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Atmaca A, Ketenci A, Sahin I, Sengun IS, Oner RI, Erdem Tilki H, Adas M, Soyleli H, Demir T. Expert opinion on screening, diagnosis and management of diabetic peripheral neuropathy: a multidisciplinary approach. Front Endocrinol (Lausanne) 2024; 15:1380929. [PMID: 38952393 PMCID: PMC11215140 DOI: 10.3389/fendo.2024.1380929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/15/2024] [Indexed: 07/03/2024] Open
Abstract
The proposed expert opinion aimed to address the current knowledge on conceptual, clinical, and therapeutic aspects of diabetic peripheral neuropathy (DPN) and to provide a guidance document to assist clinicians for the best practice in DPN care. The participating experts consider the suspicion of the disease by clinicians as a key factor in early recognition and diagnosis, emphasizing an improved awareness of the disease by the first-admission or referring physicians. The proposed "screening and diagnostic" algorithm involves the consideration of DPN in a patient with prediabetes or diabetes who presents with neuropathic symptoms and/or signs of neuropathy in the presence of DPN risk factors, with careful consideration of laboratory testing to rule out other causes of distal symmetric peripheral neuropathy and referral for a detailed neurological work-up for a confirmative test of either small or large nerve fiber dysfunction in atypical cases. Although, the first-line interventions for DPN are currently represented by optimized glycemic control (mainly for type 1 diabetes) and multifactorial intervention (mainly for type 2 diabetes), there is a need for individualized pathogenesis-directed treatment approaches for DPN. Alpha-lipoic acid (ALA) seems to be an important first-line pathogenesis-directed agent, given that it is a direct and indirect antioxidant that works with a strategy targeted directly against reactive oxygen species and indirectly in favor of endogenous antioxidant capacity for improving DPN conditions. There is still a gap in existing research in the field, necessitating well-designed, robust, multicenter clinical trials with sensitive endpoints and standardized protocols to facilitate the diagnosis of DPN via a simple and effective algorithm and to track progression of disease and treatment response. Identification of biomarkers/predictors that would allow an individualized approach from a potentially disease-modifying perspective may provide opportunities for novel treatments that would be efficacious in early stages of DPN, and may modify the natural course of the disease. This expert opinion document is expected to increase awareness among physicians about conceptual, clinical, and therapeutic aspects of DPN and to assist them in timely recognition of DPN and translating this information into their clinical practice for best practice in the management of patients with DPN.
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Affiliation(s)
- Aysegul Atmaca
- Department of Endocrinology and Metabolism, Ondokuz Mayis University Faculty of Medicine, Samsun, Türkiye
| | - Aysegul Ketenci
- Department of Physical Medicine and Rehabilitation, Koc University Faculty of Medicine, Istanbul, Türkiye
| | - Ibrahim Sahin
- Department of Endocrinology and Metabolism, Inonu University Faculty of Medicine, Malatya, Türkiye
| | - Ihsan Sukru Sengun
- Department of Neurology, Dokuz Eylul University Faculty of Medicine, Izmir, Türkiye
| | - Ramazan Ilyas Oner
- Department of Internal Medicine, Adiyaman University Faculty of Medicine, Adiyaman, Türkiye
| | - Hacer Erdem Tilki
- Department of Neurology, Ondokuz Mayis University Faculty of Medicine, Samsun, Türkiye
| | - Mine Adas
- Department of Endocrinology, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Türkiye
| | - Hatice Soyleli
- Department of Medical Affairs, Abdi Ibrahim Pharmaceuticals, Istanbul, Türkiye
| | - Tevfik Demir
- Department of Endocrinology and Metabolism, Dokuz Eylul University Faculty of Medicine, Izmir, Türkiye
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Chicharro-Luna E, Ortega-Avila AB, Requena-Martínez A, Gijon Nogueron G. Concordance between sudomotor disorder and the clinical diagnosis of diabetic peripheral neuropathy, according to various clinical guidelines. Prim Care Diabetes 2021; 15:853-858. [PMID: 34108112 DOI: 10.1016/j.pcd.2021.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/25/2021] [Accepted: 05/30/2021] [Indexed: 11/26/2022]
Abstract
AIM To assess the concordance between variations in Neuropad® results and the those in different diagnostic criteria of Diabetic Peripheral Neuropathy, according to various clinical guidelines. METHODS A descriptive observational study was conducted of 111 patients with a confirmed diagnosis of diabetes mellitus. The criteria for inclusion in the study were that patients should be aged 18 years or more and have at least 10 years' history of diabetes mellitus. RESULTS 73 (65.8%) were male and 38 (34.2%) were female. Their mean age was 57.92 ± 13.24 years (95% CI 55.45-60.38). Healthy Neuropad® findings were obtained for 35 right feet (31.5%) and 31 left feet (27.9%). CONCLUSION Neuropad® is an effective instrument for detecting macro and microvascular complications such as early-stage neuropathy, although its use should always be accompanied by a clinical examination of the foot.
