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Tian Z, Fan Y, Sun X, Wang D, Guan Y, Zhang Y, Zhang Z, Guo J, Bu H, Wu Z, Wang H. Predictive value of TCM clinical index for diabetic peripheral neuropathy among the type 2 diabetes mellitus population: A new observation and insight. Heliyon 2023; 9:e17339. [PMID: 37389043 PMCID: PMC10300217 DOI: 10.1016/j.heliyon.2023.e17339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 06/06/2023] [Accepted: 06/14/2023] [Indexed: 07/01/2023] Open
Abstract
Aims The objectives of this study were to identify clinical predictors of the Traditional Chinese medicine (TCM) clinical index for diabetic peripheral neuropathy (DPN) in type 2 diabetes mellitus (T2DM) patients, develop a clinical prediction model, and construct a nomogram. Methods We collected the TCM clinical index from 3590 T2DM recruited at the Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine from January 2019 to October 2020. The participants were randomly assigned to either the training group (n = 3297) or the validation group (n = 1426). TCM symptoms and tongue characteristics were used to assess the risk of developing DPN in T2DM patients. Through 5-fold cross-validation in the training group, the least absolute shrinkage and selection operator (LASSO) regression analysis method was used to optimize variable selection. In addition, using multifactor logistic regression analysis, a predictive model and nomogram were developed. Results A total of eight independent predictors were found to be associated with the DPN in multivariate logistic regression analyses: advanced age of grading (odds ratio/OR 1.575), smoke (OR 2.815), insomnia (OR 0.557), sweating (OR 0.535), loose teeth (OR 1.713), dry skin (OR 1.831), purple tongue (OR 2.278). And dark red tongue (OR 0.139). The model was constructed using these eight predictor's medium discriminative capabilities. The area under the curve (AUC) of the training set is 0.727, and the AUC of the validation set is 0.744 on the ROC curve. The calibration plot revealed that the model's goodness-of-fit is satisfactory. Conclusions We established a TCM prediction model for DPN in patients with T2DM based on the TCM clinical index.
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Affiliation(s)
- Zhikui Tian
- School of Health Sciences and Engineering, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Yadong Fan
- Nanjing University of Chinese Medicine, Nanjing, 210023, China
- Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210004, China
| | - Xuan Sun
- School of Health Sciences and Engineering, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Dongjun Wang
- College of Traditional Chinese Medicine, North China University of Science and Technology, Tangshan, 063000, China
| | - Yuanyuan Guan
- School of Health Sciences and Engineering, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Ying Zhang
- Fengnan District Hospital of Traditional Chinese Medicine, Tangshan, 063000, China
| | - Zhaohui Zhang
- Surgery of TCM, Second Affiliated Hospital of Tianjin University of TCM, Tianjin, 301617, China
| | - Jing Guo
- Surgery of TCM, Second Affiliated Hospital of Tianjin University of TCM, Tianjin, 301617, China
| | - Huaien Bu
- School of Health Sciences and Engineering, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Zhongming Wu
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Hongwu Wang
- School of Health Sciences and Engineering, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
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de Azevedo Vieira ARS, Porto-Dantas LB, do Prado Romani FA, Carvalho PS, Pop-Busui R, Pedrosa HC. Autonomic neuropathic symptoms in patients with diabetes: practical tools for screening in daily routine. Diabetol Metab Syndr 2023; 15:83. [PMID: 37101234 PMCID: PMC10130803 DOI: 10.1186/s13098-023-01036-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/22/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Diabetic autonomic neuropathy (DAN) is a frequent complication in people with diabetes whose screening is often neglected. This study aimed to evaluate DAN through practical tools in people with diabetes in a referral center for diabetes treatment. METHODS DAN symptoms and severity were assessed using the Survey of Autonomic Symptoms (SAS) via digital application (app) in patients attended from June 1, 2021, to November 12, 2021. SAS scoring for DAN was performed using established validated cutoffs. The adhesive with cobalt salt color indicator (Neuropad™) was used as a measure of sudomotor dysfunction. Demographical and clinical data were also collected. RESULTS Data from 109 participants, 66.9% T2DM, 73.4% female, with a median age of 54.00 (± 20.00) years, were analyzed. Symptomatic DAN was present in 69.7% of participants and was associated with older age (p = 0.002), higher HbA1c (p = 0.043), higher abdominal circumference (p = 0.019), higher BMI (p = 0.013), more likely to have metabolic syndrome (MS) with a 10-fold increased risk, and more frequent association with diabetic peripheral neuropathy (p = 0.005). Sudomotor dysfunction was found in 65 participants with positive Neuropad™ detected in 63.1% of them. CONCLUSION The use of SAS through an app proved to be a practical and easy-to-use instrument to document symptoms of DAN in busy clinical practice. The high frequency of symptoms draws attention to the importance of screening this underdiagnosed diabetes complication. The risk factors and comorbidities associated with symptomatic DAN highlight the patients' phenotypes linked to MS that should be targeted for DAN evaluations in larger samples in the community.
