title: Pupillary Light Reflexes are Associated with Autonomic Dysfunction in Bolivian Diabetics But Not Chagas Disease Patients.
abstract: Autonomic dysfunction is common in Chagas disease and diabetes. Patients with either condition complicated by cardiac autonomic dysfunction face increased mortality, but no clinical predictors of autonomic dysfunction exist. Pupillary light reflexes (PLRs) may identify such patients early, allowing for intensified treatment. To evaluate the significance of PLRs, adults were recruited from the outpatient endocrine, cardiology, and surgical clinics at a Bolivian teaching hospital. After testing for Chagas disease and diabetes, participants completed conventional autonomic testing (CAT) evaluating their cardiovascular responses to Valsalva, deep breathing, and orthostatic changes. PLRs were measured using specially designed goggles, then CAT and PLRs were compared as measures of autonomic dysfunction. This study analyzed 163 adults, including 96 with Chagas disease, 35 patients with diabetes, and 32 controls. PLRs were not significantly different between Chagas disease patients and controls. Patients with diabetes had longer latency to onset of pupil constriction, slower maximum constriction velocities, and smaller orthostatic ratios than nonpatients with diabetes. PLRs correlated poorly with CAT results. A PLR-based clinical risk score demonstrated a 2.27-fold increased likelihood of diabetes complicated by autonomic dysfunction compared with the combination of blood tests, CAT, and PLRs (sensitivity 87.9%, specificity 61.3%). PLRs represent a promising tool for evaluating subclinical neuropathy in patients with diabetes without symptomatic autonomic dysfunction. Pupillometry does not have a role in the evaluation of Chagas disease patients.
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Anthony
authors.initials: A
authors.lastname: Halperin
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Monica
authors.initials: M
authors.lastname: Pajuelo
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California tornheim@jhu.edu.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Tornheim
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Nancy
authors.initials: N
authors.lastname: Vu
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Andrés M
authors.initials: AM
authors.lastname: Carnero
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Gerson
authors.initials: G
authors.lastname: Galdos-Cardenas
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Lisbeth
authors.initials: L
authors.lastname: Ferrufino
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Marilyn
authors.initials: M
authors.lastname: Camacho
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Juan
authors.initials: J
authors.lastname: Justiniano
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Rony
authors.initials: R
authors.lastname: Colanzi
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Natalie M
authors.initials: NM
authors.lastname: Bowman
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Tiffany
authors.initials: T
authors.lastname: Morris
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Hamish
authors.initials: H
authors.lastname: MacDougall
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Caryn
authors.initials: C
authors.lastname: Bern
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Steven T
authors.initials: ST
authors.lastname: Moore
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Laboratory of Infectious Diseases Research, Universidad Peruana Cayetano Heredia, Lima, Peru; Combined Internal Medicine and Pediatrics Residency Program, Yale School of Medicine, New Haven, Connecticut; University of Utah, Salt Lake City, Utah; Universidad Católica Boliviana "San Pablo," Santa Cruz de la Sierra, Bolivia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia; Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York; School of Psychology, University of Sydney, Sydney, Australia; Division of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Gilman
mesh_terms: D000328:Adult; D001342:Autonomic Nervous System Diseases / Q000175:diagnosis* / Q000473:pathology / Q000503:physiopathology; D001838:Bolivia / Q000453:epidemiology; D014355:Chagas Disease / Q000150:complications* / Q000453:epidemiology / Q000503:physiopathology; D003920:Diabetes Mellitus / Q000503:physiopathology*; D003930:Diabetic Retinopathy / Q000175:diagnosis* / Q000453:epidemiology / Q000503:physiopathology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012025:Reflex, Pupillary