A sensitive orthostatic test on tilt table, useful in the detection of diabetic autonomic neuropathy.
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Atropine↗
Biomedical subjects
G Sundkvist
Publications and source records attributed to G Sundkvist.
Abnormal diastolic blood pressure and heart rate reactions to tilting in diabetes mellitus.
The orthostatic reaction to tilting was studied in 46 diabetics without symptoms of autonomic neuropathy and in 31 age-matched healthy control subjects. After tilting, the diastolic blood pressure rose in the control subject but was unchanged or tended to fall in the diabetics, except in those of short duration without retinopathy. After tilting, the control subjects showed an immediate increase in heart rate with the highest value at 8.4 +/- 1.0 s (mean +/- SEM), followed by a transient decrease with lowest value at 21.2 +/- 0.9 s. The acceleration and brake index measured the changes in heart rate. The brake index was lower in diabetics of short duration with retinopathy (6.9 +/- 1.6) than in those without (14.4 +/- 2.3, P < 0.01) as well as matched control subjects (18.7 +/- 2.5, P 0.01). In the diabetics of long duration no differences were shown between those with or without retinopathy but the accleration (10.3 +/- 1.6 vs 19.9 /!- 2.3, P < 0.05) and the brake index (5.3 +/- 1.4 vs 19.9 +/- 2.3, P < 0.01) were lower in those with vagal neuropathy.
Adult↗
Respiratory influence on heart rate in diabetes mellitus.
To find a simple and accurate test of autonomic nervous dysfunction in diabetes mellitus, 41 insulin-dependent diabetics and 25 controls were investigated. The diabetics, none of whom had symptoms of autonomic dysfunction, were tested for retinopathy and sensory neuropathy. Each subject also performed maximal deep-breathing procedures while undergoing electrocardiographic recording: in normal subjects the intervals are shortened during inspiration and prolonged during expiration, and a difference in the heart rate between inspiration and expiration of 10% or less seems to indicate autonomic dysfunction. This difference was calculated as an E:I ratio of the mean of the longest R-R interval during maximal expiration to the mean of the shortest during maximal inspiration. Ten of the 18 patients found to have sensory neuropathy had abnormal E:I ratios, and among those with absent ankle reflexes the proportion was even higher (9 out of 11). The E:I ratio also seemed to be as accurate as traditional tests for autonomic dysfunction and easier to perform. Diabetics with autonomic dysfunction have an increased risk of acute cardiorespiratory death during and after surgery, and maximal deep breathing and calculation of the E:I ratio may be a useful test to perform on diabetics at risk.
Adult↗
Acute intoxication. A comparative investigation at a General City Hospital for the years 1951, 1961 and 1971.
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Adolescent↗
Glutamic acid decarboxylase antibodies (GADA) is the most important factor for prediction of insulin therapy within 3 years in young adult diabetic patients not classified as Type 1 diabetes on clinical grounds.
BACKGROUND: Differentiation between Type 1 and Type 2 diabetes in adults is difficult at diagnosis. In this study we tested the hypothesis that autoantibodies at diagnosis are predictive for insulin treatment within 3 years in patients initially not classified as Type 1 diabetes. METHODS: In a nationwide population-based study, blood samples were obtained from 764 patients, all diagnosed with diabetes during a 2-year period. At diagnosis, 583 (76%) were classified as Type 1, 110 (14%) as Type 2 and 71 (9.3%) could not be classified. RESULTS: Among patients not classified as Type 1 diabetes, 52 (47%) of Type 2 and 42 (59%) of unclassified patients were positive for islet cell antibodies (ICA), glutamic acid decarboxylase antibodies (GADA) or tyrosine phosphatase antibodies (IA-2A). These patients (n=94) had lower body mass index (BMI) (p<0.001) and lower C-peptide (p<0.001) compared to the autoantibody negative patients (n=87). Compared to clinically classified Type 1 diabetes patients positive for autoantibodies (n=477), they have higher BMI (p<0.001), higher C-peptide (p<0.001) and the same levels of ICA, GADA and IA-2A. After 3 years, 93% of autoantibody positive patients initially not classified as Type 1 were on insulin. When ICA, GADA, IA-2A, BMI and C-peptide were tested in a multiple logistic regression, only GADA was significant for insulin treatment within 3 years (OR=18.8; 95% CI 1.8-191) in patients treated with diet or oral drugs at diagnosis. CONCLUSIONS: A correct classification is difficult in adult diabetic patients. The presence of pancreatic autoantibodies, especially GADA, at diagnosis of diabetes are highly predictive for insulin therapy within 3 years from diagnosis.
Adolescent↗
Peripheral and autonomic nerve function in 259 diabetic patients with peripheral neuropathy treated with ponalrestat (an aldose reductase inhibitor) or placebo for 18 months. United Kingdom/Scandinavian Ponalrestat Trial.