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Affiliation(s)
- Ana Raquel Souza de Azevedo Vieira
- Unit of Endocrinology of the Regional Hospital of Taguatinga and Research Center of the Foundation for Education and Research in Health Sciences, Secretariat of Health of the Federal District, Brasilia, Brazil
| | - Lara Benigno Porto-Dantas
- Unit of Endocrinology of the Regional Hospital of Taguatinga and Research Center of the Foundation for Education and Research in Health Sciences, Secretariat of Health of the Federal District, Brasilia, Brazil.
| | - Flaviene Alves do Prado Romani
- Unit of Endocrinology of the Regional Hospital of Taguatinga and Research Center of the Foundation for Education and Research in Health Sciences, Secretariat of Health of the Federal District, Brasilia, Brazil
| | - Patrícia Souza Carvalho
- Unit of Endocrinology of the Regional Hospital of Taguatinga and Research Center of the Foundation for Education and Research in Health Sciences, Secretariat of Health of the Federal District, Brasilia, Brazil
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Hermelinda Cordeiro Pedrosa
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Nkonge KM, Nkonge DK, Nkonge TN. Screening for diabetic peripheral neuropathy in resource-limited settings. Diabetol Metab Syndr 2023; 15:55. [PMID: 36945043 PMCID: PMC10031885 DOI: 10.1186/s13098-023-01032-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/15/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Diabetic neuropathy is the most common microvascular complication of diabetes mellitus and a major risk factor for diabetes-related lower-extremity complications. Diffuse neuropathy is the most frequently encountered pattern of neurological dysfunction and presents clinically as distal symmetrical sensorimotor polyneuropathy. Due to the increasing public health significance of diabetes mellitus and its complications, screening for diabetic peripheral neuropathy is essential. Consequently, a review of the principles that guide screening practices, especially in resource-limited clinical settings, is urgently needed. MAIN BODY Numerous evidence-based assessments are used to detect diabetic peripheral neuropathy. In accordance with current guideline recommendations from the American Diabetes Association, International Diabetes Federation, International Working Group on the Diabetic Foot, and National Institute for Health and Care Excellence, a screening algorithm for diabetic peripheral neuropathy based on multiphasic clinical assessment, stratification according to risk of developing diabetic foot syndrome, individualized treatment, and scheduled follow-up is suggested for use in resource-limited settings. CONCLUSIONS Screening for diabetic peripheral neuropathy in resource-limited settings requires a practical and comprehensive approach in order to promptly identify affected individuals. The principles of screening for diabetic peripheral neuropathy are: multiphasic approach, risk stratification, individualized treatment, and scheduled follow-up. Regular screening for diabetes-related foot disease using simple clinical assessments may improve patient outcomes.
