The blood pressure changes are accompanied by an increase in heart rate. Jermendy G, Davidovits Z, Khoor S: Silent coronary artery disease in diabetic patients with cardiac autonomic neuropathy. BP, blood pressure; CVD, cardiovascular disease; E:I difference = mean expiration to inspiration difference in R-R intervals over six consecutive breaths; R-R interval, time interval between successive ECG R-waves; sBP, systolic blood pressure. Sharpey-Schafer EP, Taylor PJ: Absent circulatory reflexes in diabetic neuritis. Abnormal HRV in one test is indicative of early autonomic neuropathy. Borst C, Weiling W, van Brederode JFM, Hond A, DeRijk LG, Dunning AJ: Mechanisms of initial heart rate response to postural change. (95). After identification, effective management must be provided. Figure 2B shows the relative risks and 95% CIs for each study, as well as the pooled risk estimate estimated by the Mantel-Haenszel procedure. Diabetic neuropathies, a family of nerve disorders caused by diabetes, affect about 60% to 70% of people with the disease. : Assessment of cardiovascular autonomic function: age-related normal ranges and reproducibility of spectral analysis, vector analysis, and standard tests of heart rate variation and blood pressure responses. Roy et al. The response to performance of the Valsalva maneuver has four phases and in healthy individuals can be observed as follows: Phase I: Transient rise in blood pressure and a fall in heart rate due to compression of the aorta and propulsion of blood into the peripheral circulation. As noted above, the relationship of CAN and mortality in diabetic individuals has been evaluated in a number of studies on an individual basis. American Diabetes Association and American Academy of Neurology: Proceedings of a consensus development conference on standardized measures in diabetic neuropathy. Greene DA, Lattimer SA, Sima AA: Are disturbances of sorbitol, phosphoinositide, and Na+-K+-ATPase regulation involved in pathogenesis of diabetic neuropathy? Delay in instituting appropriate interventions can only increase the likelihood of developing advanced neuropathies. Cohen JA, Jeffers BW, Faldut D, Marcoux M, Schrier RW: Risks for sensorimotor peripheral neuropathy and autonomic neuropathy in non-insulin-dependent diabetes mellitus (NIDDM). Two or more of the four tests were abnormal. These results suggested that a disturbed cardiovascular risk profile seen in individuals with nephropathy might lead to both cardiovascular disease and CAN. Autonomic neuropathies can either be hereditary or acquired in nature; acquired can further be divided into primary and secondary diseases. Tests of sudomotor function evaluate the extent, distribution, and location of deficits in sympathetic cholinergic function. However, virtually all of these studies also provide evidence for an association. Burgos LG, Ebert TJ, Asiddao C, Turner LA, et al. The differential diagnosis of DAN involves excluding the following conditions: Pure autonomic failure (formerly called idiopathic orthostatic hypotension), Multiple system atrophy with autonomic failure (formerly called Shy-Drager syndrome), Medications, with anticholinergic or sympatholytic effects (insulin, vasodilators, sympathetic blockers), Peripheral autonomic neuropathies (e.g., amyloid neuropathy, idiopathic autonomic neuropathy). Normal = all tests normal or one borderline; early = one of the three heart rate tests abnormal or two borderline; definite = two or more of the heart rate tests abnormal; severe = at least two of the heart rate tests abnormal and one or both of the BP tests abnormal or both borderline. Weinberg and Pfeifer (172) have also shown that reduced HRV may be predictive of the development of symptomatic somatic neuropathy, although these results require follow-up in a larger study cohort. Based on these data, they suggested that loss of hypoglycemia awareness is not invariably associated with abnormal cardiovascular autonomic function tests. In normal individuals, the systolic blood pressure falls by <10 mmHg in 30 s. In diabetic patients with autonomic neuropathy, baroreflex compensation is impaired. This study also revealed that symptoms of autonomic neuropathy, especially postural hypotension, and gastric symptoms in the presence of abnormal autonomic function tests carried a particularly poor prognosis. Some patients may experience burning pain or coldness and electric shock-like brief painful sensations. In this report, the clinical manifestations (e.g., exercise intolerance, intraoperative cardiovascular lability, orthostatic hypotension, and increased risk of mortality) of the presence of CAN will be discussed. Treatment For Diabetic Autonomic Neuropathy. This leads to incomplete bladder emptying, an increased postvoid residual, decreased peak urinary flow rate, bladder overdistention, and