The lack of interest in the development of such measures was partly due to the erroneous but commonly held view that autonomic neuropathy was only a small and relatively obscure contributor to the peripheral neuropathies affecting individuals with diabetes (116,118,120). Autonomic Symptoms and Diabetic Neuropathy: - Diabetes Care Patients with large-volume diarrhea or fecal fat should be further studied with a 72-h fecal fat collection: the d-xylose test is an appropriate screen for small bowel malabsorptive disorders. An examination of the neuroanatomy of the genitourinary system provides an insight into the extent to which autonomic fibers are involved with its proper control. Studies of CAN and silent myocardial ischemia. The heart rate slows at or around the 30th beat. Two groups concluded that unawareness of hypoglycemia and inadequate counterregulation occur independently of autonomic neuropathy. The point estimates for the prevalence rate ratios in these 12 studies ranged from 0.85 to 15.53 (Fig. The response habituates with repeated stimuli and is subject to variability. Diabetic autonomic neuropathy - UpToDate Mackay JD, Page MM, Cambridge J, Watkins PJ: Diabetic autonomic neuropathy: the diagnostic value of heart rate monitoring. The patient lies quietly and breathes deeply at a rate of six breaths per minute (a rate that produces maximum variation in heart rate) while a heart monitor records the difference between the maximum and minimum heart rates. Kitamura et al. Afferent nerve impulses of bladder sensation and reflex bladder contraction are carried by sympathetic, parasympathetic, and somatic nerves to the spinal cord (128). Ewing et al. 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. (143) reported that 7 of 17 patients with absent awareness of hypoglycemia had no evidence of autonomic dysfunction. Sacral outflow (S2, S3, and S4) assessment, which represents the sacral parasympathetic divisions: anal sphincter tone, perianal sensation, anal wink, and bulbocavernous reflex are clinical features of denervation of the important nerve supply that enable erections to occur. What is the life expectancy with neuropathy? . Evaluation of the patient with suspected diabetic gastroparesis might include the following: Medication history, including the use of anticholinergic agents, ganglion blockers, and psychotropic drugs, Gastroduodenoscopy to exclude pyloric or other mechanical obstruction, Manometry to detect antral hypomotility and/or pylorospasm. Via meta-analysis, the Mantel-Haenszel estimate for the pooled prevalence rate risk for silent myocardial ischemia was 1.96, with a 95% CI of 1.532.51 (P < 0.001; n = 1,468 total subjects). Robertson D, Krantz SB, Biaggioni I, Robertson D: The anemia of microgravity and recumbency: role of sympathetic neural control of erythropoietin production. Furthermore, individuals with abnormal autonomic function have a greater risk for severe hypoglycemia (151). In the published literature of over 100 studies, there have been no reports of deaths during testing and no reports of adverse events after completion of the tests attributable to the procedures. In diabetes, the rhythmic contraction of arterioles and small arteries is disordered. Spallone V, Maiello MR, Cicconetti E, Menzinger G: Autonomic neuropathy and cardiovascular risk factors in insulin-dependent and non insulin-dependent diabetes. Immersion of the contralateral hand in cold (ice) water typically results in a 5060% reduction in peripheral skin blood flow at the contralateral pulp index surface. The EURODIAB IDDM Complications Study. Peripheral neuropathy caused by either type 1 diabetes or type 2 diabetes is called diabetic polyneuropathy. It should be noted, however, that although GI symptoms are common, symptoms may be more likely due to other factors than to autonomic dysfunction. Introduction. Vinik AI, Richardson D: Erectile dysfunction in diabetes. Trouble eating or swallowing. Hemodynamic changes are mostly secondary to mechanical factors. Those with a score of 01 = without CAN, score of 23 = early CAN, and score of 46 = definitive CAN. Veglio M, Sivieri R, Chinaglia A, Scaglione L, Cavallo-Perin P: QT interval prolongation and mortality in type 1 diabetic patients: a 5-year cohort prospective study: Neuropathy Study Group of the Italian Society of the Study of Diabetes, Piemonte Affiliate. Cardiovascular autonomic function testing may help differentiate CAN from other causes of weakness, lightheadedness, dizziness, or fatigue and promote appropriate therapeutic intervention (62). In this test, sustained muscle contraction as measured by a handgrip dynamometer causes a rise in systolic and diastolic blood pressure and heart rate. Autonomic Neuropathy | ADA - American Diabetes Association Freeman R: Diabetic autonomic neuropathy: an overview. In practical terms, however, the risk is minimal because comparable pressures occur in the performance of daily activities. It is clear, however, that a reduced appreciation for ischemic pain can impair timely recognition of myocardial ischemia or infarction and thereby delay appropriate therapy. Spectral indexes were power and density and were compared with standard Ewing tests of HRV (I:E difference, Valsalva ratio, and 30:15 ratio). Careful examination of these studies suggests, however, that the relationship between autonomic neuropathy and hypoglycemic unawareness may be more complex than these reports suggest. In one study of type 1 diabetic individuals, hypertension along with LDL and HDL cholesterol concentrations were found to be independent correlates of CAN (97). An autonomic imbalance resulting in QT prolongation may also predispose individuals to life-threatening cardiac arrhythmias and sudden death (101). (121), the rate of deterioration of the Valsalva ratio was 0.015 per year for individuals with type 1 diabetes, which was more than twice that expected from cross-sectional studies of the aging effect in normal individuals of a similar age range. Keywords: Diabetes mellitus, Microvascular complications, Renal dynamic scintigraphy, Diabetic kidney disease, Cardiac autonomic neuropathy, Diabetic retinopathy . Treatment of GI dysfunction often improves glycemic control. Specifically with regard to cardiovascular autonomic function, the DCCT showed that intensive glycemic control prevented the development of abnormal heart rate variation and slowed the deterioration of autonomic dysfunction over time for individuals with type 1 diabetes (37). Autonomic neuropathy affects the autonomic nerves, which control the bladder, intestinal tract, and genitals, among other organs. Autonomic Neuropathy Life Expectancy (Prognosis) Learn more: https://healthery.com/autonomic-neuropathy-life-expectancy/What is Autonomic Neuropathy? : The relation between QTc interval prolongation and diabetic complications: the EURODIAB IDDM Complications Study Group. Gastroparesis in diabetes is usually clinically silent, although severe diabetic gastroparesis is one of the most debilitating of all diabetic GI complications. Thousands of people suffering from erratic blood sugar has been using this ground-breaking solution . Bosman DR, Osborne CA, Marsden JT, Macdougall IC, Gardner WN, Watkins PJ: Erythropoietin response to hypoxia in patients with diabetic autonomic neuropathy and non-diabetic chronic renal failure. Reduced sympathetic stimulation of erythropoietin production has been previously hypothesized as the cause of ineffective erythropoiesis resulting in anemia (141). The earliest bladder autonomic dysfunctions are sensory abnormalities that result in impaired bladder sensation, an elevated threshold for initiating the micturition reflex and an asymptomatic increase in bladder capacity and retention. . NPT, nocturnal peniletumescence. This site uses cookies. Ellenberg M: Development of urinary bladder dysfunction in diabetes mellitus. How to Live with Autonomic Dysfunction: 13 Steps (with Pictures) - wikiHow At stage 4 or 5, they may feel unwell and experience the . Diabetic Neuropathy: A Small-Fiber Disease - Medscape During the study period, 19 individuals had one or more strokes. Dietary and pharmacologic management to attain individualized hemoglobin A1C goal based on life expectancy, disease duration, presence or absence of micro- and macrovascular complications, . Autoimmune Autonomic Ganglionopathy and Autoimmune Autonomic Neuropathy The sensitivity, specificity, and positive/negative predictive values listed in Table A1 summarize results obtained using standardized algorithms and an offsite processing center. 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. Table 2 and Fig. Specialized assessment of bladder dysfunction will typically be performed by a urologist. Borst C, Weiling W, van Brederode JFM, Hond A, DeRijk LG, Dunning AJ: Mechanisms of initial heart rate response to postural change. 