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Lv Y, Yang Z, Xiang L, Yu M, Zhao S, Zhang X, Li R. Lower Limb Arterial Ischemia: An Independent Risk Factor of Sudomotor Dysfunction in Type 2 Diabetes. Diabetes Metab Syndr Obes 2023; 16:883-891. [PMID: 37012930 PMCID: PMC10066695 DOI: 10.2147/dmso.s402797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/17/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND As an early manifestation of diabetic peripheral neuropathy (DPN), sudomotor dysfunction significantly increases the risk of diabetic foot ulcer. The pathogenesis of sudomotor dysfunction is still unclear. Lower limb ischemia may be related to sudomotor dysfunction, but few studies have explored it. The purpose of this study is to explore the relationship between sudomotor function and comprehensive lower limb arterial ischemia including large arteries, small arteries and microvascular in type 2 diabetes mellitus (T2DM). PATIENTS AND METHODS 511 T2DM patients were enrolled in this cross-sectional study. Sudomotor function was assessed qualitatively and quantitatively by Neuropad. Lower limb arterial ischemia was defined as any abnormality of the ankle brachial index (ABI), toe brachial index (TBI) or transcutaneous oxygen tension (TcPO2). RESULTS In this study, 75.1% of patients had sudomotor dysfunction. Compared with normal sudomotor function, patients with sudomotor dysfunction had a higher incidence of lower limb arterial ischemia (51.2% vs 36.2%, p = 0.004). Similarly, compared with the non-arterial ischemia group, the proportion of sudomotor disorders was higher in the arterial ischemia group (p = 0.004). Low TBI and low TcPO2 groups also had a higher proportion of sudomotor disorders (all p < 0.05).Compare with normal groups, low ABI, low TBI, and low TcPO2 groups had lower Slop4 which quantitatively reflecting Neuropad discoloration. Arterial ischemia was an independent risk factor for sudomotor dysfunction [OR = 1.754, p = 0.024]. Low TcPO2 also independently increased the risk of sudomotor disorders [OR = 2.231, p = 0.026]. CONCLUSION Lower limb arterial ischemia is an independent risk factor of sudomotor dysfunction. Especially below the ankle (BTA) small arteries and microvascular ischemia may also be involved in the occurrence of sudomotor disorders.
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Affiliation(s)
- Yuhuan Lv
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
| | - Zheng Yang
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
| | - Linyu Xiang
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
| | - Meng Yu
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
| | - Subei Zhao
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
| | - Xiaoru Zhang
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
| | - Rong Li
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
- Correspondence: Rong Li, The Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, YouYi Road 1#, Yuzhong District, Chongqing, People’s Republic of China, Email
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Kurze C, Farn CJ, Siow J. The Interdisciplinary Approach: Preventive and Therapeutic Strategies for Diabetic Foot Ulcers. Foot Ankle Clin 2022; 27:529-543. [PMID: 36096550 DOI: 10.1016/j.fcl.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The appropriate treatment of the common diabetic foot ulcers (DFUs) in diabetic patients demands enormous human, organizational and financial resources that are finite. Interdisciplinary teams of medical and surgical specialists, as well as allied health professionals, can help to reduce the consumption of these resources, optimize treatment, and prevent DFUs. They consist primarily of vascular surgeons, endocrinologists, and orthopedic foot and ankle surgeons and are closely supported when required by infectious diseases specialists, plastic surgeons, wound care specialist nurses, podiatrists, and orthotists. A timely interdisciplinary team review in each clinic session decreases the number of hospital visits for the oftentimes-handicapped diabetic patients significantly. The interdisciplinary team clinic setup has also been shown to reduce the risk of amputations, length of hospital staz and mortality rates.
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Affiliation(s)
- Christophe Kurze
- Department of Orthopedic Surgery, Inselspital, University of Berne, Freiburgstrasse, 3010 Berne, Switzerland.
