The diabetic hand: a forgotten complication?

Carpal Tunnel Syndrome and Trigger Finger May Be an Early Symptom of Preclinic Type 2 Diabetes

Background

Type 2 diabetes (T2D) is a major risk factor for carpal tunnel syndrome (CTS) and trigger finger (TF), but less is known regarding the risk of developing T2D after being diagnosed with CTS or TF. CTS and TF could be early signs of preclinical T2D, and early detection of T2D is crucial to prevent complications and morbidity. Therefore, we investigate the association between CTS/TF and T2D in an adult population without previous T2D using big data registers in Sweden.

Methods

Data were collected by crosslinking five nationwide Swedish registers. Individuals aged 40-85 years on December 31, 2010, without prior overt diabetes, were included (n = 3,948,517) and followed up from baseline (ie, a diagnosis of CTS or TF) or January 1, 2011, for controls, until a diagnosis of T2D, prescription of oral antidiabetics or insulin, or end of follow-up four years after baseline. Multivariate Cox regression models were created to calculate hazard ratios for T2D.

Results

In total, 37,346 (0.95%) patients were diagnosed with CTS, whereof 1329 (3.46%) developed T2D. There were 17,432 (0.44%) patients who developed TF, whereof 639 (3.67%) developed T2D. Among the controls, 2.73% developed T2D. Compared with controls, there was an increased risk of developing T2D after being diagnosed with either CTS (HR 1.35; 95% confidence interval 1.28-1.43) or TF (HR 1.21; 95% confidence interval 1.12-1.31).

Conclusion

Compared with controls, a diagnosis of CTS or TF was associated with 35% and 21% higher risk for later T2D, respectively, which might indicate the existence of undetected T2D in this population.

Diabetes Mellitus Is a Possible Risk Factor for the Development of Trochanteric Bursitis-A Large-Scale Population-Based Study

BACKGROUND

Trochanteric Bursitis (TB) is a common reason to seek primary care, previously shown to be associated with female gender and obesity. Diabetes mellitus (DM) has several musculoskeletal manifestations, but was never found to be associated with TB.

PURPOSE

To explore the association between DM and TB, based on a large database. The secondary aim was to explore the influence of gender and insulin usage on the occurrence of TB.

STUDY DESIGN

cross-sectional study.

METHODS

A population-based cohort consisting of 60,610 patients (55,428 without DM and 5182 with DM), of whom 5418 were diagnosed with TB. A logistic regression model was applied to estimate propensity scores.

RESULTS

The odds of individuals with DM being diagnosed with TB were 55.8% higher compared to the odds of patients without DM (OR: 1.558, 95% CI: [1.429, 1.70], p < 0.0001). We found that insulin users had a lower risk of TB than patients not using insulin (log-rank p < 0.0001). Females are 3.3 times more likely to have TB than males (RR: 3.337, 95% CI: [3.115, 3.584], p < 0.0001).

CONCLUSIONS

DM is a risk factor for developing TB. Insulin had a protective effect against TB, suggesting that better glycemic control might prevent this painful infliction.

Patient Experiences after Open Trigger Finger Release in Patients with Type 1 and Type 2 Diabetes-A Retrospective Study Using Patient-reported Outcome Measures

Trigger finger is overrepresented among patients with diabetes mellitus (DM). Whether DM affects the outcome after open trigger finger release (OTFR) in patients with DM is not known. Our aim was thus to explore outcomes after OTFR in patients with type 1 (T1D) and type 2 DM (T2D).

Methods

Data included patient-reported outcome measures (PROMs) from all OTFRs performed between 2010 and 2020 registered in the Swedish national registry for hand surgery in individuals over 18 years cross-linked with the Swedish National Diabetes Register (NDR). PROMs included QuickDASH and HQ8, a questionnaire designed for national registry for hand surgery, preoperative and at 3 and 12 months postoperative. HQ8 included pain on load, pain on motion without load, and stiffness. Outcome was calculated using linear-mixed models and presented as means adjusted for age and stratified by sex.

Results

In total, 6242 OTFRs were included, whereof 496 had T1D (332, 67% women) and 869 had T2D (451, 52% women). Women with T1D reported more symptoms of stiffness (P < 0.001), and women with T2D reported more pain on load (P < 0.05), motion without load (P < 0.01), and worse overall result at 3 months. At 12 months, however, no differences were found in any of the HQ-8 PROMs among men or women. Women with T2D had slightly higher QuickDASH scores at 3 and 12 months.

Conclusion

Patients with T1D and T2D can expect the same results after OTFR as individuals without DM, although the improvement might take longer especially among women with T2D.

High HbA1c Levels Are Associated With Development of Trigger Finger in Type 1 and Type 2 Diabetes: An Observational Register-Based Study From Sweden

OBJECTIVE

Trigger finger (TF) is a hand disorder causing the fingers to painfully lock in flexion. Diabetes is a known risk factor; however, whether strict glycemic control effectively lowers risk of TF is unknown. Our aim was to examine whether high HbA1c was associated with increased risk of TF among individuals with diabetes.

RESEARCH DESIGN AND METHODS

The Swedish National Diabetes Register (NDR) was cross-linked with the health care register of the Region of Skåne in southern Sweden. In total, 9,682 individuals with type 1 diabetes (T1D) and 85,755 individuals with type 2 diabetes (T2D) aged ≥18 years were included from 2004 to 2019. Associations between HbA1c and TF were calculated with sex-stratified, multivariate logistic regression models with 95% CIs, with adjustment for age, duration of diabetes, BMI, and systolic blood pressure.

RESULTS

In total, 486 women and 271 men with T1D and 1,143 women and 1,009 men with T2D were diagnosed with TF. Increased levels of HbA1c were associated with TF among individuals with T1D (women OR 1.26 [95% CI 1.1-1.4], P = 0.001, and men 1.4 [1.2-1.7], P < 0.001) and T2D (women 1.14 [95% CI 1.2-1.2], P < 0.001, and men 1.12 [95% CI 1.0-1.2], P = 0.003).

CONCLUSIONS

Hyperglycemia increases the risk of developing TF among individuals with T1D and T2D. Optimal treatment of diabetes seems to be of importance for prevention of diabetic hand complications such as TF.

Diabetes mellitus tendino-myopathy: epidemiology, clinical features, diagnosis and management of an overlooked diabetic complication

Tendino-myopathy, an unexplored niche, is a non-vascular unstated T2DM complication, which is largely disregarded in clinical practice, thus, we aim to explore it in this review. Literature search using published data from different online resources. Epidemiologically, reported prevalence varies around 10-90%, which is marked variable and unreliable. Clinically, diabetic tendino-myopathy is typified by restriction of movement, pain/tenderness, cramps and decreased functions. Moreover, myopathy is characterized by muscle atrophy, weakness and ischemia, and tendinopathy by deformities and reduced functions/precision. In tendonapthy, the three most affected regions are: the hand (cheiroarthropathy, Dupuytren's contracture, flexor tenosynovitis and carpel tunnel syndrome), shoulder (adhesive capsulitis, rotator cuff tendinopathy and tenosynovitis) and foot (Achilles tendinopathy with the risk of tear/rupture), in addition to diffuse idiopathic skeletal hyperostosis. Pathologically, it is characterized by decreased muscle fiber mass and increased fibrosis, with marked extracellular matrix remodeling and deposition of collagens. The tendon changes include decreased collagen fibril diameter, changed morphology, increased packing and disorganization, with overall thickening, and calcification. Diagnosis is basically clinical and radiological, while diagnostic biomarkers are awaited. Management is done by diabetes control, special nutrition and physiotherapy, while analgesics, steroids and surgery are used in tendinopathy. Several antisarcopenic drugs are in the pipeline. This review aims to bridge clinical practice with research and update routine diabetic checkup by inclusion of tendino-myopathies in the list with an emphasis on management.

Self-Reported Disability Following Surgery for Dupuytren Contracture in Diabetic and Non-Diabetic Patients

Background: The aims of this study were to investigate the impact of diabetes mellitus on patient-reported functional outcome measures (PROMs) and satisfaction following surgical treatment of Dupuytren contracture.

Methods: Preoperative and 1-year postoperative PROMs were collected prospectively over 6 years (2013–2019). Patients completed the QuickDASH score and were asked ‘how normal is your hand?’, recording responses on a 100-point visual analogue scale. Patient satisfaction was also self-reported.