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Affiliation(s)
- Esther Chicharro-Luna
- Department of Behavioural Sciences and Health, University of Miguel Hernandez, Alicante, Spain
| | - Ana Belen Ortega-Avila
- Department of Nursing, University of Malaga, Spain; Biomedical Research Institute (IBIMA), Malaga, Spain.
| | - Aranza Requena-Martínez
- Department of Behavioural Sciences and Health, University of Miguel Hernandez, Alicante, Spain
| | - Gabriel Gijon Nogueron
- Department of Nursing, University of Malaga, Spain; Biomedical Research Institute (IBIMA), Malaga, Spain
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Early Detection of Diabetic Peripheral Neuropathy: A Focus on Small Nerve Fibres. Diagnostics (Basel) 2021; 11:diagnostics11020165. [PMID: 33498918 PMCID: PMC7911433 DOI: 10.3390/diagnostics11020165] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/14/2021] [Accepted: 01/20/2021] [Indexed: 02/07/2023] Open
Abstract
Diabetic peripheral neuropathy (DPN) is the most common complication of both type 1 and 2 diabetes. As a result, neuropathic pain, diabetic foot ulcers and lower-limb amputations impact drastically on quality of life, contributing to the individual, societal, financial and healthcare burden of diabetes. DPN is diagnosed at a late, often pre-ulcerative stage due to a lack of early systematic screening and the endorsement of monofilament testing which identifies advanced neuropathy only. Compared to the success of the diabetic eye and kidney screening programmes there is clearly an unmet need for an objective reliable biomarker for the detection of early DPN. This article critically appraises research and clinical methods for the diagnosis or screening of early DPN. In brief, functional measures are subjective and are difficult to implement due to technical complexity. Moreover, skin biopsy is invasive, expensive and lacks diagnostic laboratory capacity. Indeed, point-of-care nerve conduction tests are convenient and easy to implement however questions are raised regarding their suitability for use in screening due to the lack of small nerve fibre evaluation. Corneal confocal microscopy (CCM) is a rapid, non-invasive, and reproducible technique to quantify small nerve fibre damage and repair which can be conducted alongside retinopathy screening. CCM identifies early sub-clinical DPN, predicts the development and allows staging of DPN severity. Automated quantification of CCM with AI has enabled enhanced unbiased quantification of small nerve fibres and potentially early diagnosis of DPN. Improved screening tools will prevent and reduce the burden of foot ulceration and amputations with the primary aim of reducing the prevalence of this common microvascular complication.
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Yuan T, Li J, Fu Y, Xu T, Li J, Wang X, Zhou Y, Dong Y, Zhao W. A cardiac risk score based on sudomotor function to evaluate cardiovascular autonomic neuropathy in asymptomatic Chinese patients with diabetes mellitus. PLoS One 2018; 13:e0204804. [PMID: 30281621 PMCID: PMC6169902 DOI: 10.1371/journal.pone.0204804] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/14/2018] [Indexed: 01/17/2023] Open
Abstract
Backgrounds Cardiac autonomic neuropathy is a common but always overlooked. More convenient diagnostic methods are needed. Hypothesis Cardiac autonomic neuropathy risk score evaluated by SUDOSCAN has a fine diagnostic efficacy detecting cardiac autonomic neuropathy. Methods This is a cross-sectional study among patients with diabetes mellitus. Subjects undertook SUDOSCAN tests and cardiac autonomic reflex tests, including heart rate variability due to Valsalva maneuver, heart rate response due to deep breathing and heart rate response due to standing up. Presenting 2 abnormal results was defined as cardiac autonomic neuropathy. Results Subjects with cardiac autonomic neuropathy has significantly higher cardiac autonomic neuropathy risk score (32.88±1.60 vs 27.64±1.24,P = 0.010). Cardiac autonomic neuropathy risk score was correlated significantly with the heart rate response due to deep breathing(P = 0.004). Multiple regression analysis including significant variables showed an independent association of cardiac autonomic neuropathy risk score and heart rate response due to deep breathing (P = 0.031) and age (P = 0.000). In receiver operating characteristic curve analysis evaluating the relationship between cardiac autonomic neuropathy risk score and cardiac autonomic neuropathy, The cut-off value was 20.5, with the sensitivity of 90.48%, the specificity of 29.5%, and the positive predictive value of 46.9%. In two-step diagnostic methods, Setting 20.5 as the cut-off value of cardiac autonomic neuropathy risk score and abnormal heart rate response due to standing up as the second diagnostic step’s positive result, and setting 16.5 as the cut-off value of cardiac autonomic neuropathy risk score and abnormal heart rate response due to deep breathing as the second diagnostic step’s positive result, both achieved good diagnostic efficacy. Conclusion Cardiac autonomic neuropathy risk score evaluated by SUDOSCAN is a good screening test for cardiac autonomic neuropathy. The two-step diagnostic methods could be considered as surrogate diagnostic methods.