| | - Chui Jia Farn
- Department of Orthopedic Surgery, Inselspital, University of Berne, Freiburgstrasse, 3010 Berne, Switzerland; Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - James Siow
- Department of Orthopedic Surgery, Inselspital, University of Berne, Freiburgstrasse, 3010 Berne, Switzerland; Department of Orthopedic Surgery, Woodlands Health, Singapore
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Role of Autonomous Neuropathy in Diabetic Bone Regeneration. Cells 2022; 11:cells11040612. [PMID: 35203263 PMCID: PMC8870009 DOI: 10.3390/cells11040612] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 01/11/2023] Open
Abstract
Diabetes mellitus has multiple negative effects on regenerative processes, especially on wound and fracture healing. Despite the well-known negative effects of diabetes on the autonomous nervous system, only little is known about the role in bone regeneration within this context. Subsequently, we investigated diabetic bone regeneration in db−/db− mice with a special emphasis on the sympathetic nervous system of the bone in a monocortical tibia defect model. Moreover, the effect of pharmacological sympathectomy via administration of 6-OHDA was evaluated in C57Bl6 wildtype mice. Diabetic animals as well as wildtype mice received a treatment of BRL37344, a β3-adrenergic agonist. Bones of animals were examined via µCT, aniline-blue and Masson–Goldner staining for new bone formation, TRAP staining for bone turnover and immunoflourescence staining against tyrosinhydroxylase and stromal cell-derived factor 1 (SDF-1). Sympathectomized wildtype mice showed a significantly decreased bone regeneration, just comparable to db−/db− mice. New bone formation of BRL37344 treated db−/db− and sympathectomized wildtype mice was markedly improved in histology and µCT. Immunoflourescence stainings revealed significantly increased SDF-1 due to BRL37344 treatment in diabetic animals and sympathectomized wildtypes. This study depicts the important role of the sympathetic nervous system for bone regenerative processes using the clinical example of diabetes mellitus type 2. In order to improve and gain further insights into diabetic fracture healing, β3-agonist BRL37344 proved to be a potent treatment option, restoring impaired diabetic bone regeneration.
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Cheng Y, Cao W, Zhang J, Wang J, Liu X, Wu Q, Lin Q. Determinants of Diabetic Peripheral Neuropathy and Their Clinical Significance: A Retrospective Cohort Study. Front Endocrinol (Lausanne) 2022; 13:934020. [PMID: 35957831 PMCID: PMC9360478 DOI: 10.3389/fendo.2022.934020] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/22/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In this study, we investigated the epidemiological characteristics and predictors of diabetic peripheral neuropathy (DPN) in adult patients with type 2 diabetes mellitus (DM). METHODS The study was designed as a retrospective cohort trial at the First Affiliated Hospital of Wenzhou Medical University. From January 2017 to December 2020, a total of 1,262 patients with DM were enrolled to assess the risk factors for DPN. The patients were divided into two groups (DPN group and non-DPN group). The Mann-Whitney U test or t-test, receiver operating characteristic (ROC) analyses, univariate chi-square analyses, and multiple logistic regression analyses were used to analyze the adjusted predictors of DPN. RESULTS The overall prevalence of DPN in DM patients was 72.7% (n = 793/1,091). Multivariate analysis revealed that age > 66 years (odds ratio [OR], 2.647; 95% confidence interval [CI] 1.469-4.770; p = 0.002), history of hypertension (OR, 1.829; 95% CI 1.146-2.920; p = 0.011), neutrophil (NE) levels exceeding 4.0 × 109/L (OR 0.256; 95% CI 0.162-0.405; p = 0.001), lymphocyte (LY) levels over 3.0 × 109/L (OR 7.173; 95% CI 4.258-12.086; p = 0.000), HbA1c > 7.7% (OR 3.151; 95% CI 1.959-5.068; p = 0.000), and FT3 > 4.4 pmol/L (OR 0.417; 95% CI 0.263-0.662; p = 0.000) were six significant predictive factors for the prevalence of DPN. CONCLUSIONS High levels of LY, HbA1c, history of hypertension, and > 66 years of age increase the risk of DPN in adult patients with DM, while high levels of NE and FT3 were protective factors of DPN. Thus, the prediction of DPN can significantly be improved by identifying older patients over the age of 66 and history of hypertension, as well as establishing the biochemical cutoff values of NE, LY, HbA1c, and FT3.