Results: Paired responses were available for 520 hands (478 patients; 72% follow-up rate). There were 62 patients with diabetes (12%). Pre (12.5 vs. 9.1; p = 0.01) and postoperative (11.4 vs. 6.8; p = 0.02) QuickDASH scores were significantly, but not clinically, worse in diabetic patients. Patient satisfaction was high in both groups. A large and significant improvement in self-perceived hand normality was observed in both groups (p < 0.05). No significant differences were observed in preoperative or change in hand normality between the groups, but the postoperative normal hand score was significantly higher in non-diabetic patients (94 vs. 90; p = 0.02).

Conclusion: Our study has demonstrated statistically significantly worse disability in diabetic patients with Dupuytren contracture both pre- and postoperatively, though the observed differences were far below the minimum clinically important difference for the QuickDASH. Both groups reported a large and statistically significant improvement in self-perceived hand normality following surgery.

Level of Evidence: Level III (Therapeutic)

Carpal Tunnel Syndrome and Diabetes—A Comprehensive Review

Carpal tunnel syndrome (CTS) is the most common compression neuropathy in the general population and is frequently encountered among individuals with type 1 and 2 diabetes. The reason(s) why a peripheral nerve trunk in individuals with diabetes is more susceptible to nerve compression is still not completely clarified, but both biochemical and structural changes in the peripheral nerve are probably implicated. In particular, individuals with neuropathy, irrespective of aetiology, have a higher risk of peripheral nerve compression disorders, as reflected among individuals with diabetic neuropathy. Diagnosis of CTS in individuals with diabetes should be carefully evaluated; detailed case history, thorough clinical examination, and electrophysiological examination is recommended. Individuals with diabetes and CTS benefit from surgery to the same extent as otherwise healthy individuals with CTS. In the present review, we describe pathophysiological aspects of the nerve compression disorder CTS in relation to diabetes, current data contributing to the explanation of the increased risk for CTS in individuals with diabetes, as well as diagnostic methods, treatment options, and prognosis of CTS in diabetes.

Prevalence and Associated Factors of Carpal Tunnel Syndrome Among Diabetic Patients in Arba Minch General Hospital, South West Ethiopia, 2021

PURPOSE OF THE STUDY

This study aimed to assess the prevalence of carpal tunnel syndrome and associated factors among diabetic patients in Arba Minch General Hospital, Southwest Ethiopia. Carpal tunnel syndrome (CTS) is the second most common cause of absence from work which causes functional loss of the hands and leads to disability. However, it is understudied among diabetic patients in Ethiopia.

PATIENTS AND MATERIALS

An institution-based cross-sectional study was conducted from May 1 to October 1, 2021. Systematic random sampling method was used to select 353 study participants. CTS-6 Evaluation tool was applied to assess carpal tunnel syndrome. The data was coded and entered into Epi-Data version 3.1 statistical packages and exported to SPSS version 25 for analysis. Binary logistic regression model was applied to assess the association between outcome variable and independent variables. Odds ratio (OR) with 95% CI and p-values <0.05 were used to identify significantly associated factors with an outcome variable.

RESULTS

The study was conducted among 353 diabetic patients. The cumulative prevalence of carpal tunnel syndrome among diabetes was 3.1%. CTS was statistically significantly associated with high body mass index; AOR=0.34 (0.12, 0.97, 95% CI) (p=0.04. Majority of participants 322 (91.2%) had type 2 DM. Mean fasting blood sugar level ± standard error of study participants was 157.52 ± 1.91 mg/dl.

CONCLUSION

The prevalence of carpal tunnel syndrome was relatively low. High body mass index (BMI) was significantly but negatively associated with carpal tunnel syndrome compared to diabetic patients with normal BMI. Diabetic patients with normal BMI should be screened for CTS for early management of the disease and prevention of further complications. Further investigations are recommended.

Diabetic hand: prevalence and incidence of diabetic hand problems using data from 1.1 million inhabitants in southern Sweden

INTRODUCTION

'The diabetic hand' has traditionally referred to hand complications due to diabetes mellitus (DM), including trigger finger (TF) and Dupuytren's disease (DD). Recent publications have also proposed DM as a risk factor for carpal tunnel syndrome (CTS), ulnar nerve entrapment (UNE), and possibly osteoarthritis (OA) of the first carpometacarpal (CMC-1) joint. This study aimed to explore prevalence and incidence of diabetic hand complications among the population in southern Sweden.

RESEARCH DESIGN AND METHODS

Approximately 1.1 million inhabitants in the region of Skåne aged ≥18 years, whereof 50 000 with DM, were included. Data on incident CTS, UNE, TF, DD, and OA of the CMC-1 joint between 2004 and 2019 were collected from the Skåne Healthcare Register and cross-linked with the National Diabetes Register. Prevalences on December 31, 2019 and 10-year incidence ratios were calculated for type 1 diabetes (T1D), type 2 diabetes (T2D), and the population without DM, stratified for sex. Prevalence ratios and incidence rate ratios with 95% CIs were used for group comparisons.

RESULTS

The prevalences of all five studied diagnoses were higher in both men and women with T1D and T2D (p<0.01) and both T1D and T2D had more concomitant prevalent diagnoses (p<0.0001). The 10-year incidence rates of all diagnoses were higher among T1D and T2D (p<0.0001), except OA of the CMC-1 joint in men with T1D (p=0.055).

CONCLUSIONS

CTS, UNE, and possibly also OA of the CMC-1 joint should be included together with TF and DD when referring to 'the diabetic hand'. The incidence of hand disorders was up to eight times higher among T1D, and both T1D and T2D had more concomitant prevalent diagnoses compared with the population without DM. Future studies should elucidate the pathophysiology behind diabetic hand complications to enable development of effective preventive measures in patients with diabetes.

The impact of type 2 diabetes on the development of tendinopathy

Tendinopathy is a chronic and often painful condition affecting both professional athletes and sedentary subjects. It is a multi-etiological disorder caused by the interplay among overload, ageing, smoking, obesity (OB) and type 2 diabetes (T2D). Several studies have identified a strong association between tendinopathy and T2D, with increased risk of tendon pain, rupture and worse outcomes after tendon repair in patients with T2D. Moreover, consequent immobilization due to tendon disorder has a strong impact on diabetes management by reducing physical activity and worsening the quality of life. Multiple investigations have been performed to analyse the causal role of the individual metabolic factors occurring in T2D on the development of tendinopathy. Chronic hyperglycaemia, advanced glycation end-products, OB and insulin resistance have been shown to contribute to the development of diabetic tendinopathy. This review aims to explore the relationship between tendinopathy and T2D, in order to define the contribution of metabolic factors involved in the degenerative process and to discuss possible strategies for the clinical management of diabetic tendinopathy.

Metabolic factors and the risk of Dupuytren's disease: data from 30,000 individuals followed for over 20 years

Dupuytren’s disease (DD) is a fibroproliferative disorder affecting the palmar fascia of the hand. Risk factors include diabetes mellitus (DM), whereas a high body mass index (BMI) is associated with a lower prevalence of DD. The aim of this study was to further elucidate risk and protective factors for the development of DD using longitudinal population-based data from the Malmö Diet and Cancer Study (MDCS). During 1991–1996, the inhabitants aged 46–73 years in the city of Malmö, Sweden were invited to participate in the population-based MDCS (41% participation rate). Data on incident DD were retrieved from Swedish national registers. Associations between DM, alcohol consumption, BMI, and serum apolipoprotein A1 (ApoA1) and apolipoprotein B (ApoB) at baseline were analysed in multivariable Cox regression models adjusted for known confounders. Among 30,446 recruited participants, 347 men and 194 women were diagnosed with DD during a median follow-up time of 23 years. DM (men HR 2.23; 95% CI 1.50–3.30, women HR 2.69; 95% CI 1.48–4.90) and alcohol consumption (men HR 2.46; 95% CI 1.85–3.27, women HR 3.56; 95% CI 1.95–6.50) were independently associated with incident DD in the Cox regression models. Furthermore, inverse associations with incident DD were found for obesity among men, and ApoB/ApoA1 ratio among both sexes. DM and excess alcohol consumption constituted major risk factors for the development of DD. Furthermore, an inverse association between obesity among men and DD, and also between ApoB/ApoA1 ratio and DD was found in both sexes.

Cutaneous Manifestations of Diabetes

Diabetes mellitus is a significant worldwide health concern and cutaneous manifestations are common. This review describes characteristic skin findings of diabetes, general skin findings related to diabetes, and findings related to diabetes treatment with a focus on clinical presentation, diagnosis, pathophysiology, epidemiology, and treatment. As the prevalence of diabetes continues to rise, cutaneous manifestations of diabetes mellitus likely will be encountered more frequently by physicians in all disciplines including dermatologists and primary care physicians. Accordingly, knowledge regarding the prevention, diagnosis, and management of cutaneous manifestations is an important aspect in the care of patients with diabetes.

