Improving hand hygiene compliance in child daycare centres: a randomized controlled trial.

Gastrointestinal and respiratory infections in children attending daycare centres (DCCs) are common and compliance with hand hygiene (HH) guidelines to prevent infections is generally low. An intervention was developed to increase HH compliance and reduce infections in DCCs. The objective of this paper was to evaluate the effectiveness of this intervention on HH compliance. The intervention was evaluated in a two-arm cluster randomized controlled trial in 71 DCCs in The Netherlands. Thirty-six DCCs received the intervention including: (1) HH products; (2) training about HH guidelines; (3) two team training sessions aimed at goal setting and formulating HH improvement activities; and (4) reminders and cues for action (posters/stickers). Intervention DCCs were compared to 35 control DCCs that continued usual practice. HH compliance of caregivers and children was observed at baseline and at 1, 3 and 6 months follow-up. Using multilevel logistic regression, odds ratios (ORs) with 95% confidence intervals (CIs) were obtained for the intervention effect. Of 795 caregivers, 5042 HH opportunities for caregivers and 5606 opportunities for supervising children's HH were observed. At 1 month follow-up caregivers' compliance in intervention DCCs was 66% vs. 43% in control DCCs (OR 6·33, 95% CI 3·71-10·80), and at 6 months 59% vs. 44% (OR 4·13, 95% CI 2·33-7·32). No effect of the intervention was found on supervising children's HH (36% vs. 32%; OR 0·64, 95% CI 0·18-2·33). In conclusion, HH compliance of caregivers increased due to the intervention, therefore dissemination of the intervention can be considered.

A hand hygiene intervention to reduce infections in child daycare: a randomized controlled trial.

Infections are common in children attending daycare centres (DCCs). We evaluated the effect of a hand hygiene (HH) intervention for caregivers on the incidence of gastrointestinal and respiratory infections in children. The intervention was evaluated in a two-arm cluster randomized controlled trial. Thirty-six DCCs received the intervention including HH products, training sessions, and posters/stickers. Thirty-five control DCCs continued usual practice. Incidence of episodes of diarrhoea and the common cold in children was monitored by parents during 6 months. Using multilevel Poisson regression, incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were obtained. Diarrhoeal incidence was monitored in 545 children for 91 937 days. During follow-up, the incidence was 3·0 episodes per child-year in intervention DCCs vs. 3·4 in control DCCs (IRR 0·90, 95% CI 0·73-1·11). Incidence of the common cold was monitored in 541 children for 91 373 days. During follow-up, the incidence was 8·2 episodes per child-year in intervention DCCs vs. 7·4 in control DCCs (IRR 1·07, 95% CI 0·97-1·19). In this study, no evidence for an effect of the intervention was demonstrated on the incidence of episodes of diarrhoea and the common cold.

Newly identified risk factors for MRSA carriage in The Netherlands.

OBJECTIVES: To elucidate new risk factors for MRSA carriers without known risk factors (MRSA of unknown origin; MUO). These MUO carriers are neither pre-emptively screened nor isolated as normally dictated by the Dutch Search & Destroy policy, thus resulting in policy failure. METHODS: We performed a prospective case control study to determine risk factors for MUO acquisition/carriage (Dutch Trial Register: NTR2041). Cases were MUO carriers reported by participating medical microbiological laboratories to the RIVM from September 1st 2011 until September 1st 2013. Controls were randomly selected from the community during this period. RESULTS: Significant risk factors for MUO in logistic multivariate analysis were antibiotic use in the last twelve months, aOR 8.1 (5.6-11.7), screened as contact in a contact tracing but not detected as a MRSA carrier at that time, aOR 4.3 (2.1-8.8), having at least one foreign parent, aOR 2.4 (1.4-3.9) and receiving ambulatory care, aOR 2.3 (1.4-3.7). Our found risk factors explained 83% of the MUO carriage. CONCLUSIONS: Identifying new risk factors for MRSA carriers remains crucial for countries that apply a targeted screening approach as a Search and Destroy policy or as vertical infection prevention measure.

The role of methotrexate in the management of steroid-dependent asthma.