urine retention. The mean sudomotor (0.69; maximum 3), cardiovagal (0.84; maximum 3), and adrenergic (0.75; maximum 4) CASS scores and a total CASS score of 2.27 (maximum 10) indicate that the . There is an association between CAN and diabetic nephropathy that contributes to high mortality rates (31,44,82). It has been shown that type 1 diabetic individuals with early nephropathy and symptomatic autonomic neuropathy have inappropriately low levels of erythropoietin for the severity of their anemia (140). : Prevalence of QT prolongation in a type 1 diabetic population and its association with autonomic neuropathy. Cardiac autonomic neuropathy can be found in the elderly (age induces autonomic decline) but CAN is most common in patients with diabetes. Heart failure is, however, common in individuals with diabetes, identified by the presence of neuropathy, even in individuals without evidence of coronary artery disease or left ventricular dysfunction (106). Diabetic autonomic neuropathy (DAN) is a common and debilitating form of neuropathy. These tests use deep breathing, the Valsalva maneuver, and standing from a supine position, respectively, as provocative stimuli. The Diabetes Control and Complications Trial (DCCT), one of the largest trials to use cardiovascular autonomic function tests, evaluated 1,441 patients with type 1 diabetes in 29 centers over a mean duration of 6.5 years without procedural complications (37). Diabetic Autonomic Neuropathy Life Expectancy. Whereas symptoms suggestive of autonomic dysfunction may be common they may frequently be due to other causes rather than to true autonomic neuropathy. (84). Two of the meetings (the San Antonio Conference on Diabetic Neuropathy held in 1988 and a second conference in 1992) were jointly sponsored by the American Diabetes Association and AAN. . numbness in the feet, legs, or lower stomach. The heart rate tracing is used to calculate the ratio of the longest R-R interval (about beat 30) after the stand to the shortest R-R interval (about beat 15). Female sexual dysfunction assessment using vaginal plethysmography to measure lubrication and vaginal flushing has not been well established or standardized. In healthy subjects, the reflex response to the Valsalva maneuver includes tachycardia and peripheral vasoconstriction during strain, followed by an overshoot in blood pressure and bradycardia after release of strain. In patients with diabetes, orthostatic hypotension is usually due to damage to the efferent sympathetic vasomotor fibers, particularly in the splanchnic vasculature (52). Because afferent denervation may contribute to the problem, a bowel program that includes restriction of soluble fiber and regular effort to move the bowels is indicated. A subtype of the peripheral polyneuropathies that accompany diabetes, DAN can involve the entire autonomic nervous system (ANS). 1. This [] A table elsewhere in this issue shows conventional and Systeme International (SI) units and conversion factors for many substances. (109) showed that a simple bedside test that measured 1-min HRV during deep breathing was a good predictor of all-cause mortality for 185 patients (17.8% with diabetes) after a first MI. This is seen as a blunted heart rate response and sometimes as a lower-than-normal decline in blood pressure during strain, followed by a slow recovery after release. Vinik AI, Milicevic Z: Recent advances in the diagnosis and treatment of diabetic neuropathy. Airaksinen KEJ, Koistinen MJ: Association between silent coronary artery disease, diabetes, and autonomic neuropathy. Autonomic neuropathy may also lead to increased osteoclastic activity resulting in reduced bone density. Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB: Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. Cardiovascular autonomic function testing may help differentiate CAN from other causes of weakness, lightheadedness, dizziness, or fatigue and promote appropriate therapeutic intervention (62). Again, the results from the DCCT show that intensive glycemic treatment can prevent the development of abnormal heart rate variation and slow the deterioration of autonomic dysfunction over time for individuals with type 1 diabetes (37). Although most cases are idiopathic, diabetes is the most common identifiable cause of SFN. Diabetes. DAN may affect many organ systems throughout the body (e.g., gastrointestinal [GI], genitourinary, and cardiovascular). The test, typically done by recording from the forearm and three lower-extremity skin sites, has high sensitivity, specificity, and reproducibility, with a coefficient of variation of 20% if performed by trained personnel. The results of autonomic function testing can contribute to good patient management in the following ways. Gerritsen J, Dekker JM, ten Voorde BJ, Kostense PJ, Heine RJ, Bouter