The potential of the aldose reductase inhibitor ponalrestat (600 mg daily) to ameliorate diabetic neuropathy was evaluated in 259 diabetes mellitus patients with peripheral neuropathy (defined by abnormal vibration perception threshold and abnormal peroneal motor conduction velocity) in a double-blind placebo-controlled clinical trial running for 18 months. Overall, no beneficial effect of ponalrestat on vibration perception thresholds, nerve conduction velocities, and nerve action potential amplitudes was detected. Because vibration perception thresholds and conduction velocities in median, peroneal, and sural nerves did not deteriorate in the placebo group, the potential of ponalrestat to prevent the expected deterioration in peripheral nerve function that occurs with an increased duration of diabetes was not tested. Patients with an abnormal heart rate reaction to standing (abnormal 30:15 ratio; n = 84) on ponalrestat did not deteriorate in this autonomic nerve function test as shown in those on placebo. In conclusion, ponalrestat did not improve peripheral nerve function in diabetes mellitus patients with signs of peripheral neuropathy, although it did ameliorate a deterioration in autonomic nerve function in diabetic patients with signs of autonomic neuropathy.
Aldehyde Reductase↗
False-positive treponemal serology in patients with diabetes mellitus.
In sera from 476 diabetic outpatients, positive reaction in the Fluorescent Treponemal Antibody-Absorption (FTA-Abs) test, a commonly used serological test for syphilis, was found in 36 of the patients. None of 100 healthy control subjects were positive in the FTA-Abs test. Additional treponemal and nontreponemal tests confirmed the diagnosis of syphilis in only three of the diabetic patients. In 10 of the 36 patients, the positive FTA-Abs reactivity appeared to be due to cross-reactivity between the treponemal antigen and Borrelia burgdorferi, which causes Lyme borreliosis. In the remaining 23 patients (5%), no other explanation for a false-positive FTA-Abs reactivity was found besides diabetes. Diabetic patients with false-positive FTA-Abs reactivity had similar degree of long-term metabolic control and prevalence of islet cell antibodies (ICA) as well as late diabetic complications as FTA-Abs negative diabetic patients, matched regarding to sex, age, type, and duration of diabetes. In conclusion, false-positive FTA-Abs reactivity is not rare in diabetic patients. The reason for this phenomenon is unknown, but could be a sign of autoimmunity of its own. Hence, in diabetic patients with FTA-Abs test indicating syphilis, the diagnosis must be verified with a combination of other tests.
Adolescent↗
Cutaneous vasomotor responses in young type I diabetic patients.
Abnormal skin temperature reactions have been reported in type I diabetic patients. Whether this is due to a primary vascular disturbance or autonomic neuropathy is unclear. The aim of this study was to clarify this issue by evaluating cutaneous circulatory reactions before and after provocation. Seventeen type I diabetic patients and 17 age-matched controls were studied by recording blood flow (laser Doppler technique) on the dorsum of the hand (before, during, and after arterial occlusion), blood flow and skin temperatures on the dorsum of the foot and on the toe (before and after cooling followed by indirect body heating) and autonomic nerve function (heart rate reaction to deep breathing and to tilting). The results showed that before [4.6 +/- 0.5 perfusion units (PU) versus 6.1 +/- 0.7 PU; p = 0.0356] and after arterial occlusion (17.5 +/- 1.6 PU versus 25.3 +/- 1.7 PU; p = 0.0024), hand skin blood flow was significantly lower in patients than in controls. On the dorsum of the foot, skin temperatures was significantly lower in patients than in controls before cooling (29.2 degrees C +/- 0.3 degrees C versus 30.5 degrees C +/- 0.4 degrees C; p = 0.0107) whereas toe temperature and toe blood flow were similar before and after cooling in patients and controls. After body heating, however, toe temperature (after 30 min: 25.2 degrees C +/- 1.4 degrees C versus 30.9 degrees C +/- 1.2 degrees C; p = 0.0022) and toe blood flow (after 30 min: 10.9 +/- 2.5 degrees C versus 22.9 +/- 4.9 PU; p = 0.0313) were significantly lower in patients than in controls, especially in patients with parasympathetic neuropathy (i.e., patients with abnormal heart rate reactions to deep breathing). In conclusion, type I diabetic patients demonstrated a vascular disturbance in their skin that seemed to be exaggerated by parasympathetic neuropathy.
Adult↗
Relationships among glomerular filtration rate, albuminuria, and autonomic nerve function in insulin-dependent and non-insulin-dependent diabetes mellitus.
