ratio yielded an odds ratio of 7.7 for neuropathy. CONCLUSIONS: The sural sensory/radial motor amplitude ratio has a high sensitivity and a moderately high specificity for the diagnosis of neuropathy, low levels being associated with a nearly eightfold increase in the risk for neuropathy. These results encourage further evaluation of this and other electrophysiological indices to enable wider availability of NCS.

Magnetoencephalographic findings in two cases of juvenile myoclonus epilepsy.

The aim of this study is to investigate the electromagnetic sources of epileptic activity in two patients with juvenile myoclonus epilepsy (JME). The first patient was a 22-year old female with JME diagnosis by the age of 17 years old. Her initial EEG recording showed characteristic paroxysmal generalized activity with polyspike-wave complexes. She was on remission for 9 months. The second patient was a 29-year old male with JME diagnosis by the age 18 of years old. He showed an EEG recording with generalized spike-wave complexes of 3.5-4 Hz and presented a great improvement after therapeutic treatment. The MRI examinations for both patients did not disclose any focal lesions or areas of abnormal signal intensity or enhancement by contrast media. Magnetoencephalography (MEG) was recorded with a 122-channel whole-head system, 5 years after the disease onset for the first patient and 11 years for the second patient. For the first patient dipolar sources of MEG paroxysmal activity were localised at the vermis with extension up to the occipital region, whereas, for the second patient dipolar sources of MEG paroxysmal activity were localised at the cerebellar area (vermis and hemisphere). Implication of the cerebellum in JME, as suggested by MEG data in this study, is in accordance with previous reports employing functional MRI or cerebral blood flow evaluation in JME.

Sleep architecture in stroke and relation to outcome.

The aim of this study was to investigate sleep architecture in stroke patients, and correlate possible disturbances with the topography, severity and outcome of stroke and the presence of sleep-disordered breathing (SDB). In total, 62 acute stroke patients and 16 age- and gender-matched hospitalised controls underwent polysomnographic studies. Sleep architecture was analysed according to the topography of lesion, severity (National Institutes of Health Stroke Scale) and outcome (Barthel Index) of stroke. We found that sleep architecture is disturbed in stroke patients, regardless of SDB. Stroke patients (without SDB) have reductions in total sleep time and sleep efficiency, reduced stage II and slow wave sleep, increased wakefulness during sleep and increased sleep latency. Rapid eye movement (REM) sleep is reduced when SDB is also present. REM sleep is relatively preserved in cerebellar strokes, as opposed to other topographies. Sleep stages I and REM are negatively associated with stroke severity, and the latency to REM sleep is positively correlated with a good outcome. Sleep architecture is impaired in stroke patients (with fragmentation, increased wakefulness and reduced slow wave sleep), and this correlates with severity and outcome. Sleep disturbances should be investigated and addressed in these patients. Further studies are needed to confirm these findings and assess the clinical and therapeutic implications.

Meg evaluation of epileptic activity in the time and frequency domain.

We investigated the localization of current sources in the time and frequency domain from spontaneous MEG data recorded from nine epileptic patients (six females; three males) randomly selected, who had a mean age of 41 years old (range of 17-78 years old), with different types of epilepsy. The MEG data were recorded in a magnetically shielded room with a whole-head 122 channel biomagnetometer. For each MEG spike, we calculated the single Equivalent Current Dipole (ECD) sources at the initial spike peaks with a spherical model. MRI and EEG findings were available in patients' records. Prominent low frequencies can be seen in the majority of channels. For each patient there was an increase of the frequency range after the ECD in comparison with the frequency range before the ECD, in the whole study group due to epileptic discharge which is statistically significant (p=0.02). There was also a statistical significant difference in the increase of the frequency range in four patients with pathologic MRI (p=0.05), in five patients with normal MRI (p=0.02), in five patients with a high incidence of seizures (p=0.04) and in four patients with onset<10 years (p=0.04). The MEG analysis of neuromagnetic data gives information about the modification of the frequency range in the epileptic brains.

Apolipoprotein E and first-ever ischaemic stroke in Greek hospitalized patients.