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Affiliation(s)
- Tao Yuan
- Department of Endocrinology, Key Laboratory of Endocrinology of the National Health and Family Planning Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jiapei Li
- Department of Endocrinology, Key Laboratory of Endocrinology of the National Health and Family Planning Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yong Fu
- Department of Endocrinology, Key Laboratory of Endocrinology of the National Health and Family Planning Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Tao Xu
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Juan Li
- Department of Endocrinology, Key Laboratory of Endocrinology of the National Health and Family Planning Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xiangqing Wang
- Department of Endocrinology, Key Laboratory of Endocrinology of the National Health and Family Planning Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Zhou
- Department of Endocrinology, Key Laboratory of Endocrinology of the National Health and Family Planning Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yingyue Dong
- Department of Endocrinology, Key Laboratory of Endocrinology of the National Health and Family Planning Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Weigang Zhao
- Department of Endocrinology, Key Laboratory of Endocrinology of the National Health and Family Planning Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
- * E-mail:
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Vinik AI, Nevoret ML, Casellini C. The New Age of Sudomotor Function Testing: A Sensitive and Specific Biomarker for Diagnosis, Estimation of Severity, Monitoring Progression, and Regression in Response to Intervention. Front Endocrinol (Lausanne) 2015; 6:94. [PMID: 26124748 PMCID: PMC4463960 DOI: 10.3389/fendo.2015.00094] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 05/23/2015] [Indexed: 12/27/2022] Open
Abstract
Sudorimetry technology has evolved dramatically, as a rapid, non-invasive, robust, and accurate biomarker for small fibers that can easily be integrated into clinical practice. Though skin biopsy with quantitation of intraepidermal nerve fiber density is still currently recognized as the gold standard, sudorimetry may yield diagnostic information not only on autonomic dysfunction but also enhance the assessment of the small somatosensory nerves, disease detection, progression, and response to therapy. Sudorimetry can be assessed using Sudoscan™, which measures electrochemical skin conductance (ESC) of hands and feet. It is based on different electrochemical principles (reverse iontophoresis and chronoamperometry) to measure sudomotor function than prior technologies, affording it a much more practical and precise performance profile for routine clinical use with potential as a research tool. Small nerve fiber dysfunction has been found to occur early in metabolic syndrome and diabetes and may also be the only neurological manifestation in small fiber neuropathies, beneath the detection limits of traditional nerve function tests. Test results are robust, accomplished within minutes, require little technical training and no calculations, since established norms have been provided for the effects of age, gender, and ethnicity. Sudomotor testing has been greatly under-utilized in the past, restricted to specialized centers capable of handling the technically demanding and expensive technology. Yet, evaluation of autonomic and somatic nerve function has been shown to be one of the best estimates of cardiovascular risk. Evaluation of sweating has the appeal of quantifiable non-invasive determination of the integrity of the peripheral autonomic nervous system, and can now be accomplished rapidly at point of care clinics with the determination of ESC, allowing intervention for morbid complications prior to permanent structural nerve damage. We review here sudomotor function testing technology, the research evidence accumulated supporting the clinical utility of measuring ESC, the medical applications of sudorimetry now available to physicians with this device, and clinical vignettes illustrating its use in the clinical decision-making process.
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Affiliation(s)
- Aaron I. Vinik
- Division of Endocrinology and Metabolism, Department of Medicine, Strelitz Diabetes and Neuroendocrine Center, Eastern Virginia Medical School, Norfolk, VA, USA
| | | | - Carolina Casellini
- Division of Endocrinology and Metabolism, Department of Medicine, Strelitz Diabetes and Neuroendocrine Center, Eastern Virginia Medical School, Norfolk, VA, USA
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Papanas N, Boulton AJM, Malik RA, Manes C, Schnell O, Spallone V, Tentolouris N, Tesfaye S, Valensi P, Ziegler D, Kempler P. A simple new non-invasive sweat indicator test for the diagnosis of diabetic neuropathy. Diabet Med 2013; 30:525-34. [PMID: 22924579 DOI: 10.1111/dme.12000] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A simple non-invasive indicator test (Neuropad(®)) has been developed for the assessment of sweating and, hence, cholinergic innervation in the diabetic foot. The present review summarizes current knowledge on this diagnostic test. The diagnostic ability of this test is based on a colour change from blue to pink at 10 min, with excellent reproducibility, which lends itself to patient self-examination. It has a high sensitivity (65.1-100%) and negative predictive value (63-100%), with moderate specificity (32-78.5%) and positive predictive value (23.3-93.2%) for the diagnosis of diabetic peripheral neuropathy. It also has moderate to high sensitivity (59.1-89%) and negative predictive value (64.7-91%), but low to moderate specificity (27-78%) and positive predictive value (24-48.6%) for the diagnosis of diabetic cardiac autonomic neuropathy. There are some data to suggest that Neuropad can detect early diabetic neuropathy, but this needs further evaluation. It remains to be established whether this test can predict foot ulceration and amputation, thereby contributing to the identification of high-risk patients.