The associations among autonomic neuropathy, urinary albumin excretion, and glomerular filtration rate (GFR) measured with 51Cr-EDTA and iohexol clearance were studied in 41 patients with insulin-dependent diabetes mellitus (IDDM) and 15 patients with non-insulin-dependent diabetes mellitus (NIDDM). The study showed that increased urinary albumin excretion was more common in NIDDM than in IDDM. In contrast with IDDM, albuminuria in NIDDM was not related to GFR. Autonomic neuropathy was common in IDDM as well as in NIDDM, and also in patients without nephropathy, but was not connected with hyperfiltration. Low brake index, an ortostatic autonomic index, was associated with nephropathy in NIDDM. Iohexol, a non-ionic contrast medium, was found to be a useful alternative to 51Cr-EDTA for determination of GFR. Moreover, comparison between conventional four-sample plasma clearance and single-sample clearance showed a close correlation. Accordingly, assessment of GFR using a single plasma sample provides reliable results even at high GFR values.
Adult↗
Autonomic nervous function in asymptomatic diabetic patients with signs of peripheral neuropathy.
Fifty-two long-term diabetic patients without symptoms of autonomic neuropathy and 31 age-matched healthy controls were tested for autonomic neuropathy by deep breathing, Valsalva maneuver, and an orthostatic test on tilt table. The deep breathing and the orthostatic tests showed significant parasympathetic impairments in patients with signs of peripheral neuropathy. The Valsalva maneuver, which also mainly reflects parasympathetic function, was disturbed in patients with peripheral neuropathy, but only in those with a very long duration of diabetes. Parasympathetic neuropathy was closely correlated with peripheral neuropathy. However, five patients showed signs of parasympathetic neuropathy but not of peripheral neuropathy. Thus, parasympathetic neuropathy can appear before peripheral neuropathy. On the contrary, sympathetic denervation, as shown from the blood pressure reaction to tilting, only appeared in patients with peripheral neuropathy.
Adult↗
Autonomic neuropathy in diabetes mellitus: a follow-up study.
To evaluate the development of autonomic neuropathy, 23 patients with a moderate (group A) and 18 patients with a long (group B) duration of diabetes and without symptoms of autonomic neuropathy were re-investigated 6 yr after the initial studies. Autonomic nerve function was evaluated from heart reactions to deep breathing (E/I ratio) and to a rapid 90 degrees tilt (acceleration and brake indices). Symptoms of autonomic neuropathy (SAN) developed in 18 patients (nine in each group) who showed a low mean E/I ratio and brake index in both studies. In group A, but not in group B, patients with SAN showed a decrease in the acceleration index and most SAN patients (8/9) in group A had an abnormal acceleration index in the follow-up study. We conclude that in both groups SAN developed rapidly and was preceded by decreases in E/I ratio and brake index.
Acceleration↗
Negative association between type 1 diabetes and HLA DQB1*0602-DQA1*0102 is attenuated with age at onset. Swedish Childhood Diabetes Study Group.
HLA-associated relative risks of type 1 (insulin-dependent) diabetes mellitus were analysed in population-based Swedish patients and controls aged 0-34 years. The age dependence of HLA-associated relative risks was assessed by likelihood ratio tests of regression parameters in separate logistic regression models for each HLA category. The analyses demonstrated an attenuation with increasing age at onset in the relative risk for the positively associated DQB1*0201-A1*0502/B1*0302-A1*0301 (DQ2/8) genotype (P = 0.02) and the negatively associated DQB1*0602-A1*0102 (DQ6.2) haplotype (P = 0.004). At birth, DQ6.2-positive individuals had an estimated relative risk of 0.03, but this increased to 1.1 at age 35 years. Relative risks for individuals with DQ genotype 8/8 or 8/X or DQ genotype 2/2 or 2/X, where X is any DQ haplotype other than 2, 8 or 6.2, were not significantly age-dependent. An exploratory analysis of DQ haplotypes other than 2, 8 and 6.2 suggested that the risk of type 1 diabetes increases with age for DQB1*0604-A1*0102 (DQ6.4) and that the peak risk for the negatively associated DQB1*0301-A1*0501 haplotype is at age 18 years. There was also weak evidence that the risk for DQB1*0303-A1*0301 (DQ9), which has a positive association in the Japanese population, may decrease with age. We speculate that HLA-DQ alleles have a significant effect on the rate of beta cell destruction, which is accelerated in DQ2/8-positive individuals and inhibited, but not completely blocked, in DQ6.2-positive individuals.
Adolescent↗
Esophageal motor function evaluated by scintigraphy, video-radiography and manometry in diabetic patients.
Prolonged esophageal scintigraphic transit time is frequent in diabetic patients and is related to autonomic neuropathy. In this study, esophageal scintigraphic transit time was correlated to esophageal motor function as evaluated by video-radiography and manometry in 13 diabetic patients. An abnormal scintigraphic transit time (greater than 15 s) occurred in 6 patients. All patients with abnormal transit time showed abnormal results at video-radiography (n = 4) and/or manometry (n = 5), which were observed in only 2 of 7 patients with normal transit time (both with abnormal video-radiography and manometry). A prolonged scintigraphic transit appears reliable as an indicator of disturbed esophageal smooth muscle function since it is well correlated with abnormalities shown by a combination of video-radiography and manometry.
Adult↗