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Affiliation(s)
- Yifan Cheng
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Wen Cao
- Department of Neurology, The Third Hospital of Peking University, Beijing, China
| | - Junzhe Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jiabin Wang
- Department of Neurology, Hebei Medical University, Shijiazhuang, China
| | - Xiang Liu
- Department of Neurology, Hebei Medical University, Shijiazhuang, China
| | - Qianqian Wu
- Department of Geriatrics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Qingxia Lin
- Department of Psychiatry, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Qingxia Lin,
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Wang Z, Hazlehurst J, Subramanian A, Tahrani AA, Hanif W, Thomas N, Singh P, Wang J, Sainsbury C, Nirantharakumar K, Crowe FL. Diabetic Foot Risk Classification at the Time of Type 2 Diabetes Diagnosis and Subsequent Risk of Mortality: A Population-Based Cohort Study. Front Endocrinol (Lausanne) 2022; 13:888924. [PMID: 35898465 PMCID: PMC9309507 DOI: 10.3389/fendo.2022.888924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/13/2022] [Indexed: 12/02/2022] Open
Abstract
AIM We aimed to compare the mortality of individuals at low, moderate, and high risk of diabetic foot disease (DFD) in the context of newly diagnosed type 2 diabetes, before developing active diabetic foot problem. METHODS This was a population-based cohort study of adults with newly diagnosed type 2 diabetes utilizing IQVIA Medical Research Data. The outcome was all-cause mortality among individuals with low, moderate, and high risk of DFD, and also in those with no record of foot assessment and those who declined foot examination. RESULTS Of 225,787 individuals with newly diagnosed type 2 diabetes, 34,061 (15.1%) died during the study period from January 1, 2000 to December 31, 2019. Moderate risk and high risk of DFD were associated with increased mortality risk compared to low risk of DFD (adjusted hazard ratio [aHR] 1.50, 95% CI 1.42, 1.58; aHR 2.01, 95% CI 1.84, 2.20, respectively). Individuals who declined foot examination or who had no record also had increased mortality risk of 75% and 25% vs. those at low risk of DFD, respectively (aHR 1.75, 95% CI 1.51, 2.04; aHR 1.25, 95% CI 1.20, 1.30). CONCLUSION Individuals with new-onset type 2 diabetes who had moderate to high risk of DFD were more likely to die compared to those at low risk of DFD. The associations between declined foot examination and absence of foot examinations, and increased risk of mortality further highlight the importance of assessing foot risk as it identifies not only patients at risk of diabetic foot ulceration but also mortality.
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Affiliation(s)
- Zhaonan Wang
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Jonathan Hazlehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Department of Diabetes and Endocrinology, University Hospital Birmingham Foundation Trust, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Anuradhaa Subramanian
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Abd A. Tahrani
- Department of Diabetes and Endocrinology, University Hospital Birmingham Foundation Trust, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Wasim Hanif
- Department of Diabetes and Endocrinology, University Hospital Birmingham Foundation Trust, Birmingham, United Kingdom
| | - Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Pushpa Singh
- Department of Diabetes and Endocrinology, University Hospital Birmingham Foundation Trust, Birmingham, United Kingdom
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Jingya Wang
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Christopher Sainsbury
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Department of Diabetes, Gartnavel General Hospital, National Health Service Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Health Data Research UK, London, United Kingdom
| | - Francesca L. Crowe
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- *Correspondence: Francesca L. Crowe,
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Diabetic Foot Ulcers and Cardiac Autonomic Neuropathy. Clin Ther 2021; 44:323-330. [PMID: 34974945 DOI: 10.1016/j.clinthera.2021.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/21/2021] [Accepted: 12/08/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE Diabetic foot ulcers (DFUs) and cardiac autonomic neuropathy (CAN) are severe complications of diabetes mellitus (DM). Both DFU and CAN are associated with increased risk of major cardiovascular events and mortality. Because of the clinical impact of both these conditions, it is important to establish what effect the presence of CAN has on DFU outcomes. METHODS This is a narrative review of original research articles identified through an electronic search of PubMed, Scopus, and Google scholar databases until June 2021 exploring CAN in individuals with DFUs. We explored prevalence, patient outcomes (DFU healing and amputation), and mortality. FINDINGS Evidence suggests that the prevalence of CAN is high, ranging from 43% to 66% among those with DFUs. The presence of CAN may also increase the odds of developing DFUs. A single-center, prospective, observational study has suggested that the presence of CAN significantly reduces DFU healing time. The impact on amputation is indeterminate, with conflicting reports from studies reporting either no or increased risk. On the basis of limited evidence, CAN may be associated with increased mortality in individuals with DFUs. IMPLICATIONS The interplay between CAN and DFUs is poorly understood from current literature. Given the high prevalence of CAN in individuals with DFUs and the potential for suboptimal outcomes, further high-quality studies are required to determine future management approaches when both conditions coexist and to establish whether early CAN screening in individuals with diabetes at high risk of foot ulceration may ultimately improve their outlook.