LM, Heethaar RM, Stehouwer CD: Impaired autonomic function is associated with increased mortality, especially in subjects with diabetes, hypertension, or a history of cardiovascular disease: the Hoorn Study. Assessment of diarrhea in patients with diabetes might include the following: History to rule out diarrhea secondary to ingestion of lactose, nonabsorbable hexitols, or medication (especially biguanides, -glucosidase inhibitors, and tetrahydrolipostatin), History to rule out other causes, especially iatrogenic ones, Travel and sexual histories and questioning regarding similar illnesses among both household members and coworkers, History of pancreatitis and biliary stone diseases, Examination for enteric pathogens and ova and parasites. It affects women and men equally. Schumer MP, Joyner SA, Pfeifer MA: Cardiovascular autonomic neuropathy testing in patients with diabetes. Gastroparesis and general signs of bowel dysfunction, such as constipation, diarrhoea and abdominal pain are most often encountered and involve both pharmacological and non . Cold pressor. Chen HS, Hwu CM, Kuo BI, Chiang SC, Kwok CF, Lee SH, Lee YS, Weih MJ, Hsiao LC, Lin SH, Ho LT: Abnormal cardiovascular reflex tests are predictors of mortality in type 2 diabetes mellitus. The autonomic nervous system (ANS) is a subcomponent of the peripheral nervous system (PNS) that regulates involuntary physiologic processes, including blood pressure, heart rate, respiration, digestion, and sexual arousal. In this test, sustained muscle contraction as measured by a handgrip dynamometer causes a rise in systolic and diastolic blood pressure and heart rate. Morley JE, Asvat MS, Klein C, Lowenthal MN: Autonomic neuropathy in black diabetic patients. Outcome was silent myocardial infarction, Asymptomatic middle-aged men, no symptoms or signs of heart disease, At least two of the first three tests = mild CAN, At least two abnormal parasympathetic function tests, Men >40 years old. Whereas a radiographic gastric emptying study can definitively establish the diagnosis of gastroparesis, a reasonable approach is to exclude autonomic dysfunction and other known causes of these upper-GI symptoms. Diabetes Care 1 May 2003; 26 (5): 15531579. Primary prevention of diabetes is the absolute goal. In a large cohort study of men 5390 years old, a significant association between diabetes (and duration of diabetes) and ED was found when comparing diabetic men with nondiabetic men of similar age (137). In patients with diabetes and autonomic neuropathy, there is only a gradual increase in heart rate. Despite its high prevalence in individuals with diabetes mellitus (DM) neuropathies are the most underdiagnosed and undertreated diabetic chronic complication ().The involvements of somatic and autonomic nerve fibers in DM present complex pathophysiologies (1-4).The impairment of sympathetic and parasympathetic divisions of the autonomic nervous system (ANS) leads to . Evidence from clinical literature can be found that support recommendations for various subpopulations. Several different factors have been implicated in the potential metabolic-vascular pathogenic process of diabetic neuropathy (e.g., activation of the polyol pathway, increased oxidative stress, reduction in neurotrophic growth factors, deficiency of essential fatty acids, and formation of advanced glycosylation end products) (10,21,183,184). Hoeldtke RD, Boden G: Epinephrine secretion, hypoglycemia unawareness, and diabetic autonomic neuropathy. It should also be noted that decreased ejection fraction, systolic dysfunction, and diastolic filling limit exercise tolerance (1). One potential cause of sudden death may be explained by severe but asymptomatic ischemia, eventually inducing lethal arrhythmias (85). The heart rate power spectrum is typically divided into two frequency bands: low (0.040.15 Hz) and high (0.150.4 Hz). Episodes of nausea or vomiting may last days to months or occur in cycles (125). A large body of evidence indicates that these factors can, to various degrees, affect the cardiovascular ANS and potentially other autonomic organ systems (157). Keywords: Diabetes mellitus, Microvascular complications, Renal dynamic scintigraphy, Diabetic kidney disease, Cardiac autonomic neuropathy, Diabetic retinopathy . Two separate population-based studies have also examined the association of CAN and mortality. (77), using 24-h ambulatory electrocardiographic recordings, demonstrated that HRV is reduced in diabetic patients with silent ischemia when compared with nondiabetic individuals with silent or painful ischemia. Glucose is the main source of energy for the body's cells and is obtained from the food we consume. OBrien et al., however, compared the relative importance of various factors associated with mortality by discriminate analysis of survivors and