Severe asthma often requires high-dose corticosteroid therapy. However, steroid therapy is fraught with many side effects. There are conflicting reports in the literature regarding the role of methotrexate in reducing the steroid requirements of these patients. This study examined the role of low-dose methotrexate in the management of steroid-dependent asthma. Eleven subjects with stable steroid-dependent asthma were enrolled in a placebo-controlled double-blind crossover trial. Patients received methotrexate, 15 mg/wk, or placebo each for two 12-week periods. There was significant improvement of pulmonary function and reduction of prednisone requirement in both placebo and methotrexate treatment periods. However, methotrexate was not superior to placebo. Only 3 of 11 patients responded to methotrexate. Although low-dose methotrexate therapy may have a role in a small select group of steroid-dependent asthmatics, it provided no additional benefit overall.

Treatment of diabetic polyneuropathy with the neurotrophic peptide ORG 2766.

The efficacy of the neurotrophic peptide ORG 2766 in diabetic patients with polyneuropathy was evaluated in a double-blind, placebo-controlled, multicentre trial. One hundred and twenty four patients were randomised in five groups to receive 0.1, 0.4, 2 or 5 mg ORG 2766 or placebo, once daily, administered subcutaneously 52 weeks. Thermal discrimination thresholds (TDT) and vibration perception thresholds (VPT), motor and sensory nerve conduction velocity, Hoffmann reflex, heart rate variation during deep breathing and heart rate response after standing up, neurological examination score and neuropathic symptom score were determined at baseline and after 17, 34 and 52 weeks of treatment. Of the nerve function indices studied, at week 52 the TDTwarmth of the hand in the ORG 2766 0.1, 0.4 and 5 mg groups and the TDTcold of the foot in the ORG 2766 0.1 and 0.4 mg groups significantly improved compared with placebo. Further significant improvement as compared with placebo was observed in the paraesthesia score at week 34 and week 52 in the ORG 2766 2 mg group. Only at week 34 had both the heartbeat variation during deep breathing and the VPT of the foot in the ORG 2766 0.1 mg group improved significantly, compared with placebo. No further statistically significant differences were observed at time for the other measures. No adverse reactions were observed. The only recorded drug-induced side effect was pain at the injection site. Taking all measures of efficacy into account, the statistically significant results observed did not show consistency within each measure. Therefore, it is concluded that ORG 2766, in contrast to earlier reports, is not effective in treating diabetic polyneuropathy.

Determinants of vibration perception thresholds in IDDM and NIDDM patients.

The relative influence of diabetes mellitus-related and physiological factors on vibration perception thresholds was assessed in 353 patients in a hospital-based setting (173 insulin-dependent and 180 non-insulin dependent patients, aged 51.1 +/- 15.9 years) and 80 healthy controls (aged 43.3 +/- 15.2 years) employing a Biothesiometer. Vibration perception thresholds were bilaterally measured at the thumbs, medial malleoli and halluces. Sixty (17.0%) older patients had off-scale thresholds (> 50 V). As no systematic side differences were found, values of contralateral sites were averaged. Considering the effects of age, height, gender and skin temperature in controls, age accounted for 46.7 and 52.2% threshold variance at the ankles and halluces, respectively, while height explained 5.1 and 5.1%, respectively. At the thumbs, only age was of relevance. Age relationships with vibration thresholds in health did not differ from published reports at any site. In the patient group, influences of age, height, gender, skin temperature, years from diagnosis, HbAlc, serum creatinine, drop in systolic blood pressure on standing, and ankle/arm blood pressure indices were assessed for each type of diabetes. For both types, age and height again had relevant effects at the lower extremities as did age and gender at the thumbs. Skin temperature was only marginally significant at the halluces of NIDDM patients. Of the disease-related factors, HbAlc had the strongest effect: for both IDDM and NIDDM higher levels were associated with lower vibration sensitivity. Increasing disease duration led to significantly higher thresholds in IDDM patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The efficacy of aldose reductase inhibitors in the management of diabetic complications. Comparison with intensive insulin treatment and pancreatic transplantation.