Trigger finger is associated with risk of incident cardiovascular disease in individuals with type 2 diabetes: a retrospective cohort study

INTRODUCTION

Trigger finger is one of the complications affecting the upper extremity in patients with diabetes. Diabetes is also a well-known risk factor that predisposes individuals to cardiovascular diseases (CVDs). This retrospective cohort study aimed to establish the association between trigger finger and the patients with incident CVD with type 2 diabetes.

MATERIALS AND METHODS

Trigger finger was diagnosed by palpating a thickened tendon during flexion or on the manifestation of a locking phenomenon during extension or flexion of either finger. The relationship between trigger finger and other clinical parameters or complications of diabetes was examined by a comparative analysis. Cox regression analysis was used to evaluate the association between trigger finger and incidence of CVD. We calculated the propensity scores using sex, body mass index, age, smoking status, duration of diabetes, estimated glomerular filtration rate, hypertension, dyslipidemia, and hemoglobin A1c as the number of patients with incident CVD during the follow-up period was low.

RESULTS

Among the 399 patients with type 2 diabetes, 54 patients had trigger finger. Patients with trigger finger were significantly older in age and had been suffering from diabetes for a longer duration. They also displayed worse renal function and glycemic control, along with a higher incidence of hypertension, neuropathy and nephropathy. During the average 5.66±1.12 years of follow-up, a total of 18 incidents occurred. According to the Cox regression analysis, trigger finger was shown to be associated with enhanced risk of the incidence of CVD after adjustment for the covariates (adjusted HR=3.33 (95% CI 1.25 to 8.66), p=0.017).

CONCLUSIONS

Trigger finger is associated with the risk of incident CVD in patients with type 2 diabetes. Thus, clinicians must consider these factors at the time of diagnosis of such patients.

Electrodiagnostic Testing Characteristics of Diabetic People with Carpal Tunnel Syndrome

Objective  The present study aimed to correlate electroneuromyography (ENMG) findings in diabetic and nondiabetic subjects with carpal tunnel syndrome (CTS).

Methods  In total, 154 patients were evaluated in a hand surgery outpatient clinic. All ENMG tests were bilaterally performed by a single neurologist. Qualitative variables were described for all patients with CTS according to their diabetic status, and the chi-squared test was used to reveal any association. A joint model was adjusted to determine the influence of diabetes on ENMG severity in CTS patients.

Results  The sample consisted of 117 women and 37 men, with an average age of 56.9 years old. Electroneuromyography demonstrated bilateral CTS in 82.5% of the patients. Diabetes was identified in 21.4% of the cases. Severe ENMG was prevalent.

Conclusion  There was no association between diabetes and ENMG severity in patients with CTS. Level of evidence IV, case series.

Cutaneous and muscular afferents from the foot and sensory fusion processing: Physiology and pathology in neuropathies

The foot-sole cutaneous receptors (section 2), their function in stance control (sway minimisation, exploratory role) (2.1), and the modulation of their effects by gait pattern and intended behaviour (2.2) are reviewed. Experimental manipulations (anaesthesia, temperature) (2.3 and 2.4) have shown that information from foot sole has widespread influence on balance. Foot-sole stimulation (2.5) appears to be a promising approach for rehabilitation. Proprioceptive information (3) has a pre-eminent role in balance and gait. Reflex responses to balance perturbations are produced by both leg and foot muscle stretch (3.1) and show complex interactions with skin input at both spinal and supra-spinal levels (3.2), where sensory feedback is modulated by posture, locomotion and vision. Other muscles, notably of neck and trunk, contribute to kinaesthesia and sense of orientation in space (3.3). The effects of age-related decline of afferent input are variable under different foot-contact and visual conditions (3.4). Muscle force diminishes with age and sarcopenia, affecting intrinsic foot muscles relaying relevant feedback (3.5). In neuropathy (4), reduction in cutaneous sensation accompanies the diminished density of viable receptors (4.1). Loss of foot-sole input goes along with large-fibre dysfunction in intrinsic foot muscles. Diabetic patients have an elevated risk of falling, and vision and vestibular compensation strategies may be inadequate (4.2). From Charcot-Marie-Tooth 1A disease (4.3) we have become aware of the role of spindle group II fibres and of the anatomical feet conditions in balance control. Lastly (5) we touch on the effects of nerve stimulation onto cortical and spinal excitability, which may participate in plasticity processes, and on exercise interventions to reduce the impact of neuropathy.

Sensory nerve conduction study of median ulnar and radial nerves in type 2 diabetic individuals in the age group 40-80 years

Aim

The study intends to find out the effect of Type 2 diabetes on the sensory nerve of the upper extremity.

Method

This research includes 100 subjects, both male and female, within the age group of 40-80 years. The subjects were divided into two groups, A and B. Where Group A includes 50 subjects which diagnosed type 2 diabetic mellitus. Furthermore, Group B holds 50 normal healthy subjects investigated and normal healthy subjects without diabetes mellitus. Written consent was obtained from the subjects who were ready to be part of this study. Orthodromic sensory nerve conduction studies of median, ulnar, and radial nerve were assessed by using EMG diagnostic device for bilateral upper extremities in both groups. The sensory nerve conduction study included nerve conduction velocity (m/s), latency (ms), and amplitude (μV). The data analyzed using paired 't' test within the group and unpaired 't' test between two groups, using computational statistical software Graph Pad Prism. 'p' value < 0.05 was considered to be statistically significant.

Results

The sensory nerve amplitude of all three nerves reduced the velocity of the median & ulnar nerve was reduced and prolonged latency of ulnar nerve in type 2 diabetics as compared to the Non-diabetics group.

Conclusion

This study concluded that the type 2 diabetics group has severe sensory nerve affections of the median and ulnar nerve. The therapist should examine the upper extremity of all diabetic subjects, and hand care should be taught to the patients to prevent further complications of diabetic peripheral neuropathy.

A Multicenter, Prospective, Observational, Open-Label Study of the Safety and Comfort of Gensulin® Delivery Device Use in a Large Cohort of Adult and Elderly Patients with Type 2 Diabetes

Insulin treatment is necessary for many patients with type 2 diabetes, and its delivery must be safe and comfortable. This study evaluated patients' safety and comfort when using a Gensulin^® delivery device, GensuPen (Bioton), a reusable insulin pen device for injecting Gensulin^® insulin among adult and elderly patients with type 2 diabetes. This was a 4-week multicenter, prospective, observational, open-label study in patients with diabetes mellitus type 2 who have recently started using a GensuPen. Overall, 10,309 patients (mean age: 63 ± 12.0 years; 47.9% female) were analyzed in this study. Of these, 2.5% had used an insulin delivery device before, and for 97.5%, GensuPen was the first delivery device they had used. Most (87.8%) of the patients rated the GensuPen as very good in setting the dose, 92.0% in confirmation of successful insulin administration, 80.9% in trigger location, and 75.0% in force needed for injection. The overall safety of the GensuPen use was high since severe hypoglycemia occurred only in 0.2% of the studied patients. There were 0.6% adverse events, none of which were serious. This real-life observation data shows that the GensuPen was well accepted and safe in this large patient population of adult and elderly patients with type 2 diabetes.

Diabetes mellitus as a risk factor for compression neuropathy: a longitudinal cohort study from southern Sweden

INTRODUCTION

Compression neuropathies (CN) in the upper extremity, the most common being carpal tunnel syndrome (CTS) and ulnar nerve entrapment (UNE), are frequent among patients with diabetes mellitus (DM). Earlier studies have shown contradicting results regarding DM as a risk factor for CN. Thus, the aim of the present population-based, longitudinal study was to explore potential associations between DM, CTS, and UNE during long-term follow-up.

RESEARCH DESIGN AND METHODS

A total of 30 466 participants aged 46-73 years, included in the population-based Malmö Diet and Cancer Study during 1991-1996, were followed up in Swedish national registries regarding incident CTS and UNE until 2016. Associations between prevalent DM at baseline and incident CTS or UNE were calculated using Cox proportional hazard models, adjusted for baseline confounders, such as sex, age at study entry, smoking, hypertension, use of antihypertensive treatment, alcohol consumption, and body mass index (BMI). HbA1c and fasting plasma glucose levels had been measured at baseline in a subgroup of 5508 participants and were related to incident CTS and UNE in age and sex-adjusted binary logistic regression models.