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. Since SFSN usually does not involve large sensory fibers that convey . Life Expectancy Of Someone With Diabetic Neuropathy - Epainassist Page MM, Watkins PJ: Provocation of postural hypotension by insulin in diabetic autonomic neuropathy. Fava et al. And gastroparesis can lead to death in some people (in others it's "just" really unco. Basic diagnostic tests include upper-GI endoscopy or barium series to rule out structural or mucosal abnormalities of the GI tract. There are several key factors that affect a patient's prognosis in familial amyloid polyneuropathy (FAP), but most people with the rare, inherited, progressive disease have a life expectancy of about 10 years after being diagnosed.Jan 7, 2022. Neither age nor type of diabetes are limiting factors in its emergence, being found in young individuals with newly diagnosed type 1 diabetes and older individuals newly diagnosed with type 2 diabetes (5,24,40,44,113,114). Indeed, because the vagus nerve (the longest of the ANS nerves) accounts for 75% of all parasympathetic activity (4), and DAN manifests first in longer nerves, even early effects of DAN are widespread. Verrotti A, Chiarelli F, Blasetti A, Morgese G: Autonomic neuropathy in diabetic children. Search for other works by this author on: Vinik AI, Erbas T: Recognizing and treating diabetic autonomic neuropathy. This may reflect postprandial blood pooling, the hypotensive role of insulin, and changing patterns of fluid retention due to renal failure or congestive heart failure (5759). In a study of individuals with and without CAN, Kahn et al. : Mortality in diabetic patients with cardiovascular autonomic neuropathy. Feldman EL, Stevens MJ, Greene DA: Pathogenesis of diabetic neuropathy. All 52 individuals manifested ischemia during exercise. Early identification of CAN permits timely initiation of therapy with the antioxidant -lipoic acid (thioctic acid), which appears to slow or reverse progression of neuropathies in some studies (185), but further testing is necessary. Relative risk = 2.25 (1.134.45); diabetic subjects (, Unique diagnostic criteria defined by scoring 3 or more, Copyright American Diabetes Association. The TST is semiquantitative (percentage of anterior body anhidrosis) and has a high sensitivity. 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. Depending on the affected nerves, diabetic neuropathy symptoms include pain and numbness in the legs, feet and hands. The patients history and physical examination are ineffective for early indications of autonomic nerve dysfunction, and thus recommendations for the use of noninvasive tests that have demonstrated efficacy are warranted. Autophagy is considered to be potentially involved in the. In people with diabetes, the body's capability to use or produce insulin, a hormone that assists . Bradley WE: Diagnosis of urinary bladder dysfunction in diabetes mellitus. A search of PubMed using the Mesh terms "diabetes," "type 1," "insulin-dependent," "T1DM," and "diabetic autonomic neuropathy" was performed to find relevant primary literature. Case subjects (. Motivation to adhere and remain compliant with nonpharmacological interventions is difficult. Individuals with constipation may have less than three bowel movements per week, and these may alternate with diarrhea. Once diagnosed, treatment may include withdrawal from offending medications coupled with psychological counseling, medical treatment, or surgery. Over a number of years, there have been several different measures of R-R variation. A trial on a gluten-free diet is warranted, and confirmation of the diagnosis with upper-GI endoscopy and/or small bowel biopsy may be required. However, in patients with autonomic damage from diabetes, the reflex pathways are damaged, resulting in a slow and steady decline in blood pressure during strain, followed by gradual return to normal after release. Some people have mild symptoms. . The orthostatic stress of tilting evokes a sequence of compensatory cardiovascular responses to maintain homeostasis. bladder . Those with CAN had greater prevalence of other complications, but in multivariate analysis, CAN was the most important predictor of mortality. Of the 12 studies, 5 showed a statistically significant increased frequency of silent myocardial ischemia in individuals with CAN compared with individuals without CAN. Parasympathetic neuropathy = abnormal E:I ratio, Mortality rates for CVD mortality only. But people with this condition usually have a life expectancy of only about 5 to 10 . Cholinergic agents or clean intermittent self-catheterization may also be used to facility emptying. For example, using a variety of simple, validated, and noninvasive tests (e.g., fall in systolic