nonsurvivors using Raos stepwise selection method and revealed that autonomic neuropathy was more of an independent predictive factor than systolic blood pressure, foot disease, BMI, sensory neuropathy, proteinuria, and macrovascular disease (36) (Table 4). The three tests recommended were heart rate response to 1) deep breathing, 2) standing, and 3) the Valsalva maneuver. : Heart rate variability and cardiovascular tests in young patients with diabetes mellitus type 1. Excess mortality was restricted to those with symptomatic CAN (18/49 vs. 4/38). An estimated 2030 million men in the U.S. have ED (136). Ryder et al. Diabetic cystopathy manifests as an increase in threshold of occurrence of a detrusor reflex contraction. Those with a score of 01 = without CAN, score of 23 = early CAN, and score of 46 = definitive CAN. The portion of the ANS concerned with conservation and restoration of energy. In practical terms, however, the risk is minimal because comparable pressures occur in the performance of daily activities. Kong MF, Horowitz M, Jones KL, Wishart JM, Harding PE: Natural history of diabetic gastroparesis. Although individuals with diabetes are faced with the immediate pressures of disease management on a day-to-day basis, it is the long-term risks of micro- and macrovascular complications that pose the most serious risks (191). Diabetic autonomic neuropathy is a serious complication of diabetes. Bacon CG, Hu FB, Giovannucci E, Glasser DB, Mittleman MA, Rimm EB: Association of type and duration of diabetes with erectile dysfunction in a large cohort of men. These tests were judged suitable for both routine screening and monitoring the progress of autonomic neuropathy (3). Winocour PH, Dhar H, Anderson DC: The relationship between autonomic neuropathy and urinary sodium and albumin excretion in insulin-treated diabetics. Unfortunately, however, one cannot predict what the metabolic control will be (or has been) over a long period of time by looking at current HbA1c results. Ewing DJ, Irving JB, Kerr F, et al. Jaffe et al. The mechanism that underlies the erythropoietin-deficient anemia is unclear. With increasing life-expectancy of patients with diabetes mellitus, awareness of DAN and its implications to older adults is needed in primary care. Diminished cardiac acceleration and cardiac output, particularly in association with exercise, may also be important in the presentation of this disorder (53,54). Stevens MJ, Raffel DM, Allman KC, Dayanikli F, Ficaro E, Sandford T, Wieland DM, Pfeifer MA, Schwaiger M: Cardiac sympathetic dysinnervation in diabetes: implications for enhanced cardiovascular risk. Small fiber neuropathy (SFN) is a subset of peripheral neuropathy caused by selective injury to A and C fibers resulting in neuropathic pain and autonomic dysfunction. A: +CAN, CAN present; CAN, no CAN found; +SMI, SMI present. (Abstract). It is true, however, that at least some of the association between CAN and mortality appears to be due to an increased prevalence of other complications in individuals with CAN. The EURODIAB IDDM Complications Study. These data suggest that preoperative cardiovascular autonomic screening may provide useful information for anesthesiologists planning the anesthetic management of diabetic patients and identify those at greater risk for intraoperative complications. Basic diagnostic tests include upper-GI endoscopy or barium series to rule out structural or mucosal abnormalities of the GI tract. In another study, Katz et al. In addition, trials of gluten-free diet, restriction of lactose, cholestyramine, clonidine, somatostatin analog, pancreatic enzyme supplements, and antibiotics such as metronidazole may be indicated. Nonetheless, CAN cosegregates with indexes of macrovascular risk, which may contribute to the marked increase in cardiovascular mortality. Interventions to modulate reduced heart rate variation currently being studied in clinical trials are based on theories of the pathogenesis of CAN. I have gastroparesis, paralysis of the stomach. Diabetic autonomic neuropathy accounts for silent myocardial infarction and shortens the lifespan resulting in death in 25%-50% patients within 5-10 years of autonomic diabetic neuropathy. Mackay JD, Page MM, Cambridge J, Watkins PJ: Diabetic autonomic neuropathy: the diagnostic value of heart rate monitoring. Reduced sympathetic stimulation of erythropoietin production has been previously hypothesized as the cause of ineffective erythropoiesis resulting in anemia (141). Heating and gravity. Its importance has been clarified in recent years during which the extent of autonomic control over all areas of body function has been defined. There is a fall in cardiac output due to impaired venous return causing compensatory cardiac acceleration, increased muscle sympathetic activity, and peripheral resistance. Clinical