RESULTS

A total of 1081 participants developed CTS and 223 participants developed UNE during a median follow-up of 21 years. Participants with incident CTS or UNE had higher prevalence of DM and higher BMI at baseline. Using multivariate Cox regression models, prevalent DM at baseline was independently associated with both incident CTS (HR 2.10; 95% CI 1.65 to 2.70, p<0.0001) and incident UNE (HR 2.20; 95% CI 1.30 to 3.74, p=0.003). Higher levels of HbA1c and plasma glucose were associated with an increased risk for CTS, but not for UNE.

CONCLUSION

This study establishes DM as a major risk factor in the development of both CTS and UNE. Furthermore, a higher BMI is associated with both CTS and UNE. Finally, hyperglycemia seems to affect the median and ulnar nerves differently.

Limited joint mobility of the hand correlates incident hospitalisation with infection in patients with type 2 diabetes

AIM

Limited joint mobility (LJM) of the hand is one of the important complications of diabetes. Diabetes is a risk factor for hospitalisation with infection. This study investigated the relationship between LJM of the hand and the incidence of hospitalisation with infection in type 2 diabetic patients.

MATERIALS AND METHODS

LJM of hand was defined as the 'prayer sign' or 'table test'. The association between LJM of the hand and incident hospitalisations was evaluated using Cox regression analysis. The number of incident hospitalisations was small over the course of the study, which we compensated for by calculating propensity scores using age, body mass index, sex, duration of diabetes, creatinine, smoking status, haemoglobin A1c and dyslipidaemia.

RESULTS

In this retrospective cohort study of 502 patients with type 2 diabetes, 102 patients had LJM of the hand. These patients were, on average, older and had worse renal function and glycaemic control, and a higher proportion of microangiopathy significantly. During the study period, 56 patients were hospitalised with infection. A Cox regression analysis showed that LJM of the hand was associated with an increased probability of incident hospitalisation with infection after adjustment for covariates (HR = 1.65 [95% CI 1.60-1.70], p < 0.001).

CONCLUSIONS

Our results reveal that LJM of the hand is associated with incident of hospitalisation with infection. A diagnosis of LJM of the hand might, therefore, be a useful indicator for assessing the risk of hospitalisation with infection in type 2 diabetic patients.

Clinical Examination and Self-Reported Upper Extremity Impairments in Patients with Long-Standing Type 1 Diabetes Mellitus

AIM

The aims of the current study were (1) to determine the prevalence of upper extremity impairments (UEIs) in patients with type 1 diabetes by clinical investigation; (2) to investigate if self-reported impairments were concordant with clinical findings and if key questions could be identified; and (3) to investigate if answers to our self-reported questionnaire regarding UEIs are reliable.

METHODS

Patients with type 1 diabetes were invited to participate in a cross-sectional study of clinical and self-reported (12 items) UEIs in adjunction to ordinary scheduled clinical visit. Before the visit, a questionnaire on UEIs was filled in twice (test-retest) followed by clinical testing at the planned visit.

RESULTS

In total, 69 patients aged 45 ± 14 years and with diabetes duration 26 ± 15 were included in the study. In the clinical examination, two-thirds (65%) of the patients showed one or more UEI, with failure to perform hand against back as the most common clinical finding (40%) followed by positive Phalen's test (27%), Tinel's test (26%), and Prayer's sign (24%). UEIs observed by clinical examination were often bilateral, and multiple impairments often coexisted. Self-reported shoulder stiffness was associated with impaired shoulder mobility and with Prayer's sign. Self-reported reduced hand strength was associated to lower grip force, Prayer's sign, trigger finger, fibrosis string structures, and reduced thenar strength as well as reduced shoulder mobility. In addition, self-reporting previous surgery of carpal tunnel and trigger finger was associated with several clinical UEIs including shoulder, hand, and finger. The test-retest of the questionnaire showed a high agreement of 80-98% for reported shoulder, hand, and finger impairments.

CONCLUSION

UEIs are common in type 1 diabetes. Self-reported shoulder stiffness and reduced hand strength might be used to capture patients with UEIs in need of clinical investigation and enhanced preventive and therapeutic strategies, as well as rehabilitative interventions.

Effects of Type II Diabetes Mellitus on Tendon Homeostasis and Healing

Over 300,000 tendon repairs are performed annually in the United States to repair damage to tendons as a result of either acute trauma or chronic tendinopathy. Individuals with type II diabetes mellitus (T2DM) are four times more likely to experience tendinopathy, and up to five times more likely to experience a tendon tear or rupture than non-diabetics. As nearly 10% of the US population is diabetic, with an additional 33% pre-diabetic, this is a particularly problematic health care challenge. Tendon healing in general is challenging and often unsatisfactory due to the formation of mechanically inferior scar-tissue rather than regeneration of native tendon structure. In T2DM tendons, there is evidence of an amplified scar tissue response, which may be associated with the increased the risk of rupture or impaired restoration of range of motion. Despite the dramatic effect of T2DM on tendon function and outcomes following injury, there are few therapies available to promote improved healing in these patients. Several recent studies have enhanced our understanding of the pro-inflammatory environment of T2DM healing and have assessed potential treatment approaches to mitigate pathological progression in pre-clinical models of diabetic tendinopathy. This review discusses the current state of knowledge of diabetic tendon healing from molecular to mechanical disruptions and identifies promising approaches and critical knowledge gaps as the field moves toward identification of novel therapeutic strategies to maintain or restore tendon function in diabetic patients. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:13-22, 2020.

The impact of diabetic peripheral neuropathy on pinch proprioception

This study aims to investigate the impact of type 2 diabetes (T2D) and diabetic peripheral neuropathy (DPN) on pinch proprioception and to establish the correlations with sensory impairments. We collected data from a total of 36 participants (healthy, n = 12; T2D without DPN, n = 11; and T2D + DPN, n = 13), all matched for age, 60 ± 6 years. Pinch proprioception was determined through 3 trials of attempts to actively reproduce 15° of pinch position without visual feedback. Target accuracy and precision was compared between groups using Kruskal-Wallis test. Sensation was tested through the two-point discrimination and Semmes-Weinstein monofilaments applied on the fingers. Sensory measures were correlated with pinch proprioception measures via Spearman's rank test. The T2D + DPN group showed significant decrements in accuracy and precision as compared to the T2D-only (p = 0.003 and p = 0.006, respectively) and the healthy groups (both p = 0.002); no significant differences were found between T2D-only and healthy. Spearman's rank showed moderate (r = 0.45-0.66, p < 0.001) correlations between pinch proprioception and sensory measures. Our results showed pinch proprioception disruption in people with T2D + DPN, but not in people with T2D-only. The awareness of pinch proprioceptive deficits is paramount for the safety of individuals with T2D and DPN. Moderate correlations between sensory impairments and pinch proprioceptive deficits suggest that not only superficial/discriminative sensation is implicated in proprioceptive decrements. Other mechanisms such as damage to muscle spindles or central nervous system associated with T2D + DPN warrant further investigations.

Open carpal tunnel release and diabetes: a retrospective study using PROMs and national quality registries

OBJECTIVES

To study patient-reported outcome after open carpal tunnel release (OCTR) for carpal tunnel syndrome (CTS) in patients with or without diabetes using national healthcare quality registries.

DESIGN

Retrospective cohort study.

SETTING

Data from the Swedish National Quality Registry for Hand Surgery (HAKIR; www.hakir.se) were linked to data from the Swedish National Diabetes Register (NDR; www.ndr.nu).

PARTICIPANTS

We identified 9049 patients (10 770 hands) operated for CTS during the inclusion period (2010-2016).

PRIMARY OUTCOME MEASURES

Patient-reported outcome measures were analysed before surgery and at 3 and 12 months postoperatively using the QuickDASH as well as the HAKIR questionnaire with eight questions on hand symptoms and disability.

RESULTS

Patients with diabetes (n=1508; 14%) scored higher in the QuickDASH both preoperatively and postoperatively than patients without diabetes, but the total score change between preoperative and postoperative QuickDASH was equal between patients with and without diabetes. The results did not differ between patients with type 1 or type 2 diabetes. Patients with diabetic retinopathy scored higher in QuickDASH at 3 months postoperatively than patients with diabetes without retinopathy. In the regression analysis, diabetes was associated with more residual symptoms at 3 and 12 months postoperatively.

CONCLUSIONS

Patients with diabetes experience more symptoms both before and after OCTR, but can expect the same relative improvement from surgery as patients without diabetes . Patients with retinopathy, as a proxy for neuropathy, may need longer time for symptoms to resolve after OCTR. Smoking, older age, higher HbA1c levels and receiving a diabetes diagnosis after surgery were associated with more residual symptoms following OCTR.