blood pressure and heart rate response after standing), Verrotti et al. The important criteria for appraising clinical tests of autonomic function include reliability, reproducibility, general correlation with each other and with tests of peripheral somatic nerve function, well-established normal values, and demonstrated prognostic value. Despite research evidence that clinical observations (whether they be symptoms or routine vital signs) should not be the sole basis for the diagnosis of cardiovascular autonomic dysfunction, screening for abnormalities is infrequently done. (36). Abnormalities of parasympathetic and sympathetic autonomic function were found to be independent predictors of stroke in this cohort (110). Assess sensory and motor functions. Another study group observed nearly an identical prevalence rate (16.6%) for individuals with insulin-dependent diabetes (39). I have gastroparesis, paralysis of the stomach. The parasympathetic nerves that originate in the intermediolateral column of sacral segments S2S4 provide the major excitatory input to the urinary bladder. : Changes in autonomic nervous function during the 4-year follow-up in middle-aged diabetic and nondiabetic subjects initially free of coronary heart disease. Apfel SC, Arezzo JC, Brownlee M, Federoff H, Kessler JA: Nerve growth factor administration protects against experimental diabetic sensory neuropathy. (Heart,. (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. Aaron I. Vinik, Raelene E. Maser, Braxton D. Mitchell, Roy Freeman; Diabetic Autonomic Neuropathy . These studies have consistently provided evidence for an increased mortality risk among diabetic individuals with CAN compared with individuals without CAN (Table 3). Sandroni P, Benarroch EE, Low PA: Pharmacological dissection of components of the Valsalva maneuver in adrenergic failure. Diabetic autonomic neuropathy (DAN) is a common and debilitating form of neuropathy. DAN may be either clinically evident or subclinical. Gastroparesis and general signs of bowel dysfunction, such as constipation, diarrhoea and abdominal pain are most often encountered and involve both pharmacological and non . Evidence from clinical trials evaluating the use of antioxidants is promising. This causes a sudden transient increase in intrathoracic and intra-abdominal pressure and a consequent hemodynamic response. Hemodynamic changes occur during surgery for individuals with and without diabetes. In patients with diabetes and autonomic neuropathy, there is only a gradual increase in heart rate. Channer KS, Jackson PC, OBrien I, Corrall RJ, Coles DR, Davies ER, Virjee JP: Oesophageal function in diabetes mellitus and its association with autonomic neuropathy. Additional complicating factors include the wide variety of clinical syndromes and confounding variables such as age, sex, duration of diabetes, glycemic control, diabetes type, height, and other factors. Johnson BF, Nesto R, Pfeifer M, Slater W, Vinik A, Wackers F, Young L: Systolic and diastolic dysfunction in diabetic patients with neuropathy (Abstract). Ewing DJ, Campbell IW, Clarke BF: The natural history of diabetic autonomic neuropathy. Diabetes is a persistent disease that affects the method the body procedures blood sugar level (glucose). Diabetes. Freeman R, Saul P, Roberts M, Berger RD, Broadbridge C, Cohen R: Spectral analysis of heart rate in diabetic autonomic neuropathy. Major clinical manifestations of DAN include resting tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile dysfunction, sudomotor dysfunction, impaired neurovascular function, brittle diabetes, and hypoglycemic autonomic failure. The neuropathic disorder includes manifestations in the somatic and/or autonomic parts of the peripheral nervous system (3). QTc prolongation was associated with increased mortality risk. Perspiration. Abnormal HRV in one test is indicative of early autonomic neuropathy. In addition, the investigators suggested that cardiovascular autonomic dysfunction in individuals already at high risk (e.g., those with diabetes, high blood pressure, or a history of cardiovascular disease) may be particularly hazardous (93). Deceased subjects were older and had more complications at baseline. ED should alert physicians to perform cardiovascular evaluations for these patients. It's a rare disorder that usually occurs in adults over the age of 40. . Tests for the diagnosis and assessment of constipation might include the following: Anorectal manometry for evaluating sphincter tone and the rectal anal inhibitory reflex to