Recently, aldose reductase inhibitors (ARIs) have been registered in several countries for the improvement of glycaemic control. However, their efficacy is still controversial. ARIs inhibit the enhanced flux of glucose through the polyol pathway. As such, they can never be more effective than normoglycaemia, and so their potential benefits and limitations should be considered relative to the effects of prolonged euglycaemia. The clinical effects of ARIs can be put into perspective by assessing the effects of improved glycaemic control attained in randomised trials of intensive insulin treatment [such as the Diabetes Control and Complications Trial (DCCT)] and after pancreatic transplantation. Although direct comparison of these 3 interventions is hampered by differences in patient populations, duration and methods of follow-up and in the potency of ARIs, the effects of these 3 metabolic interventions and their course in time appear remarkably similar. For neuropathy, all 3 interventions induce an increase in average motor nerve conduction velocity of approximately 1 m/sec during the first months of treatment. At the same time, improvement of painful symptoms may occur. These changes probably largely represent a metabolic amelioration of the condition of the nerves. Around the second year of treatment with all 3 forms of metabolic improvement, an acceleration of nerve conduction of a similar magnitude occurs, with signs of structural nerve regeneration and some sensory recuperation. Experience with ARIs in nephropathy is still limited, but similar improvements in glomerular filtration rate and, less consistently, in urinary albumin excretion were found during short term normoglycaemia produced by all 3 forms of treatment. Comparison of a small number of studies, however, shows differences between intensive insulin regimens, pancreatic transplantation and ARIs in effects on retinopathy. Retinopathy often temporarily deteriorates in the early phases of improved glycaemic control, but this is not noted with ARIs. New microaneurysm formation was slightly reduced in a single long term study with the ARI sorbinil, but the preventive effects on the overall levels of retinopathy seemed less strong than in normoglycaemia trials of similar duration. However, the pharmacodynamic effects on inhibiting the polyol pathway differ among ARIs, and the half-life of the inhibiting effect of sorbinil may have been too short for a complete reduction of polyol pathway activity. The trials of prolonged intensive insulin therapy and pancreatic transplantation have demonstrated that very strict metabolic control must be maintained continuously for many years before a significant reduction of complications can be demonstrated.(ABSTRACT TRUNCATED AT 400 WORDS)

Solar urticaria: a case report.

Solar urticaria is a rare disorder characterized by erythema, pruritus, and urticaria occurring minutes after exposure to a light source. It is one of several photosensitive conditions, such as phototoxic reaction, photoallergic reaction, systemic lupus erythematosus, and porphyria, that can cause photosensitivity. Herein we report a case of solar urticaria and review the rational approaches to its diagnosis and treatment.

Emergence of MRSA of unknown origin in the Netherlands.

The Netherlands is known for its low methicillin-resistant Staphylococcus aureus (MRSA) prevalence. Yet MRSA with no link to established Dutch risk factors for acquisition, MRSA of unknown origin (MUO), has now emerged and hampers early detection and control by active screening upon hospital admittance. We assessed the magnitude of the problem and determined the differences between MUO and MRSA of known origin (MKO) for CC398 and non-CC398. National MRSA Surveillance data (2008-2009) were analysed for epidemiological determinants and genotypic characteristics (Panton-Valentine leukocidin, spa). A quarter (24%) of the 5545 MRSA isolates registered were MUO, i.e. not from defined risk groups. There are two genotypic MUO groups: CC398 MUO (352; 26%) and non-CC398 MUO (998; 74%). CC398 MUO needs further investigation because it could suggest spread, not by direct contact with livestock (pigs, veal calves), but through the community. Non-CC398 MUO is less likely to be from a nursing home than non-CC398 MKO (relative risk 0.55; 95% CI 0.42-0.72) and Panton-Valentine leukocidin positivity was more frequent in non-CC398 MUO than MKO (relative risk 1.19; 95% CI 1.11-1.29). Exact transmission routes and risk factors for non-CC398 as CC398 MUO remain undefined.

Evaluation of physician and patient compliance with the use of peak flow meters in commercial insurance and Oregon health plan asthmatic populations.