Characteristics and Clinical Outcomes of Open Surgery for Trigger Digits in Diabetes

Introduction Trigger digit is a common condition of the hand. Diabetes has a known association with the development of trigger digit. It is thought to influence the clinical presentation and efficacy of open surgical release. This study aimed to assess the differential characteristics of trigger digits and the clinical outcomes of open surgery for trigger digits in diabetics. Materials and Methods This was a retrospective study of all patients who underwent open surgical release of trigger digits in a single institution from 2012 to 2013. Patients were divided into two groups with group 1 consisting of all patients with a history of diabetes. Group 2 consisted of all patients without diabetes. Demographics and clinical presentation were reviewed. All patients were reviewed via a telephone questionnaire at least 2 years after the initial surgery and were assessed for patient-reported outcomes. Results There were 201 patients who met the inclusion criteria, of which 191 patients were recruited. This included 87 (45.5%) males and 104 (54.5%) females. A total of 260 open releases were performed. Sixty-one (31.9%) patients were diabetic, and 130 (68.1%) patients were nondiabetic. The diabetic group was significantly older than the nondiabetic group ( p = 0.002). The dominant hand was not significantly more affected than the nondominant hand ( p = 0.51). The middle finger was most commonly involved (43.5%), and the little finger was the least commonly involved (1.2%). There was no significant increase in multiple-digit presentation in the diabetic population when compared with the nondiabetic population ( p = 0.52). There was a low complication rate and a high rate of postoperative satisfaction after open surgery in both groups. Conclusion Diabetes does not predispose patients to increased rates of multiple trigger digit presentation or increased clinical severity on presentation. Open surgery for trigger digit is an effective and safe treatment modality for diabetics.

Integrative genomic and transcriptomic analysis of genetic markers in Dupuytren's disease

Background

Dupuytren’s disease (DD) is a fibroproliferative disorder characterized by thickening and contracting palmar fascia. The exact pathogenesis of DD remains unknown.

Results

In this study, we identified co-expressed gene set (DD signature) consisting of 753 genes via weighted gene co-expression network analysis. To confirm the robustness of DD signature, module enrichment analysis and meta-analysis were performed. Moreover, this signature effectively classified DD disease samples. The DD signature were significantly enriched in unfolded protein response (UPR) related to endoplasmic reticulum (ER) stress. Next, we conducted multiple-phenotype regression analysis to identify trans-regulatory hotspots regulating expression levels of DD signature using Genotype-Tissue Expression data. Finally, 10 trans-regulatory hotspots and 16 eGenes genes that are significantly associated with at least one cis-eQTL were identified.

Conclusions

Among these eGenes, major histocompatibility complex class II genes and ZFP57 zinc finger protein were closely related to ER stress and UPR, suggesting that these genetic markers might be potential therapeutic targets for DD.

Electronic supplementary material

The online version of this article (10.1186/s12920-019-0518-3) contains supplementary material, which is available to authorized users.

Normative Data on Grip Strength in a Population-Based Study with Adjusting Confounding Factors: Sixth Korea National Health and Nutrition Examination Survey (2014-2015)

Background: We investigated population-based data on grip strength, analyzed for demographic factors, and proposed a formula to estimate grip strength that could be generalized to a population with different anthropometric and background characteristics. Methods: This study used a complex, stratified, multistage probability cluster survey with a representative sample of the population. Select household Korean participants (n = 6577) over age 10 who were able to perform daily tasks without issue were included. Grip strength was measured in both hands, alternately, three times using a digital grip strength dynamometer. Results: There was a curvilinear relationship between grip strength and age, and grip strength was higher in males than females (p = 0.001). Hand preference significantly affected grip strength (p = 0.001). Weight and height were positively correlated with strength in both hands (p = 0.001), but waist circumference was negatively correlated with strength in both hands (p = 0.001). The intensity of occupational labor did significantly affect grip strength in both hands (p = 0.001). The formulas for estimating grip strength of each hand are presented as main results. Conclusions: To determine normative data on grip strength, we may consider factors such as occupations with different physical demands, underlying medical conditions, anthropometric characteristics, and unmodifiable factors such as age and sex.

An overlooked rheumatologic manifestation of diabetes: diabetic cheiroarthropathy

OBJECTIVES

The objectives of the study were to analyze the clinical characteristic of diabetic cheiroarthropathy (DCA) in patients with type 1 diabetes mellitus (DM), type 2 DM, and prediabetes and to evaluate the frequency of DCA among groups.

METHOD

The cross-sectional study was conducted at the Division of Endocrinology and Metabolism outpatient clinic over a 14-month period. A total of 239 patients (160 female, 79 male), who had type 1 DM, type 2 DM, and prediabetes, were enrolled. The demographics, clinical variables, and laboratory outcomes were recorded. Diabetic cheiroarthropathy was defined according to physical examination. The functional disability of patients with DCA was assessed by the self-administered questionnaire (disabilities of the arm, shoulder and hand-DASH).

RESULTS

Diabetic cheiroarthropathy was determined in 35.1% of all patients. The frequency of DCA was higher in patients with prediabetes (x² = 0.009, post hoc power = 0.794). According to the logistic regression analysis, prediabetes (OR = 4.52, 95% CI 2.16-9.47, p < 0.001), presence of polyneuropathy (OR = 3.82, 95% CI 1.61-9.07, p = 0.002), and fasting glucose level (OR = 1.01, 95% CI 1.00-1.01, p = 0.004) found as the most effective risk factors in determining DCA. DASH disability scores were significantly higher in prediabetic patients than that in type 2 DM group (p = 0.021).

CONCLUSION

High frequency of DCA and impaired hand function are observed in prediabetic patients. Musculoskeletal manifestations can emerge as an early sign of diabetic status. Also, people who suffer from hand involvement should be examined for diabetes along with rheumatologic diseases.

Neutrophil-lymphocyte ratio correlates with limited joint mobility of hand in patients with type 2 diabetes

Limited joint mobility (LJM) of hand, which is one of the complications of diabetic hand, is associated with diabetic micro- and macroangiopathy although the precise pathogenesis is not completely understood. Neutrophil-lymphocyte ratio (NLR), a simple and novel inflammatory marker, has been reported to have a predictive effect to some diabetic complications in recent years. However, it is not elucidated about the relationship between LJM of hand and NLR in patients with type 2 diabetes. We evaluated the relationships between LJM of hand and NLR in 335 consecutive patients with type 2 diabetes in this cross-sectional study. LJM of hand was diagnosed by a 'prayer sign' or 'table test'. LJM of hand was present in 80 patients. The patients with LJM of hand had significantly older age, longer duration of diabetes, worse renal function, and higher proportion of diabetic neuropathy, retinopathy and nephropathy. NLR in patients with LJM of hand was higher than that in patients without LJM of hand (2.54 ± 1.46 vs. 2.11 ± 1.04, p = 0.004). Multivariate logistic regression analysis revealed that LJM of hand was positively correlated with NLR (odds ratio, 1.31; 95% confidence interval 1.03-1.69, p = 0.027) after adjustment for age, sex, duration of diabetes, body mass index, hemoglobin A1c, hypertension and dyslipidemia. Our results demonstrate a positive relation between LJM of hand and NLR in patients with type 2 diabetes.

Insulin Dependence Is Associated With Increased Risk of Complications After Upper Extremity Surgery in Diabetic Patients

Diabetes mellitus (DM) is associated with the development of carpal tunnel syndrome, Dupuytren disease, trigger digits, and limited joint mobility. Despite descriptions of poorer response to nonsurgical treatment, previous studies have not shown increased complication rates in diabetic patients after hand surgery. Few studies, however, differentiate between insulin-dependent (IDDM) and non-insulin-dependent (NIDDM) diabetes mellitus. The purpose of this study was to evaluate the impact of insulin dependence on the postoperative risk profile of diabetic patients after hand surgery using a national database.

MATERIALS AND METHODS

The data were obtained through the National Surgical Quality Improvement Program (NSQIP) database. Patients undergoing surgery from the distal humerus to the hand, between 2005 and 2015, were identified using 297 distinct Current Procedural Terminology codes. Thirty-day postoperative complications were collected and categorized into medical complications, surgical site complications, and readmission. Surgical complications, medical complications, and readmissions were compared between patients with NIDDM or IDDM to those without DM using multivariable logistic regression, adjusting for baseline patient and operative characteristics.

RESULTS

The study cohort included 52,727 patients. Patients with IDDM had a 5.7% overall complication rate compared with 2.3% and 1.5% in NIDDM and nondiabetic patients, respectively. After controlling for differences in patient and surgical characteristics, patients with IDDM had a statistically significant increased rate of any complication, surgical site complications, superficial surgical site infections, and readmission. There was no significant difference in complication rates between patients with NIDDM and nondiabetic patients.