distinguish colonic hypomotility from rectosigmoid dysfunction causing outlet obstructive symptoms. Interpretability of serial HRV testing requires accurate, precise, and reproducible procedures that use established physiological maneuvers. Diabetic autonomic neuropathy is associated with an increased risk of cardiovascular mortality. Toyry JP, Niskanen LK, Lansimies EA, Partanen KPL, Uusitupa MIJ: Autonomic neuropathy predicts the development of stroke in patients with non-insulin-dependent diabetes mellitus. Overt signs and symptoms of autonomic disease fall into one or more of the following categories. Two separate population-based studies have also examined the association of CAN and mortality. Sivieri R, Veglio M, Chinaglia A, et al. According to an estimate, tw. One suffering from neuropathy may experience a variety of symptoms such as pain, tingling, numbness, burning, or weakness in the affected extremity. It comprises sympathetic, parasympathetic, and enteric nervous systems, which are three anatomically distinct divisions. A band from 0.15 to 5.0 Hz was assigned as the high-frequency band, whereas low frequency was 0.005 to 0.15 Hz. 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). Diabetes and Parkinson's disease are two examples of . Treatment focuses on managing the symptoms of autonomic neuropathy. The E:I ratio is significantly affected by shifting of the heart rate and regularity of the respiratory cycling. Diabetes affects more than million worldwide. The QSART involves iontophoresis of a cholinergic agonist to measure axon reflex-medicated sudomotor responses quantitatively to evaluate postganglionic sudomotor function. Jalal S, Alai MS, Khan KA, Jan VM, Rather HA, Iqbal K, Tramboo NA, Lone NA, Dar MA, Hayat A, Abbas SM: Silent myocardial ischemia and cardiac autonomic neuropathy in diabetics. Cardiac autonomic neuropathy can be found in the elderly (age induces autonomic decline) but CAN is most common in patients with diabetes. Heating and gravity. Finally, overflow incontinence occurs because of denervation of the external and internal sphincter (129,130). (180) showed a significantly reduced E:I ratio for females in a random sample of 120 type 1 diabetic individuals, along with older age, longer duration, and elevated glucose, triglycerides, blood pressure, and urinary albumin excretion. There are differences in the glabrous and hairy skin circulations. R-R variation between supine and standing position, All subjects with overt diabetic nephropathy. Failure of the response suggests venous incompetence. In addition, it would appear that autonomic function testing is a valuable tool in identifying a subgroup of post-MI patients who are at high risk for death. Blood pressure. Taken together, even these data suggest that there is some overlap between the features of autonomic neuropathy and hypoglycemic unawareness. Dyrberg T, Benn J, Christiansen JS, Hilsted J, Nerup J: Prevalence of diabetic autonomic neuropathy measured by simple bedside tests. (75) measured the anginal perceptual threshold (i.e., the time from onset of 0.1 mV ST depression to the onset of angina pectoris during exercise) in individuals with and without diabetes. CAN is known to occurs in approximately 17% of patients with type 1 diabetes and approximately 22% of those with type 2. (40) found that 47 of 110 diabetic children and adolescents showed one or more abnormal tests for cardiovascular autonomic dysfunction. It will also be shown that autonomic dysfunction can affect daily activities of individuals with diabetes and may invoke potentially life-threatening outcomes. An abnormal response is defined similarly to that associated with standing. Orthostatic hypotension is defined as a fall in blood pressure (i.e., >20 mmHg for systolic or >10 mmHg for diastolic blood pressure) in response to postural change, from supine to standing (51). An expert panel from the AAN reviewed a number of standardized measures and found that noninvasive autonomic tests were found to have a high value-to-risk ratio (163). Advertisement Jaffe RS, Aoki TT, Rohatsch PL, Disbrow EA, Fung DL: Predicting cardiac autonomic neuropathy in type 1 (insulin-dependent) diabetes mellitus. Hathaway DK, El-Gebely S, Cardoso SS, Elmer DS, Gaber AO: Autonomic control dysfunction in diabetic transplant recipients succumbing to sudden cardiac death. Diabetic patients with CAN are predisposed to a lack of the normal nighttime decrease in blood pressure because of an increased prevalence of sympathetic activity (100). Beat-to-beat variation