signs and symptoms of autonomic dysfunction do not always progress. Several mechanisms have been suggested including a relationship with autonomic control of respiratory function. The normal autonomic response of vasoconstriction and tachycardia did not completely compensate for the vasodilating effects of anesthesia. A total of 16 individuals did not experience angina, and 10 of these had diabetes. Proceedings from a consensus conference in 1992 recommended that three tests (R-R variation, Valsalva maneuver, and postural blood pressure testing) be used for longitudinal testing of the cardiovascular autonomic system. R-R variation between supine and standing position, All subjects with overt diabetic nephropathy. Stansberry KB, Hill MA, Shapiro SA, McNitt PM, Bhatt BA, Vinik AI: Impairment of peripheral blood flow responses in diabetes resembles an enhanced aging effect. Patients with DAN show delayed or absent reflex response to light and diminished hippus due to decreased sympathetic activity and reduced resting pupillary diameter (7). Miettinen H, Lehto S, Salomaa V, Mahonen M, Niemela M, Haffner SM, Pyorala K, Tuomilehto J: Impact of diabetes on mortality after the first myocardial infarction: The FINMONICA Myocardial Infarction Register Study Group. For example, taking medicines and eating small, frequent meals that are low in fiber and fat may help digestive problems like gastroparesis. In fact, Howorka et al. There is no response in the presence of either a proximal or distal ANS lesion. The battery of three recommended tests for assessing CAN is readily performed in the average clinic, hospital, or diagnostic center with the use of available technology. DAN frequently coexists with other peripheral neuropathies and other diabetic complications, but DAN may be isolated, frequently preceding the detection of other complications. The ubiquitous distribution of the ANS renders virtually all organs susceptible to autonomic dysfunction. Peripheral contralateral (index finger, pulp surface) response to sustained 40% maximum grip on a dynamometer is biphasic over 60 s. The initial normal response is 4050% reduction of flow from basal during the initial 2030 s, followed by a dilation resulting in a return to typically super-basal levels; there is no response if the peripheral ANS is damaged. Sandroni P, Benarroch EE, Low PA: Pharmacological dissection of components of the Valsalva maneuver in adrenergic failure. This site uses cookies. Poor glycemic control may also be a consequence of DAN (e.g., gastroparesis that goes unidentified). Positive Schillings test may be diagnostic of bacterial overgrowth. Langer A, Freeman MR, Josse RG, Armstrong PW: Metaiodobenzylguanidine imaging in diabetes mellitus: assessment of cardiac sympathetic denervation and its relation to autonomic dysfunction and silent myocardial ischemia. Thus, timely identification of autonomic dysfunction in diabetic patients may expedite end-organ prophylaxis such as the use of ACE inhibitors and aspirin and the use of pharmacological and nonpharmacological interventions to improve blood pressure and lipid control. . One of the most overlooked of all serious complications of diabetes is cardiovascular autonomic neuropathy (CAN), 1-3 which encompasses damage to the autonomic nerve fibers that innervate the heart and blood vessels, resulting in abnormalities in heart rate control and vascular dynamics. Individuals that do develop diabetes, however, are likely to suffer from its complications. Low PA, Walsh JC, Huang CY, McLeod JG: The sympathetic nervous system in diabetic neuropathy: a clinical and pathological study. DAN affects sensory, motor, and vasomotor fibers innervating a large number of organs. Sivieri R, Veglio M, Chinaglia A, et al. Diabetic peripheral neuropathy (DPN) occurs as a consequence of damage to the sensory, autonomic and motor nerves and can present with diverse symptoms and deficits ().The commonest presentations are those of somatic and autonomic neuropathy, and early diagnosis of these subtypes is recommended. Other symptoms of small fiber neuropathy include: a tingling or prickling sensation. Phase II: Early fall in blood pressure with a subsequent recovery of blood pressure later in the phase. In addition, there is a decrease in cutaneous, splanchnic, and total vascular resistance that occurs in the pathogenesis of this disorder. For example, in the DCCT, the presence of autonomic neuropathy correlated with male sex along with age and duration (178). A disturbed circadian pattern of sympathovagal activity with prevalent nocturnal sympathetic activity combined with higher blood pressure values during the night and increased left ventricular hypertrophy could represent another important link between CAN and an increased risk of mortality. (76) examined 22 diabetic and 30 nondiabetic