BACKGROUND: Home use of peak expiratory flow (PEF) meters is recommended by NIH management guidelines for patients with moderate to severe asthma. OBJECTIVE: To evaluate whether differences in physician PEF meter prescription patterns and patient compliance rates with PEF meter use exist between populations of commercially insured and Oregon Health Plan (OHP) patients. METHODS: A prospective, case-series study was conducted at the Bay Clinic Coos Bay, Oregon. Volunteers responded to a short survey. Patient asthma severity was evaluated by responses to the following questions: (1) frequency of shortness of breath per week, (2) daily and weekly frequency of albuterol rescue inhaler use, and (3) other prescription medications used. Additional questions included: (1) possession of a PEF meter, (2) physician instruction of meter use, (3) patient compliance with instructions, and (4) type of medical insurance. Using NIH asthma stratification guidelines, only respondents with moderate to severe asthma were included in this study. Respondents were age restricted to between 6 and 60 years. Incomplete surveys were not accepted. RESULTS: Ninety-six surveys were received and 54 accepted. Only 24 (44%) of the 54 respondents with moderate to severe asthma had a PEF meter. Nineteen (79%) used it according to physician instructions. Of the 29 patients reporting to have commercial insurance, 18 (62%) had a PEF meter and 15 (83%) used it as prescribed. Of the 21 asthmatic patients with OHP coverage, only 5 (24%) P = .007 had a peak flow meter and 4 (80%) used it as prescribed. CONCLUSIONS: We conclude physician prescription compliance of peak flow meters for asthma monitoring falls short of the NIH guidelines. When a PEF meter is prescribed, patients will likely use it regardless of their medical insurance. Significant differences exist in physician compliance with PEF meter prescription between populations of commercially insured and OHP patients. More study is necessary to further understand this divergence in care delivery.

Combined diesel exhaust particulate and ragweed allergen challenge markedly enhances human in vivo nasal ragweed-specific IgE and skews cytokine production to a T helper cell 2-type pattern.

We have previously shown that in vivo nasal challenge with diesel exhaust particles (DEP) induces both quantitative and qualitative changes in local IgE production and stimulates generalized local cytokine production. We have now investigated the combined effects of intranasal challenge with DEP plus ragweed allergen on local humoral immune responses. We collected nasal lavages from ragweed sensitized subjects at different times after nasal challenge. As compared with challenge with ragweed alone, challenge with both DEP and ragweed induced markedly higher ragweed-specific IgE but not total IgE levels or IgE-secreting cell numbers. Total and specific IgG4 levels also were enhanced, while total IgG levels were not. Synergy was also observed between the DEP and ragweed in altering the profile of epsilon mRNAs generated by alternative splicing, mRNAs that code for different expressed IgE proteins. Intranasal challenge with ragweed alone induced inconsistent and low levels of mucosal cytokine mRNAs. In contrast, challenge with both ragweed plus DEP resulted in decreased expression for Th1-type cytokines (IFN-gamma and IL-2) but elevated expression of mRNA for other cytokines (IL-4, -5, IL-6, IL-10, IL-13). This synergy between DEP and natural allergen exposure is suggested as a key feature in increasing allergen-induced respiratory allergic disease.

The organic component of diesel exhaust particles and phenanthrene, a major polyaromatic hydrocarbon constituent, enhances IgE production by IgE-secreting EBV-transformed human B cells in vitro.

Suspended airborne particulate matter such as diesel exhaust particles (DEP) have been implicated in the increased incidence of respiratory allergic diseases that has occurred over the past century. Studies in vitro and in vivo have shown that DEP may enhance allergic antibody (IgE) expression. DEP contain a wide spectrum of polycyclic aromatic hydrocarbons (PAH) that have been reported to have direct effects on the immune system, including the modulation of IgE production using various human and murine cell populations. We investigated the effects of the organic extract of DEP (PAH-DEP) and particularly, phenanthrene, a major component of DEP, in vitro on IgE production by 2C4/F3, a human Epstein-Barr virus transformed isotype switched, IgE producing B cell line. Phenanthrene consistently enhanced 2C4/F3 IgE production two- to threefold. This in vitro enhancement was associated with an increased expression of total IgE mRNA. Furthermore, the pattern of mRNA's coding for distinct isoforms of the epsilon chain was altered by both DEP-PAH and phenanthrene. While phenanthrene increased the level of productive epsilon transcripts, it did not increase epsilon germ line transcription. These effects were not due to an alteration of the cell cycle. Unstimulated 2C4/F3 cells contained detectable mRNA for IL6, IL10, TNF-alpha, and interestingly IL4; however, addition of PAH-DEP or phenanthrene did not significantly alter the level of these cytokines and thus did not appear to account for our findings. Thus, we have used our in vitro model to dissect the mechanism of DEP-PAH on IgE production in postswitch IgE producing cells and shown that phenanthrene, an important component in DEP and other pollutants, can act in a similar manner.