The association between apolipoprotein E (ApoE) polymorphism and stroke is still controversial. This study investigated the potential association between ApoE genotypes and stroke subtypes, and risk factors for ischaemic stroke in Greek patients hospitalized with their first-ever ischaemic stroke. One hundred patients (70 men and 30 women; mean age +/- SD 60.7 +/-9.8 years) were included in the study. The control group comprised 96 age- and sex-matched healthy volunteers. Cerebral infarction was classified as atherothrombotic, cardioembolic or lacunar small-vessel stroke. The three common ApoE alleles (E2, E3 and E4) were determined using the semi-nested polymerase chain reaction. No significant difference in the ApoE alleles was found between patients and controls. Similarly, there was no significant association between ApoE alleles and stroke subtypes, common risk factors for ischaemic stroke and neck vessel stenosis. Although the sample size was small, these results do not support a role for ApoE polymorphism in the pathogenesis of ischaemic stroke.

Use of the new indicator test (Neuropad) for the assessment of the staged severity of neuropathy in type 2 diabetic patients.

UNLABELLED: The new indicator test for sudomotor function (Neuropad) has been shown to represent a highly sensitive and reproducible tool for the diagnosis of diabetic peripheral neuropathy. This study aimed to examine the utility of the indicator test in the assessment of the staged severity of neuropathy in patients with type 2 diabetes mellitus. The study included 120 type 2 diabetic patients (58 men) with a mean age of 67.3+/-5.9 years and a mean diabetes duration of 13.1+/-3.2 years. Neuropathy was diagnosed and staged by clinical examination and nerve conduction study, according to the Michigan classification system. Patients were also examined with the indicator test, applied on the plantar aspect of the feet. Time until complete colour change of the test was recorded and stratified into deciles according to the spread of measurements in the study population. Neuropathy was staged as class 0 in 37 patients, class 1 in 44 patients, class 2 in 28 patients and class 3 in 11 patients. Time until complete colour change was 436.5+/-62.9, 740+/-88.1, 1192.5+/-161 and 1817.3+/-127.4 seconds in patients staged as class 0, 1, 2 and 3 respectively (p=0.001). Use of a threshold lower than 530 seconds until complete colour change had 97% sensitivity and 100% specificity for diagnosis of class 0 neuropathy. Use of a threshold lower than 1000 seconds until complete colour change had 100% sensitivity and 97% specificity for class 1 neuropathy. A threshold lower than 1440 seconds had 93% sensitivity and 100% specificity for class 2 neuropathy. A threshold above 1440 seconds had 100% sensitivity and 99% specificity for class 3 neuropathy. A highly significant (Kendall's tau-b=0.848, p=0.001) correlation was shown between time until complete colour change of the test and Michigan class of neuropathy. CONCLUSIONS: It appears that the indicator test contributes substantially to the assessment of the staged severity of neuropathy in patients with type 2 diabetes mellitus. There is excellent agreement between the indicator test and the Michigan classification system. These results suggest a role for the indicator test in the assessment of diabetic neuropathy.

Simultaneous, painless, homolateral oculomotor and trochlear nerve palsies in a patient with type 2 diabetes mellitus. Neuropathy or brainstem infarction?

Combined palsies of cranial nerves, especially of the oculomotor nerves, are distinctly uncommon, even in patients with diabetes mellitus. We present a patient with type 2 diabetes mellitus, arterial hypertension and hyperlipidaemia, who had simultaneous oculomotor and trochlear nerve palsies. An MRI scan showed multiple brainstem ischaemic infarcts. The patient was treated with intensified insulin regimen and clopidogrel. Symptoms gradually improved, and at 9 months there was no further improvement.

Evaluation of a new indicator test for sudomotor function (Neuropad) in the diagnosis of peripheral neuropathy in type 2 diabetic patients.