CONCLUSIONS

Our data demonstrate a greater risk of complications following hand and upper extremity surgery for patients with IDDM, specifically surgical site infections. The NIDDM patients did not have an increased rate of complications relative to nondiabetic patients. These findings are important for patient risk stratification and may guide further investigation to decrease complication rates in IDDM patients after upper extremity surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

A randomized, open-label, comparative, crossover trial on preference, efficacy, and safety profiles of lispro insulin u-100 versus concentrated lispro insulin u-200 in patients with type 2 diabetes mellitus: a possible contribution to greater treatment adherence

BACKGROUND

Several outstanding pharmacological advances making innovative drugs sophisticateddevices available during the last few years. Nevertheless too many patients still disappointingly fail to meetthe metabolic targets suggested by current guidelines. Incorrect insulin administration techniques may greatly affect metabolic control in T2DM people. The aim of our study was to compare glycemic control associated with a concentrated insulin analog preparation (U-200 lispro) in people with T2DM to the one observed with standard U-100 lispro. The secondary endpoint of our study was patients' preference and performance ratings of U-200 lispro.

METHODS

126 patients with T2DM were enrolled. They were also assessed for limited joint mobility syndrome (LJMS),defined as limitation in at least two anatomical areas of the dominant upper extremity. After a 4-weekstructured insulin injection education period. Half of them were randomized to U-100 lispro, half to U-200 and after 12 weeks they were switched to the other preparation for 12 weeks. At the end a questionnaire was also administered to investigate patient preference.

RESULTS

No significant variation in fasting blood glucose, HbA1c, severe or mild hypoglycemic rate and daily fast-acting insulin analog dose was observed with U-100 lispro while U-200 lispro treatment was associated with a significant improvement of all the above mentioned parameters and with around 20% decrease in insulin requirement. Moreover patients' answers to the questionnaire pointed out a higher preference for U-200 lispro for continuing treatment due to fewer difficulties completing injection.

DISCUSSION

The explanation of better metabolic results with the U-200 device might be the lower inner piston inertia and volume and shorter duration of a complete injection.

CONCLUSIONS

Checking for LJIMS before insulin prescription could be adopted as a standard practiceaimed at choosing the most suitable device for patient's specific characteristics and abilities. The use of U-200 lispro might improve treatment adherence and metabolic control. This would also result intocost reduction by saving about half the amount of pens per year and of time spent to both fill prescriptionand dump the pharmacy.

Dynamical Coordination of Hand Intrinsic Muscles for Precision Grip in Diabetes Mellitus

This study investigated the effects of diabetes mellitus (DM) on dynamical coordination of hand intrinsic muscles during precision grip. Precision grip was tested using a custom designed apparatus with stable and unstable loads, during which the surface electromyographic (sEMG) signals of the abductor pollicis brevis (APB) and first dorsal interosseous (FDI) were recorded simultaneously. Recurrence quantification analysis (RQA) was applied to quantify the dynamical structure of sEMG signals of the APB and FDI; and cross recurrence quantification analysis (CRQA) was used to assess the intermuscular coupling between the two intrinsic muscles. This study revealed that the DM altered the dynamical structure of muscle activation for the FDI and the dynamical intermuscular coordination between the APB and FDI during precision grip. A reinforced feedforward mechanism that compensates the loss of sensory feedbacks in DM may be responsible for the stronger intermuscular coupling between the APB and FDI muscles. Sensory deficits in DM remarkably decreased the capacity of online motor adjustment based on sensory feedback, rendering a lower adaptability to the uncertainty of environment. This study shed light on inherent dynamical properties underlying the intrinsic muscle activation and intermuscular coordination for precision grip and the effects of DM on hand sensorimotor function.

The comparison of frequency of the upper limb musculoskeletal disorders among patients with diabetes type II with normal cases

Background and aim

Musculoskeletal disease, that is recognized in diabetes and diabetes mellitus (DM) has shown a higher prevalence of chronic musculoskeletal complications. This study aimed at assessing the frequency of upper limb musculoskeletal disorders among patients with diabetes type II with normal cases in Mashhad, Iran.

Methods

A cross-section of 100 patients with upper limb musculoskeletal disorders were enrolled in this study. The patients were examined by a unique physician considering carpal tunnel syndrome disorder, trigger finger, adhesive capsulitis, and Dupuytren's contracture at Ghaem hospital, Mashhad, Iran in 2015. All collected data were recorded by using SPSS version 21 and were analyzed through independent-samples t-test for comparing changes, and Chi-square.

Results

In this study, the mean age was 51.7±8.7 years old. Gender frequency was 114 (57%) male, and 86 (43%) female. There was no significant difference between groups in cases of gender frequency and mean of age (p>0.05). In evaluation of association between the two groups, there was significant difference for adhesive capsulitis, (p=0.04). Chi-square test showed significant association for age and adhesive capsulitis between the two groups, (p=0.040); but no other diabetes-related disorders, (p<0.05).

Conclusion

The results of this study showed that in patients with diabetes mellitus and musculoskeletal complications such as upper limb musculoskeletal abnormalities, it will lead to an increase in skeletal muscle effects in DM patients. It is recommended that musculoskeletal examination is done periodically in DM patients for identification of these disorders and necessary actions are carried out for prevention of the disorders as soon as possible.

Quantifying the Effect of Diabetes on Surgical Hand and Forearm Infections

PURPOSE

Diabetes has long been established as a risk factor for hand and forearm infections. The purpose of this study was to review the effect of glycemic factors on outcomes among diabetic patients with surgical upper-extremity infections. We hypothesized that diabetic inpatients may benefit from stronger peri-infection glycemic control.

METHODS

A prospective cohort study enrolled diabetic and nondiabetic surgical hand and forearm infections over 3 years. Glycemic factors included baseline glycosylated hemoglobin, blood glucose (BG) at presentation, and inpatient BG. Poor baseline control was defined as glycosylated hemoglobin of 9.0% or greater and poor inpatient control as average BG of 180 mg/dL or greater. The main outcome of interest was the need for repeat therapeutic drainage. Multivariable logistic regression quantified the association between diabetic factors and this outcome.

RESULTS

The study involved 322 patients: 76 diabetic and 246 nondiabetic. Diabetic infections were more likely than nondiabetic infections to result from idiopathic mechanisms, occur in the forearm, and present as osteomyelitis, septic arthritis, and necrotizing fasciitis. Diabetic microbiology was more likely polymicrobial and fungal. After first drainage, diabetic patients were more likely to require repeat drainage and undergo eventual amputation. Among diabetic patients, poor inpatient control was associated with need for repeat drainage.

CONCLUSIONS

Diabetes exacerbates the burden of surgical upper-extremity infections: specifically, more proximal locations, deeper involved anatomy at presentation, broader pathogenic microbiology, increased need for repeat drainage, and higher risk for amputation. Among diabetic patients, poor inpatient glycemic control is associated with increased need for repeat drainage.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

Limited Joint Mobility Progression in Type 1 Diabetes: A 15-Year Follow-Up Study

OBJECTIVE

To assess the evolution of joint mobility over a period of 15 years in type 1 diabetic patients and healthy controls and to determine whether microalbuminuria is associated with a different evolution of joint mobility.

METHODS

Joint mobility of hand and wrist was determined in 63 patients with type 1 diabetes and 63 healthy subjects. Fifteen years later, 37 (58.7%) diabetic patients and 16 (25.4%) healthy subjects were studied again. Joint mobility was assessed with the Prayer sign and by measuring the angle of maximal flexion of the fifth and third metacarpophalangeal (MCP) joints and wrist. Patients with diabetes were visited 2-4 times every year with regular assessment of glycated hemoglobin (HbA1_c), urinary albumin excretion (UAE), and ophthalmoscopy.

RESULTS

Fifteen years after the initial exam, diabetic patients showed reduced flexion of the fifth MCP joint (82.6 ± 5.8 versus 76.0 ± 6.4 degrees, p < 0.001) and wrist (75.9 ± 8.1 versus 73.2 ± 7.4 degrees, p = 0.015) compared to baseline examination. Joint mobility did not change significantly in healthy subjects. Patients with microalbuminuria showed greater reduction in hand joint mobility than diabetic patients with normal UAE or than healthy subjects (p < 0.001).

CONCLUSIONS

In type 1 diabetic patients, the severity of LJM progresses with time, and the progression is enhanced in patients with microalbuminuria.

Comparison of Hand Function Between Children With Type 1 Diabetes Mellitus and Children Without Type 1 Diabetes Mellitus

PURPOSE

This study compared the hand function of children between the ages of 8 and 12 years with type 1 diabetes mellitus (T1DM) with that of children without diabetes.