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Affiliation(s)
- N Papanas
- Outpatient Clinic of the Diabetic Foot, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece University of Manchester and Manchester Diabetes Centre, Manchester, UK.
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Papanas N, Ziegler D. New diagnostic tests for diabetic distal symmetric polyneuropathy. J Diabetes Complications 2011; 25:44-51. [PMID: 19896871 DOI: 10.1016/j.jdiacomp.2009.09.006] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Revised: 09/13/2009] [Accepted: 09/28/2009] [Indexed: 11/24/2022]
Abstract
Neuropathy needs to be diagnosed early to prevent complications, such as neuropathic pain or the diabetic foot. It is obvious that diagnosis of neuropathy needs to be improved. New peripheral nerve function tests that appear to facilitate diagnosis are now emerging. This review outlines the new tests that have been proposed for the diagnosis of diabetic distal symmetric polyneuropathy, the commonest form of neuropathy in diabetes. New tests are classified into those mainly assessing large-fiber function (tactile circumferential discriminator, steel ball-bearing, and automated nerve conduction study) and those mainly assessing small-fiber function (NeuroQuick and Neuropad). Emerging tests are promising but must be evaluated in prospective studies. Moreover, their cost-effectiveness needs more careful appraisal. The clinician should, therefore, still rely on established modalities to diagnose neuropathy, but wider use of the new tests is expected in the near future.
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Affiliation(s)
- Nikolaos Papanas
- Outpatient Clinic of the Diabetic Foot in the Second Department of Internal Medicine at Democritus University of Thrace, Greece.
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Elisa B, Silvia M, Valentina D, Loredana R, Anna T, Alessia S, Chiara G, Fabrizio C, Marco R, Piaggesi A. Use of Nanotechnology-Designed Footsock in the Management of Preulcerative Conditions in the Diabetic Foot: Results of a Single, Blind Randomized Study. INT J LOW EXTR WOUND 2008; 7:82-7. [DOI: 10.1177/1534734608318138] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Difoprev system constituted by a sock loaded with nanocapsules containing a hydrating agent in the diabetic foot is tested. A total of 30 neuropathic outpatients with foot anhydrosis were randomized into group A, treated with the application of the sock with the nanocapsules, and group B wearing only the socks without the nanocapsules. Patients were blindly evaluated with a clinical score, hygrometry, transepidermal water loss, skin temperature, and skin hardness at baseline and after 6 weeks. No difference between the groups emerged at baseline. Although group B showed no changes at the end of the treatment, group A significantly ( P < .05) improved in all the parameters evaluated. No adverse events were recorded in both groups during the study. The use of hydrating agents carried by nanocapsules-loaded socks is safe and effective for the neuropathic diabetic foot.
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Affiliation(s)
- Banchellini Elisa
- Department of Endocrinology and Metabolism, Diabetic
Foot Section, University of Pisa
| | - Macchiarini Silvia
- Department of Endocrinology and Metabolism, Diabetic
Foot Section, University of Pisa
| | - Dini Valentina
- Department of Surgery, Dermatologic Clinic University
of Pisa, Italy
| | - Rizzo Loredana
- Department of Endocrinology and Metabolism, Diabetic
Foot Section, University of Pisa
| | - Tedeschi Anna
- Department of Endocrinology and Metabolism, Diabetic
Foot Section, University of Pisa
| | - Scatena Alessia
- Department of Endocrinology and Metabolism, Diabetic
Foot Section, University of Pisa
| | - Goretti Chiara
- Department of Endocrinology and Metabolism, Diabetic
Foot Section, University of Pisa
| | - Campi Fabrizio
- Department of Endocrinology and Metabolism, Diabetic
Foot Section, University of Pisa
| | - Romanelli Marco
- Department of Surgery, Dermatologic Clinic University
of Pisa, Italy
| | - Alberto Piaggesi
- Department of Endocrinology and Metabolism, Diabetic
Foot Section, University of Pisa,
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