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Kress S, Anderten H, Borck A, Freckmann G, Heinemann L, Holzmüller U, Kulzer B, Portele A, Schnell O, Varlemann H, Zemmrich C, Lobmann R. Preulcerous Risk Situation in Diabetic Foot Syndrome: Proposal for a Simple Ulcer Prevention Score. J Diabetes Sci Technol 2021; 15:816-826. [PMID: 32522035 PMCID: PMC8258539 DOI: 10.1177/1932296820922592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Preulcerous risk situations in patients with diabetes are often undiagnosed and care administered too late. Even with regular medical check-ups and status documentation, foot examinations have not been given enough attention. Diagnosing an individual patients' risk of developing diabetic foot ulcers may increase vigilance for diabetic foot syndrome (DFS), and the appropriate prevention measures matching the risk involved may prevent the emergence of diabetic ulcers. The classical DFS risk factors are well established and have been extensively covered in the literature; however, there is a lack of efficient screening tools that could be used for a rapid assessment of diabetic foot ulcer risk. METHODS A methodical literature search was conducted to assess relevant publications for the preparation of a simple risk score for amputation related to diabetic foot ulcer. We then analyzed the risk factors for predictive value as odds ratios in foot ulcers and/or amputation. We used the available data to deduce a mean value to reflect the authors' consensus. RESULTS In view of the current literature on the matter, we have developed a semi-quantitative scoring system using just a few items to allow rapid and visual risk assessment for diabetic foot ulcers alongside recommendations for prevention and a sensible follow-up strategy to match the risk. CONCLUSION This relatively simple score enables rapid risk classification for patients that can ease the way for both physicians and patients in gaining an insight into individual risk situations. The score provides more effective preventative measures for high-risk patients against future complications.
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Affiliation(s)
- Stephan Kress
- Vinzentinus-Krankenhaus, Landau, Germany
- Stephan Kress, MD, Diabeteszentrum, Vinzentius-Krankenhaus, Cornichonstrasse 4, 76829 Landau, Germany.
| | - Helmut Anderten
- Gemeinschaftspraxis Anderten-Krok & Partner, Hildesheim, Germany
| | - Anja Borck
- Sanofi-Aventis Deutschland GmbH, Berlin, Germany
| | - Guido Freckmann
- Institut für Diabetes-Technologie Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Germany
| | | | - Ulrike Holzmüller
- Klinik für Endokrinologie und Nephrologie der Universität Leipzig, Germany
| | - Bernd Kulzer
- Forschungsinstitut der Diabetes Akademie Bad Mergentheim (FIDAM), Germany
| | | | | | | | - Claudia Zemmrich
- Praxis für Cardiovascular- und Ultraschalldiagnostik, Herz-Kreislauf-Erkrankungen und Psychotherapie, Berlin, Germany
| | - Ralf Lobmann
- Klinik für Endokrinologie, Diabetologie und Geriatrie, Stuttgart, Germany
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M SL, O P. Inflammatory biomarkers as a part of diagnosis in diabetic peripheral neuropathy. J Diabetes Metab Disord 2021; 20:869-882. [PMID: 34222094 PMCID: PMC8212194 DOI: 10.1007/s40200-021-00734-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/05/2021] [Indexed: 01/09/2023]
Abstract
Diabetic peripheral neuropathy (DPN), a chronic neurological complication of diabetes mellitus, remains scantily addressed area of research. Many lacunae in the temporal sequence between cause and effect of DPN still remain unfilled and therefore treatment of DPN remains unsatisfactory. This is largely due to the conventional glucocentric focus to resolve the problem. This focus over hyperglycemia should be shifted to consider, chronic low grade inflammation as the major determinant in DPN. Rapidly emerging evidences from recent studies suggest that chronic low grade inflammation leads to the activation of innate immune system response, loss of insulin signaling and insulin resistance, endoplasmic reticulum stress, mitochondrial stress, leading to production of kinases like protein kinase C, mitogen activated protein kinase and jun-N-terminal kinase, pro-inflammatory cytokines and inter leukins-1b, 2, 6 and 8, tumour necrosis factor-alpha and other chemokines, leading to DPN. These biomarkers can be early predictors of DPN and therefore should be the focus of work testing their clinical utility to identify high-risk individuals as well as perhaps to target interventions. In this paper, we would like to review all the aspects of DPN, laying greater emphasis on inflammatory biomarkers as a tool for early diagnosis of DPN and the possible research approaches to address it satisfactorily.