METHODS

The Modified Jebsen-Taylor Hand Function Test and the Purdue Pegboard Test were used to assess hand function. The Pediatric Quality of Life Inventory 4.0 was used for evaluating health-related quality of life.

RESULTS

Duration of writing was found to be significantly longer on the dominant side of the T1DM group compared with the children without T1DM. The durations of card turning, moving large, light objects, and large, heavy objects on the nondominant side of the T1DM group were also found to be significantly longer than those in the children without T1DM. The total scale score of health-related quality of life was significantly lower in the T1DM group compared with the children without T1DM.

CONCLUSIONS

T1DM affects hand function, particularly the dominant side for writing and nondominant side for card turning and moving large objects.

Hand Grip Strength And Peak Expiratory Flow Among Individuals With Diabetes: Findings From the China Health and Retirement Longitudinal Study Baseline Survey

The manifestation of muscle dysfunction associated with diabetes is commonly observed in skeletal muscles. The negative effect of hyperglycemia on muscle function is systemic and it may extend to abdominal muscles. Hence, the purpose of this study was to determine whether hand grip strength (HGS), an indicator of peripheral muscle strength, correlates with peak expiratory flow (PEF), which reflects the strength of abdominal muscles, among middle-aged and older Chinese individuals with diabetes. After controlling for all variables except for physical activity, 10 L/min increase in PEF was associated with 0.2 kg increase in HGS (β = .02, p < .0001). In the model additionally controlling for physical activity, the effect size of PEF on HGS did not change (β = .02, p < .0001). Our results suggest that among individuals with diabetes, PEF is positively related to HGS. The relationship may suggest a decline in PEF and a weakness of abdominal muscles.

Relationship between limited joint mobility of hand and carotid atherosclerosis in patients with type 2 diabetes

AIM

Limited joint mobility (LJM) of hand, which is one of a complication of diabetic hand, has a close association with diabetic microangiopathy. However, it remains to be elucidated about the relationships between LJM of hand and subclinical atherosclerosis in patients with type 2 diabetes. Therefore, we conducted a cross-sectional study to evaluate the relationships between LJM of hand and carotid intima-media thickness (IMT) and plaque score in patients with type 2 diabetes.

METHODS

We evaluated the relationships between LJM of hand, and carotid IMT and plaque score, evaluated by carotid ultrasound examination, in 341 consecutive patients with type 2 diabetes. LJM of hand was diagnosed using a 'prayer sign' or 'table test'.

RESULTS

LJM of hand was present in 72 patients. Carotid IMT and plaque score were higher in patients with LJM of hand than those in patients without (1.45±0.66vs. 1.14±0.68mm, P=0.013 and 8.0±5.3vs. 5.4±4.8mm, P<0.001). Multivariate linear regression analysis revealed that LJM of hand was positively correlated with plaque score (β=0.423, P=0.043) after adjusted for age, sex, durations of diabetes, body mass index, hemoglobin A1c, creatinine, uric acid, smoking, hypertension and dyslipidemia.

CONCLUSIONS

Our results demonstrate a relation between LJM of hand and subclinical atherosclerosis, especially plaque score, in patients with type 2 diabetes. Diagnosis of diabetic hand is simple and non-invasive, and thus is a useful method for assessment of subclinical atherosclerosis in patients with type 2 diabetes.

Predictors of Outcomes Following Fasciectomy for Dupuytren’s Disease in Diabetic and Non-Diabetic Patients

Background: The aim of this study was to compare clinical outcomes, and identify predictors thereof, after fasciectomy for Dupuytren’s disease in a series of diabetic patients compared with non-diabetic patients.

Methods: Thirty-eight patients were examined following partial palmar and/or digital fasciectomy for Dupuytren’s disease (11 diabetics, 27 non-diabetics). Each patient was assessed for degree of pre- and post-operative flexion contractures at the MCP and PIP joints, post-operative Patient Evaluation Measure (PEM) total score, post-operative grip strength, limited joint mobility (LJM), recurrence, extension, and a composite outcomes score based upon grip strength and the degree of joint contractures. All measurements in the diabetic cohort were compared to those in the non-diabetic group, and a logistic regression analysis was performed to identify the predictive value of several variables on outcomes.

Results: Complication rates between the two groups were statistically similar (p = 0.67). There were no significant differences in pre-operative MCP (p = 0.69), post-operative MCP (p = 0.39), pre-operative PIP (p = 0.40), or post-operative PIP (p = 0.13) joint flexion contractures between the two groups. Additionally, there was no significant difference in extension (p = 0.35) or recurrence (p~1) rates, post-operative grip strengths (p = 0.64), or PEM total scores (p = 0.32). However, the rate of LJM was significantly higher in the diabetic population (p = 0.02). Both female gender (p = 0.01) and a non-smoking status (p = 0.04) were found to be predictive of better outcomes following fasciectomy. Diabetes was not found to be an independent predictor of outcome (p = 0.73).

Conclusions: Clinical results after fasciectomy for Dupuytren’s disease in diabetic patients are not different from results obtained in non-diabetic patients. Diabetes is not independently predictive of surgical outcomes. Female gender and non-smoking status are independent predictors of a better outcome following fasciectomy.

Prevalence of hand syndromes among patients with diabetes mellitus in Taiwan: A population-based study

BACKGROUND

Population-based data for diabetic hand syndrome (DHS) are limited. The aim of the present epidemiological study was to estimate the overall and cause-specific prevalence and rate ratio (RR) of DHS in patients with diabetes.

METHODS

The present study was a cross-sectional study based on a random sample of 57 093 diabetics and matched controls, both identified from Taiwan National Health Insurance claims in 2010. The DHS analyzed in the present study included carpal tunnel syndrome (CTS), stenosing flexor tenosynovitis (SFT), limited joint mobility (LJM), and Dupuytren's disease (DD).

RESULTS

The prevalence of overall DHS was estimated at 2472 per 10⁵ for the diabetics, compared with 1641 per 10⁵ for the controls, representing a prevalence RR of 1.51 (95 % confidence interval [CI] 1.39-1.64). Stratified analyses further revealed that the significantly increased prevalence of overall DHS was more evident in females than males (1.59 vs 1.36) and was only noted in diabetics aged ≥35 years. Cause-specific analysis suggested that patients with diabetes had the highest prevalence of CTS (1244 per 10⁵ ), followed by SFT (1209 per 10⁵ ), LJM (39 per 10⁵ ), and DD (6 per 10⁵ ). In addition, diabetes was only significantly associated with CTS (RR 1.34; 95 % CI 1.20-1.51) and SFT (1.74; 95 % CI 1.54-1.97).

CONCLUSION

The prevalence of overall and certain cause-specific DHS was significantly elevated in patients with diabetes in Taiwan.

Relationship between limited joint mobility of the hand and diabetic foot risk in patients with type 2 diabetes

BACKGROUND

Foot ulceration is a serious problem for patients with type 2 diabetes (T2D), and the early detection of risks for this condition is important to prevent complications. The present cross-sectional study in T2D patients determined the relationship between limited joint mobility (LJM) of the hand and diabetic foot risk classified using the criteria of the International Working Group on the Diabetic Foot (IWGDF).

METHODS

Relationships between LJM of the hand and foot risk according to IWGDF category, HbA1c, age, body mass index, blood pressure, estimated glomerular filtration (eGFR), and diabetic complications (including diabetic peripheral neuropathy [DPN] and peripheral arterial disease [PAD]) were evaluated in 528 consecutive T2D patients. Poor glycemic control was defined as HbA1c ≥ 7%.

RESULTS

Patients with LJM of the hand were older and had a longer duration of diabetes, a higher prevalence of diabetic complications, including DPN and PAD, and a higher IWDGF category (all P < 0.001). Multivariate logistic regression analysis revealed that the foot risk assessed with IWDGF category was correlated with age (odds ratio [OR] 1.04; 95% confidence interval [CI] 1.01-1.06; P = 0.001), poor glycemic control (OR 1.66; 95% CI 1.00-2.77; P = 0.04), eGFR (OR 0.98; 95% CI 0.97-0.99; P = 0.02), and the presence of LJM of the hand (OR 3.86; 95% CI 2.21-6.86; P < 0.001).

CONCLUSIONS

The results demonstrate a correlation between LJM of the hand and foot risk. Diagnosis of diabetic hand is simple and non-invasive, and is thus a useful method for assessing the risk of diabetic foot in T2D patients.

Do we underestimate influences of diabetic mononeuropathy or polyneuropathy on hand functional performance and life quality?