Effect of topical fluticasone propionate on the mucosal allergic response induced by ragweed allergen and diesel exhaust particle challenge.

Glucocorticoids block the local allergic response in a variety of ways. However, studies have also shown that glucocorticoids increase in vitro IgE synthesis and that treatment with corticosteroids may result in elevated serum IgE concentrations. The ability of topical glucocorticoids to modulate the mucosal IgE response has not been elucidated. We studied the effect of topical steroid (fluticasone propionate) treatment on the local allergic antibody response induced by challenge with either allergen or diesel exhaust particles (DEP). A parallel group study was performed with ragweed-allergic subjects, each subject serving as his/her own control. Nasal provocation challenges were performed on three groups. One group received ragweed allergen, another diesel exhaust particles, and the third saline. The study was repeated following 1 week of treatment with intranasal fluticasone propionate. Each group received the same challenge as before. The concentrations of total immunoglobulins (IgE, IgG, IgA, and IgM), anti-ragweed antibody, IgE- and IgA-secreting cells, epsilon (epsilon) mRNA, and cytokine mRNAs (IL-2, -4, -5, -6, TNF-alpha, INF-gamma) were measured in nasal lavages performed before and at various time points after challenge. Treatment with fluticasone propionate for 7 days caused a decrease in the concentrations of nasal IgE protein, IgE-producing cells, total epsilon mRNA, and all the cytokine mRNAs tested. Furthermore, treatment with fluticasone propionate inhibited the production of allergen-specific IgE and cytokine mRNAs following challenge with ragweed antigen. However, fluticasone treatment did not significantly inhibit the enhancement of mucosal IgE production or cytokine mRNAs observed following nasal challenge with DEP. These results indicate that 1-week treatment with topical fluticasone propionate was effective in blocking local effects of allergen exposure but was unable to inhibit the adjuvant-like effect of DEP.

Enhanced nasal cytokine production in human beings after in vivo challenge with diesel exhaust particles.

BACKGROUND: Diesel exhaust particles (DEPs) have been implicated in the worldwide increased incidence of allergic airway disorders over the past century. They can enhance in vivo IgE production in the human upper respiratory mucosa. OBJECTIVES: The study was carried out to determine whether DEPs can alter the production of cytokines by cells residing in the nasal mucosa. METHODS: Eighteen hours after intranasal challenge with saline solution or DEPs, we studied the levels of messenger RNA for cytokines in nasal lavage cells and the number of subjects in whom cytokine mRNA could be detected. RESULTS: Before challenge, most subjects' nasal lavage cells had detectable levels of only interferon-gamma, Il-2, and IL-13 mRNA. After challenge, the cells produced readily detectable mRNA for IL-2, IL-4, IL-5, IL-6, IL-10, IL-13, and interferon-gamma. In addition, the levels of all cytokine mRNA increased. Enhanced IL-4 protein was also present in the postchallenge lavage fluid. Although the cells in nasal lavage before and after challenge do not necessarily represent the same cells either in number or type, the broad increase in cytokine production was not simply the result of an increase in T cells recovered in the lavage fluid. CONCLUSION: An increase in nasal cytokine expression after exposure to DEPs can be predicted to contribute to enhanced local IgE production and thus play a role in the increased incidence of respiratory allergic disease.

Enhanced human IgE production results from exposure to the aromatic hydrocarbons from diesel exhaust: direct effects on B-cell IgE production.

Epidemiologic and experimental studies suggest that air pollution, and particularly diesel exhaust particles (DEPs) may play a role in the increasing prevalence and severity of airway allergic disease. We show that the extract of polyaromatic hydrocarbons (PAHs) from DEPs (PAH-DEP) enhances human IgE production from purified B cells. Interleukin-4 plus CD40 monoclonal antibody-stimulated IgE production was enhanced 20% to 360% by the addition of PAH-DEP over a period of 10 to 14 days. This effect was increased when PAH-DEP was added 2 to 5 days after cultures were initiated. PAH-DEP itself did not induce IgE production or synergize with interleukin-4 alone to induce IgE from purified B cells, suggesting that it was enhancing ongoing IgE production rather than inducing germline transcription or isotype switching. The prototype nonmetabolized aromatic hydrocarbon 2,3,7,8 tetracholorodibenzo-p-dioxin, which functions solely through activation of the cytosolic aromatic hydrocarbon receptor complex, also increased IgE production. Additionally, the pattern of mRNAs coding for distinct isoforms of the epsilon chain was altered by PAH-DEP, and B-cell expression of the low-affinity IgE receptor was upregulated by PAH-DEP. Enhanced IgE production in the human airway, resulting from exposure to PAH-DEP, may be an important factor in the increase in airway allergic disease.