UNLABELLED: Sudomotor neuropathy is associated with reduction of plantar sweating and contributes to the pathogenesis of diabetic foot ulcers. The aim of the present study was to evaluate the new indicator test for sudomotor function (Neuropad) in the diagnosis of peripheral neuropathy among type 2 diabetic patients. This study included 104 type 2 diabetic patients (51 men) with a mean age of 64.2+/-5.6 years and a mean diabetes duration of 12.8+/-3.7 years. Peripheral neuropathy was diagnosed by means of the Diabetic Neuropathy Index (DNI). Sudomotor neuropathy was assessed by means of colour change in the indicator test. Peripheral neuropathy was diagnosed in 71 patients (68.3 %). Sudomotor neuropathy was diagnosed in 67 patients (94.4 %) with peripheral neuropathy and in 10 patients (30.3 %) without peripheral neuropathy (p=0.0001). Compared with DNI, sensitivity of the indicator test for diagnosing peripheral neuropathy was 94.4 % and specificity was 69.7 %. Overall prevalence of neuropathy was higher using the indicator test (77 patients, 74.0 %) than using the DNI (71 patients, 68.3 %). Time until complete colour change of the indicator test was 23.8+/-6.7 min in patients with peripheral neuropathy and 7.7+/-1.2 min in patients without peripheral neuropathy (p=0.001). Among patients with peripheral neuropathy, time until complete colour change of the indicator test was 14.2+/-1.9 min in those with a DNI value between 2.5 and 4.5, while it was 32.8+/-2.6 min in those with a DNI value between 5 and 8 (p=0.003). CONCLUSIONS: Use of the new indicator test has a very high sensitivity in detection of diabetic peripheral neuropathy. Sudomotor dysfunction can be demonstrated in a considerable part of patients with normal clinical examination. Time until complete colour change of the indicator test is associated with severity of peripheral neuropathy.

Carotid plaque echomorphology and serum vascular endothelial growth factor levels.

Neovascularization in atherosclerotic plaques plays an essential role in the progression and rupture of plaques. Vascular endothelial growth factor (VEGF) is an important angiogenic factor. Echomorphologic evaluation of carotid plaques using computer-assisted imaging was found to have a good correlation with the histology of the lesion. The aim of this study was to investigate whether the serum VEGF level could be a determinant of the echomorphology of the carotid plaque. In 28 carotid plaques causing 60-99% stenosis, serum VEGF levels and the mean gray value (MGV) of three-dimensional image of the carotid plaques were measured. A statistically significant inverse correlation was found between serum VEGF concentrations and MGVs (Spearman's correlation coefficient: -0.415, p = 0.028). Our finding indicates that in patients with > or =60% carotid stenosis the serum VEGF levels are associated with the echogenicity of the atherosclerotic plaque.

Identification of kappa and lambda chains of the major immunoglobulin G subclasses by capillary zone electrophoresis.

Immunoglobulins are present in most tissues and plasma and play crucial role in immune system. Alteration of the levels of the immunoglobulin G (IgG) subclasses (IgG1, IgG2, IgG3 and IgG4) is an indication of a disturbed immunological response. The aim of the present study was the development of a capillary electrophoresis (CE) method for the analysis of IgG subclasses in respect to their variable kappa and lambda chains. Various analytical conditions and CE modes, including capillary zone electrophoresis (CZE), capillary isoelectric focusing (CIEF) and micellar electrokinetic capillary chromatography (MECC) have been thoroughly studied. CZE was found to be the most convenient way to separate IgG subclasses. Three of the human IgG subclasses were resolved using uncoated fused-silica and 50 mM phosphate, pH = 9.3, as operating buffer at 20 kV and detection at 214 nm. IgG1kappa was completely separated from IgG2kappa and IgG3kappa, whereas IgG2kappa co-migrated with IgG4kappa, which is the minor IgG subclass. Under the same conditions IgG4lambda was completely separated from IgG1lambda, IgG2lambda and IgG3lambda, enabling the identification of the various lambda chains. The developed CE method is rapid and can be applied to the identification of the major immunoglobulin G subclasses in respect to their variable kappa and lambda chains.

Retrospective study of febrile seizures: subsequent electroencephalogram findings, unprovoked seizures and epilepsy in adolescents.

A retrospective questionnaire to determine the prevalence of febrile seizures was given to adolescents (16- and 17-year-olds) in the final 2 years of secondary school at the five schools in Alexandroupolis, Greece. Parents were interviewed, and clinical and electroencephalographic examinations were performed in all adolescents with a history of febrile seizures. Of 1708 adolescents, 56 (3.3%) had experienced at least one febrile seizure. Of these, 44 (78.6%) were simple and 12 (21.4%) were complex febrile seizures. Recurrent seizures occurred in 22 cases (39.3%), and the mean age at onset was 25.1 months. There was a positive first-degree family history in eight cases (14.3%) and this increased to 27.3% in cases with recurrent seizures. Two of the adolescents (3.6%) had had one unprovoked seizure before the age of 3 years, and another two children developed epilepsy. Epileptiform electroencephalogram discharges were observed in only one case (1.8%) with generalized tonic-clonic epilepsy.