in heart rate with respiration depends on parasympathetic innervation. A descriptive term meaning a demonstrable disorder, either clinically evident or subclinical, that occurs in the setting of diabetes mellitus without other causes for peripheral neuropathy. Sampson MJ, Wilson S, Karagiannis P, Edmonds M, Watkins PJ: Progression of diabetic autonomic neuropathy over a decade of insulin-dependent diabetics. . These same challenges may also apply to elderly patients, where deterioration of physiological response is of concern, and to developmentally and cognitively disabled individuals. Normally, in response to postural change there is an increase in plasma norepinephrine. No patients had an abnormal sBP response to standing. Rather, it is a complication or side-effect caused by disrupted signals between the brain and the nervous system. Farup CE, Leidy NK, Murray M, Williams GR, Helbers L, Quigley EMM: Effect of domperidone on the health-related quality of life of patients with symptoms of diabetic gastroparesis. Glucose is the main source of energy for the body's cells and is acquired from the food we consume. It can be present at birth or appear gradually or suddenly at any age. The gastrocolic reflex is impaired, but stimulation of colonic smooth muscle with neostigmine is normal (170). Hand grip. Clark CM, Vinicor F: Introduction: Risks and benefits of intensive management in non-insulin-dependent diabetes mellitus: the fifth Regenstrief conference. DCCT Research Group: The effect of intensive diabetes therapy on measures of autonomic nervous system function in the Diabetes Control and Complications Trial (DCCT). The association of cardiovascular autonomic dysfunction in the absence of coronary disease and cardiomyopathy requires further study. Treatment of diarrhea with or without constipation should always involve the use of a prokinetic agent rather than constipating agents that create vicious cycles of constipation and diarrhea (1). (110), who followed a group of 133 type 2 diabetic patients for 10 years. tract complications, and even skin discoloration. A task force of the American Academy of Neurology (AAN) and the American Autonomic Society defined orthostatic hypotension as a fall in systolic blood pressure of 20 mmHg or diastolic blood pressure of 10 mmHg accompanied by symptoms (51). It should also be noted that decreased ejection fraction, systolic dysfunction, and diastolic filling limit exercise tolerance (1). Diabetic neuropathy - Symptoms and causes - Mayo Clinic Discriminant analysis of 5-year survival in type 1 diabetic patients. Dysautonomia symptoms, causes, types, life expectancy and treatment There appears to be two different mechanisms operating: (1) sensory neuropathy in diabetes appears to be effected by poor blood sugar control and may be related to metabolic or oxidative end products with poorly controlled diabetes; whereas, (2) the diabetic type 1 Autonomic Neuropathy appears to be autoimmune as an individual produces . A: +CAN, CAN present; CAN, no CAN found; +SMI, SMI present. Veves A, King GL: Can VEGF reverse diabetic neuropathy in human subjects? Sochett E, Daneman D: Early diabetes-related complications in children and adolescents with type 1 diabetes: implications for screening and intervention. 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. Autonomic dysfunction was found to be an independent risk factor with poor prognosis. What would the approximate life expectancy for a Diabetic with Autonomic, cardiac Autonomic, Cranial, Focal and Periphrial neuropathy. In response to subsequent underlying blood pressure changes while standing, a baroreceptor-mediated reflex involves the sympathetic nerves for further heart rate control (160). Milan Study on Atherosclerosis and Diabetes (MiSAD) Group: Prevalence of unrecognized silent myocardial ischemia and its association with atherosclerotic risk factors in noninsulin-dependent diabetes mellitus. Low PA, Nickander KK: Oxygen free radical effects in sciatic nerve in experimental diabetes. 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. 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. Chest pain in any location in a patient with diabetes should be considered to be of myocardial origin until proven otherwise; but, of equal importance, unexplained fatigue, confusion, tiredness, edema, hemoptysis, nausea and vomiting, diaphoresis, arrhythmias, cough, or dyspnea should alert the clinician to the possibility of silent MI (1). Can Diabetic Neuropathy Cause Death - How To Reverse Type 2 Diabetes