Aims/Introduction

The purpose of the present study was to identify whether there are differences in hand dexterity, hand functional performance and quality of life between diabetes patients with mononeuropathy and polyneuropathy of their hands to further present the importance regarding the impacts of diabetic neuropathic deficits on patients’ functional capacity.

Materials and Methods

The neurological deficits of 127 patients with type 2 diabetes were examined by electrophysiological tests for the median and ulnar nerves, and were stratified into the diabetic mononeuropathy, diabetic polyneuropathy and non‐diabetic neuropathy groups by sensory amplitude of these nerves. The Purdue pegboard test, Michigan Hand Outcomes Questionnaire, and Diabetes‐39 were carried out to understand patients’ hand dexterity, functional hand performance and quality of life, respectively.

Results

The results showed significant differences in all subtests of the Purdue pegboard test among the three groups. Furthermore, aesthetics, patient's satisfaction of the Michigan Hand Outcomes Questionnaire and diabetes control, sexual functioning, energy, and mobility of the Diabetes‐39 also showed significant differences among the three groups.

Conclusions

The present study shows the patients with polyneuropathy suffer from more negative impacts on hand functional performance and quality of life than those with mononeuropathy and without neuropathy. These findings might assist both patients and clinicians in better realizing the impacts of neuropathic hands, and planning suitable strategies of intervention or health education to prevent declines in hand functions.

Medical claims-based case-control study of temporal relationship between clinical visits for hand syndromes and subsequent diabetes diagnosis: implications for identifying patients with undiagnosed type 2 diabetes mellitus

OBJECTIVES

To investigate whether a temporal relationship is present between clinical visits for diabetes-related hand syndromes (DHSs) and subsequent type 2 diabetes mellitus (T2DM) diagnosis and, accordingly, whether DHSs can be used for identifying patients with undiagnosed T2DM.

DESIGN

This study had a case-control design nested within a cohort of 1 million people from the general population, which was followed from 2005 to 2010. The odds of prior clinical visits for DHSs, namely carpal tunnel syndrome (CTS), flexor tenosynovitis, limited joint mobility and Dupuytren's disease, were estimated for cases and controls. We used a conditional logistic regression model to estimate the OR and 95% CI of T2DM in association with a history of DHSs. The validity and predictive value of using the history of DHSs in predicting T2DM diagnosis were calculated.

SETTING

Taiwan National Health Insurance medical claims.

PARTICIPANTS

We identified 33 571 patients receiving a new diagnosis of T2DM (cases) between 2005 and 2010. Each T2DM case was matched with 5 controls who had the same sex and birth year and were alive on the date of T2DM diagnosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was T2DM diagnosis.

RESULTS

The OR of T2DM in association with prior clinical visits was significantly increased for overall DHS and CTS, being 1.15 (95% CI 1.10 to 1.20) and 1.22 (95% CI 1.16 to 1.29), respectively. Moreover, 11% of patients with T2DM made clinical visits for CTS within 3 months prior to T2DM diagnosis. The history of DHSs had low sensitivity (<0.1% to 5.2%) and a positive predictive value (9.9% to 11.7%) in predicting T2DM.

CONCLUSIONS

Despite the unsatisfactory validity and performance of DHSs as a clinical tool for detecting patients with undiagnosed T2DM, this study provided evidence that clinical visits for DHSs, particularly for CTS, can be a sign of undiagnosed T2DM.

Impacts of elevated glycaemic haemoglobin and disease duration on the sensorimotor control of hands in diabetes patients

BACKGROUND

To understand the impacts of disease chronicity and hyperglycaemia on sensorimotor control of hands of diabetic patients, this study investigated the differences in hand sensation, strength and motor control by applying the pinch-holding-up activity test for patients with diabetes mellitus (DM) with different levels of glycaemic control and disease chronicity.

METHODS

One hundred and fifty-nine patients with clinically defined DM were included. Semmes-Weinstein monofilament, static two-point discrimination and moving two-point discrimination, maximal pinch strength precision pinch performance tests and nerve conduction studies (NCS) of the subjects were carried out. Forty-seven (29.6%) patients were in the HbA(1c) < 7% category, and 112 (70.4%) patients were in the >7% group. There were 87 (54.7%) patients with the disease duration <10 years, and 72 (45.3%) patients with disease duration ≧10 years.

RESULTS

The severity of hyperglycaemia significantly impacts the results for Semmes-Weinstein monofilament, precision pinch force control, sensory and motor NCS tests (p < 0.05). In addition, the chronicity of disease influences the motor control of precision pinch performance and the amplitude of motor NCS (p < 0.05) for the diabetes patients.

CONCLUSIONS

The evidence suggests that disease chronicity and hyperglycaemia have impacts on sensorimotor control in the hands of DM patients. In addition, the efficiency of prehensile forces of hand-to-object interactions in the pinch-holding-up activity test could be significant for identifying hand function, as well as pathologic changes in median nerve function, for patients with DM.

A comparison of glide force characteristics between 2 prefilled insulin lispro pens

Glide force, average glide force, and glide force variability of the insulin lispro 200 units/mL pen (Eli Lilly and Company, Indianapolis, IN, USA) were compared to the Humalog KwikPen 100 units/mL pen (hereafter, KwikPen; Eli Lilly and Company, Indianapolis, IN, USA). Data were collected on 2 doses, 2 injection speeds, and 2 needle types. Insulin lispro 200 units/mL pen showed significantly lower maximum glide force, average glide force, and glide force variability than the KwikPen across all combinations of dose size, dose speed, and needle type. The lower glide force observed with the insulin lispro 200 units/mL pen offers another treatment option for patients with type 1 or type 2 diabetes who require greater than 20 units of mealtime insulin daily.

Trigger matters: an ergonomy analysis of insulin pens

BACKGROUND

Excessive force required to deliver a set dose of insulin as well as a localization of the push button and its upwards extension may result in significant difficulties to safely perform insulin injection, including bending/breakage of the injector's needle. The GensuPen2 (Copernicus/Bioton, Warsaw, Poland) pen has a unique spring-assisted delivery system and a lateral trigger device for injection of insulin to improve its ergonomics. We tested the force required to administer insulin using three pens: GensuPen2, NovoPen(®) 4 (Novo Nordisk, Bagsværd, Denmark), and HumaPen Ergo(®) (Eli Lilly, Indianapolis, IN).

MATERIALS AND METHODS

Using a certified dynamometer we tested injection force at three doses of insulin: 2, 30, and 60 U, using each of the three injectors (n=10) in triplicate. Area under the curve (AUC) and maximum force used were calculated for each series of injections.

RESULTS

When administering doses of 2, 30, and 60 units of insulin, the GensuPen2 (6.55±1.09, 6.52±1.92, and 6.89±1.15 N, respectively) required significantly lower maximum force than the NovoPen 4 (9.04±0.61, 12.96±1.45, and 15.42±0.99 N, respectively) and the HumaPen Ergo (17.66±1.88, 32.14±6.08, and 40.39±7.64 N, respectively) (all P<0.0001). The AUC of force used for insulin injection with GensuPen2 did not differ between doses (P=0.82). At all dose levels, GensuPen2 required significantly lower force than the other two injectors. Moreover, the mode of holding of GensuPen2 was more similar to the natural arrangement of the hand while gripping a cylindrical item in comparison with NovoPen 4 and HumaPen Ergo.

CONCLUSIONS

Usage of the GensuPen2 injector with a lateral trigger location and spring-assisted delivery system reduces the force required for drug administration, especially at high doses of insulin.

Factors determining poor prognostic outcomes following diabetic hand infections

BACKGROUND AND OBJECTIVE

Hand ulcers are seen in a small percentage of patients with diabetes. The predisposing factors of diabetic hand varies between different countries. However, the effects of predisposing factors on prognosis are not clear in diabetic hand infections. In this study, our aim was to determine the effects of predisposing factors on poor prognostic outcomes in patients with diabetes mellitus.

METHODS

Thirty-four patients with diabetes mellitus who were treated and followed up for a hand infection in between 2008 and 2014 were investigated retrospectively. Patients were evaluated according to predisposing factors defined in the literature that included disease period, age, gender, admission time, presence of neuropathy, smoking habits, HbA1c levels at admission time, peripheral vascular disease, end-stage renal disease (ESRD), and trauma. Death and minor/major amputation cases during treatment were defined as poor prognosis.

RESULTS

Patients who had ESRD, peripheral neuropathy, or an HbA1c level greater than 10% had significantly higher amputation rates.

CONCLUSIONS

Peripheral neuropathy, ESRD, and HbA1c levels greater than 10% at the time of admission were determined as poor prognosis criteria for diabetic hand treatment.