CMAP variability as a function of electrode site and size.

The site of the recording electrode influences the amplitude of the compound muscle action potential (CMAP) and its variation over a length of nerve. The effects of large electrodes on this source of intraindividual variability were assessed. Right median nerves of 20 healthy subjects were studied, and recordings made at three sites (at 1-cm intervals) using five electrode sizes (0.01, 1, 2, 4, and 10 cm2). Site-induced variability was defined as the standard deviation (SDi) and coefficient of variation (CVi) of the measurements of the three sites. Site induced variability of all parameters (latency, duration, amplitude, area, MNCV, and the percentile changes of duration, amplitude, and area over the forearm) decreased significantly with electrode size. Decreases were most pronounced for amplitude and area: CVi fell from 29% and 30% (0.01-cm2 electrode) to 10% and 8% (10 cm2). It is argued that large electrodes record activity of more motor units than small electrodes, and that their measurement fields overlap to a greater extent. The use of large electrodes is recommended in order to reduce site-induced CMAP variability.

Effects of supine blood pressure on interpretation of standing up test in 500 patients with diabetes mellitus.

The relationship between fall in blood pressure (BP) on standing and supine BP before standing up was studied in 75 healthy controls and in 500 patients with diabetes mellitus (DM) using conventional BP measurements. The influences of physiological (sex, age, height) and DM-related factors (type, duration, HbA1c-level, use of insulin, oral antidiabetic and anti-hypertensive medication) on BP-fall were assessed. The effects of using a fixed abnormality threshold and a new supine BP-related abnormality definition on interpretation of the test were determined. Highly significant relationships of BP-fall with supine BP were found in control and DM subjects. Slopes did not differ between these groups. Slopes for systolic BP-fall were steeper in type 1 than in type 2 DM patients. A forward stepwise regression procedure revealed that supine BP (explaining 24% of variance) and HbA1c (explaining 1%) had significant influences on systolic BP-fall. Diastolic supine BP explained 14% of diastolic BP-fall, age 3%, and sex 2%. Only supine BP was thus of practical relevance in explaining BP-fall. Taking supine BP into consideration affected test results: of 74 subjects with an abnormal conventional systolic BP-fall, 10 (13.5%) had been misclassified according to the new method, and 4 additional patients had been misclassified as normal. Classification changes were much larger for diastolic BP-fall (63% of conventionally abnormal results were reclassified as normal), but the range of diastolic BP is smaller than for systolic BP, meaning that the measurement error interferes with its clinical utility.(ABSTRACT TRUNCATED AT 250 WORDS)

Large electrodes improve nerve conduction repeatability in controls as well as in patients with diabetic neuropathy.

Recording site is an important cause of variability of compound muscle action potential (CMAP) and conduction parameters, which can be reduced by using large electrodes. Repeatability of CMAP and conduction parameters of conventional and large electrodes was compared in 16 controls and 17 diabetic neuropathic patients, using defined recording sites linked to anatomical landmarks. Right-sided median, peroneal, and tibial nerves were investigated twice with a 1-2 week interval by the same examiner. Compared to previous studies, conventional electrodes on strictly defined recording sites resulted in better repeatability: intraindividual coefficients of variation (CV) varied between 4% and 14.4% for all parameters. CV of conduction parameters, not published previously, was smaller than CV of CMAP parameters. The use of large electrodes improved repeatability further: large electrodes resulted in substantially smaller CV for duration, amplitude, area, and changes of amplitude and area over a length of nerve, which were reduced by 10%, 31%, 29%, 27%, and 16%, respectively. Patients had higher CV than controls; large electrodes reduced patient CV more than control CV, resulting in less contrast between groups. Strictly defined recording sites and large electrodes improve repeatability of motor conduction studies to relevant degrees: all CMAP and conduction parameters are suitable for longitudinal studies of neuropathic patients.