individuals who had similar left ventricular function and severity of coronary artery disease as assessed by coronary angiography and ventriculography. Reduction in neurotrophic growth factors (19), deficiency of essential fatty acids (20), and formation of advanced glycosylation end products (localized in endoneurial blood vessels) (21) also result in reduced endoneurial blood flow and nerve hypoxia with altered nerve function (8,11,12). Long-term follow-up studies are needed to distinguish the exact roles of cardiovascular risk factors, nephropathy, and CAN in the etiology of cardiovascular disease. Pittenger GL, Malik RA, Burcus N, Boulton AJ, Vinik AI: Specific fiber deficits in sensorimotor diabetic polyneuropathy correspond to cytotoxicity against neuroblastoma cells of sera from patients with diabetes. Orienting response is the vasoconstriction and resulting drop in peripheral (index finger, pulp surface) skin blood flow when a subject engages in speech after several minutes of relaxation with music. Many major organs, including the heart, blood vessels, nerves, eyes, and kidneys can be affected. Marchant B, Umachandran V, Stevenson R, Kopelman PG, Timmis AD: Silent myocardial ischemia: role of subclinical neuropathy in patients with and without diabetes. A neuropathic disorder associated with diabetes that includes manifestations in the peripheral components of the ANS. Clarke BF, Ewing DJ, Campbell IW: Diabetic autonomic neuropathy. The magnitude of heart rate fluctuations (R-R interval) around the mean heart rate that are modulated by the ANS. Three tests of cardiovascular autonomic nerve function that fulfill these criteria are 1) the E:I ratio (obtained from R-R variations), 2) the Valsalva ratio, and 3) the standing 30:15 ratio. Analysis of each of these studies as a single entity, however, only includes a limited number of subjects. QTc prolongation was associated with increased mortality risk. Abnormalities of parasympathetic and sympathetic autonomic function were found to be independent predictors of stroke in this cohort (110). A three-stage model was proposed as follows: Early stage: abnormality of heart rate response during deep breathing alone, Intermediate stage: an abnormality of Valsalva response, Severe stage: the presence of postural hypotension. Autonomic neuropathy is not a single condition. Veves A, King GL: Can VEGF reverse diabetic neuropathy in human subjects? Less frequently, there is a rise in norepinephrine that may be due to low blood volume or reduced red cell mass (55,56). Liquid emptying gives false-negative results. Poor glycemic control plays a central role in development and progression (44,115117). This test can be used to determine sweat gland density, sweat droplet size, and sweat volume per area. In. The heart rate slows at or around the 30th beat. ED is a marker for the development of generalized vascular disease and for premature demise from a myocardial infarct, and penile failure may be a portent of upcoming, and possible preventable, cardiovascular events (138). Use blocks or risers under the head of your bed to keep your head raised and help with low blood pressure. Veglio M, Borra M, Stevens LK, Fuller JH, et al. Given the potential for impaired exercise tolerance, it has been suggested that diabetic patients who are likely to have CAN have cardiac stress testing before undertaking an exercise program (45). An abnormal result for each test is defined as HRV below that of the 5th percentile of the normal age-matched population. Several different techniques have been described in clinical literature, but measurement during paced deep breathing is considered the most reliable. Table 2 and Fig. Many organs are dually innervated, receiving fibers from the parasympathetic and sympathetic divisions of the ANS. Vinik AI: Diabetic neuropathy: pathogenesis and therapy. The pooled estimate of the relative risk, based on 2,900 total subjects, was 2.14, with a 95% CI of 1.832.51 (P < 0.0001). Quantitative tests of autonomic function have historically lagged behind measures of motor nerve function and sensory nerve function deficits. HRV is considered the earliest indicator and most frequent finding in symptomatic cardiovascular autonomic dysfunction. Young MJ, Marshall A, Adams JE, Selby PL, Boulton AJM: Osteopenia, neurological dysfunction, and the development of charcot neuroarthropathy. The TST assesses both central and peripheral aspects of the efferent sympathetic nervous system, from the hypothalamus to the sweat glands. Such a recommendation does not diminish the importance of clinical evaluation and patient observation; rather, it enhances the clinical assessment of the diabetic patient by providing an objective, quantifiable, and reproducible measure of autonomic function.
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