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in the most severe and long-standing cases, presumably due to sensory analgesia, trophic changes, and repetitive injury (Foot ulcerations are more common simply as a result of the microvascular disease of skin in diabetic patients) Muscle weakness is usually mild, but in some patients a distal sensory neuropathy is combined with a proximal weakness and wasting of the types mentioned earlier Treatment of the acral pain may be a major problem and is discussed further on In another group of patients with diabetic polyneuropathy the clinical picture may be dominated instead by loss of deep sensation, ataxia, and atony of the bladder, with only slight weakness of the limbs, in which case it resembles tabes dorsalis (hence the term diabetic pseudotabes) The similarity is even closer if lancinating pains in the legs, unreactive pupils, and neuropathic arthropathy are present Acute Diabetic Mononeuropathies Among these, diabetic ophthalmoplegia is a common occurrence, usually in a patient with well-established diabetes It commonly presents as an isolated, painful third nerve palsy with sparing of pupillary function In the rst autopsied patient reported by Dreyfus, Adams, and colleagues, there was an ischemic lesion in the center of the retro-orbital portion of the third nerve Subsequently, a similar case was described by Asbury and colleagues Less often, the sixth nerve is involved The disorder was described earlier in the chapter on page 233 Isolated involvement of practically all the major peripheral nerves has been described in diabetes, but the ones most frequently involved are the femoral, sciatic, and peroneal nerves in about that order Rarely is a nerve in the upper extremity affected As mentioned, the acute mononeuropathies, both cranial and peripheral, are presumably due to infarction of the nerve but it is in studies of the third nerve that this pathologic basis has been most convincingly established as noted above Recovery is the rule but may take many months Diabetic Multiple Mononeuropathies and Radiculopathies This category overlaps with the mononeuropathies A syndrome of painful unilateral or asymmetrical multiple neuropathy tends to occur in older patients with relatively mild or even unrecognized diabetes These affections of several single nerves occur in a random distribution and cause a mononeuritis multiplex They often emerge during periods of transition in the diabetic illness, for example, when severe hyper- or hypoglycemia arises, when insulin treatment is being initiated or adjusted, or when there has been rapid weight loss In the most characteristic type, which affects the lumbar roots, pain, which can be severe, begins in the low back or hip and spreads to the thigh and knee on one side The discomfort has a deep, aching character with superimposed lancinating jabs, and there is a propensity for pain to be most severe at night Weakness and later atrophy are evident in the pelvic girdle and thigh muscles, although the distal muscles of the leg may also be affected The patellar re ex is lost on the affected side Curiously, we have found the opposite patellar re ex to be absent in some patients Deep and super cial sensation may be intact or mildly impaired, conforming to either a multiple nerve or multiple adjacent root distribution (ie, L2 and L3) or both Recovery is the rule although months and even years may elapse before it is complete There is a tendency for the same syndrome to recur after an interval of months or years in the opposite leg The EMG shows denervation in the L2 L3 and sometimes adjacent myotomes As with the diabetic mononeuropathies, the upper extremities are only rarely affected by this process. rdlc pdf 417 PDF417 Barcode Creating Library for RDLC Reports | Generate ...
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how to generate qr code in vb.net Free trial package available to insert PDF - 417 barcode image into Client Report RDLC . microsoft word qr code mail merge This form of neuropathy is often referred to as diabetic amyotrophy, a term that draws attention to one facet of the syndrome but is otherwise uninformative Garland s name has also been attached to this diabetic lumbar radiculoplexopathy based on his early and thorough report (but he mistakenly attributed the condition to a spinal cord lesion) A potentially vasculitic mechanism demonstrated by Raff and colleagues has been supported by PJB Dyck and others A vasculopathy involving vaso nervorum, the traditional explanation, seems more likely to us Clinical experience has shown that an identical painful lumbofemoral neuropathy may develop in nondiabetics; possibly this form is also vasculopathic or vasculitic While lumbar disc herniation, retroperitoneal hematoma compressing upper lumbar roots, carcinomatous meningeal seeding, and neoplastic and sarcoid in ltration of the proximal lumbar plexus enter into the differential diagnosis, the diabetic type is usually so distinctive as to permit an early recognition on clinical grounds Also observed in diabetic patients is a syndrome of proximal symmetrical leg weakness, wasting, and re ex loss of more insidious onset and gradual evolution as discussed by Pascoe and colleagues The iliopsoas, quadriceps, and hamstrings are involved in varying degrees The muscles of the scapulae and upper limbs, usually the deltoid and triceps, are affected less frequently Pain is not a consistent feature, as it is in the acute asymmetrical type, and sensory changes, if present, are distal, symmetrical, and usually mild In this attempt to delineate two types of proximal diabetic neuropathy, it must be emphasized that there is an overlap between them and that distal parts of a limb may be involved to a lesser degree in both conditions and that the timing of evolution of symptoms varies Nor can the proximal and distal type be distinguished on pathologic or electrophysiologic grounds alone Whether they should even be considered as separate entities is not clear Well known to diabetologists is a syndrome of thoracoabdominal radiculopathy characterized by severe pain and dysesthesia Almost always the diabetes has been of long-standing (Kikta et al) The pain is distributed over one or several adjacent segments of the chest or abdomen; it may be unilateral or less often bilateral and tends to follow recent weight loss Super cial sensory loss can be detected over the involved area in most patients The pathology of this state is not known but it is also presumed to be an ischemic radiculopathy The EMG changes consist of brillations of the paraspinal and abdominal muscles in one or more adjacent myotomes, corresponding to the painful area With better control of the diabetes, or perhaps spontaneously, recovery eventually occurs but it may be protracted The differential diagnosis includes pre-eruptive herpes zoster, sarcoid in ltration of nerve roots, and the rare entity of thoracic disc rupture In all forms of diabetic polyneuropathy, the CSF protein may be elevated from 50 to 150 mg/dL and sometimes even higher The protein concentration is usually normal in cases of diabetic mononeuropathy (Whether a slight elevation of CSF protein, discovered incidentally, can be attributed to diabetes in the absence of a polyneuropathy is uncertain) In this type and the ones described further on, both type 1 and type 2 diabetic patients are susceptible, the duration of diabetes being a major factor Autonomic Neuropathy Symptoms of autonomic involvement include any combination of pupillary and lacrimal dysfunction, impairment of sweating and vascular re exes, nocturnal diarrhea, at-. rdlc pdf 417 How to add Barcode to Local Reports ( RDLC ) before report ...
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