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Affiliation(s)
- Sai Laxmi M
- Department of Pharmacology, GITAM Institute of Pharmacy, GITAM Deemed to be University, Visakhapatnam, Andhra Pradesh India
| | - Prabhakar O
- Department of Pharmacology, GITAM Institute of Pharmacy, GITAM Deemed to be University, Visakhapatnam, Andhra Pradesh India
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Yang H, Sloan G, Ye Y, Wang S, Duan B, Tesfaye S, Gao L. New Perspective in Diabetic Neuropathy: From the Periphery to the Brain, a Call for Early Detection, and Precision Medicine. Front Endocrinol (Lausanne) 2020; 10:929. [PMID: 32010062 PMCID: PMC6978915 DOI: 10.3389/fendo.2019.00929] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/19/2019] [Indexed: 12/12/2022] Open
Abstract
Diabetic peripheral neuropathy (DPN) is a common chronic complication of diabetes mellitus. It leads to distressing and expensive clinical sequelae such as foot ulceration, leg amputation, and neuropathic pain (painful-DPN). Unfortunately, DPN is often diagnosed late when irreversible nerve injury has occurred and its first presentation may be with a diabetic foot ulcer. Several novel diagnostic techniques are available which may supplement clinical assessment and aid the early detection of DPN. Moreover, treatments for DPN and painful-DPN are limited. Only tight glucose control in type 1 diabetes has robust evidence in reducing the risk of developing DPN. However, neither glucose control nor pathogenetic treatments are effective in painful-DPN and symptomatic treatments are often inadequate. It has recently been hypothesized that using various patient characteristics it may be possible to stratify individuals and assign them targeted therapies to produce better pain relief. We review the diagnostic techniques which may aid the early detection of DPN in the clinical and research environment, and recent advances in precision medicine techniques for the treatment of painful-DPN.
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Affiliation(s)
- Heng Yang
- Endocrinology Department, Renmin Hospital of Wuhan University, Wuhan, China
| | - Gordon Sloan
- Diabetes Research Unit, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Yingchun Ye
- Endocrinology Department, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shuo Wang
- Endocrinology Department, Renmin Hospital of Wuhan University, Wuhan, China
| | - Bihan Duan
- Endocrinology Department, Renmin Hospital of Wuhan University, Wuhan, China
| | - Solomon Tesfaye
- Diabetes Research Unit, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Ling Gao
- Endocrinology Department, Renmin Hospital of Wuhan University, Wuhan, China
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Panagoulias GS, Eleftheriadou I, Papanas N, Manes C, Kamenov Z, Tesic D, Bousboulas S, Tentolouris A, Jude EB, Tentolouris N. Dryness of Foot Skin Assessed by the Visual Indicator Test and Risk of Diabetic Foot Ulceration: A Prospective Observational Study. Front Endocrinol (Lausanne) 2020; 11:625. [PMID: 33013702 PMCID: PMC7506164 DOI: 10.3389/fendo.2020.00625] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/30/2020] [Indexed: 12/24/2022] Open
Abstract
Research Question: Previous cross-sectional studies have shown an association between sudomotor dysfunction and diabetic foot ulceration (DFU). The aim of this prospective multicenter study was to determine the role of dryness of foot skin and of established neurological modalities in the prediction of risk for foot ulceration in a cohort of individuals with diabetes mellitus (DM). Design: The study was conducted from 2012 to 2017. A total of 308 subjects with DM without history of DFU or critical limb ischemia completed the study. Diabetic neuropathy was assessed using the neuropathy symptom score (NSS) and neuropathy disability score (NDS). In a subset of participants, vibration perception threshold (VPT) was evaluated. Dryness of foot skin was assessed by the visual indicator plaster method (IPM). The diagnostic performance of the above neurological modalities for prediction of DFU was tested by receiver operating characteristic curve (ROC) analysis. Results: During the 6-year follow-up, 55 patients (annual ulceration incidence 2.97%) developed DFU. Multivariate Cox-regression analysis after controlling for the effect of age, gender, and DM duration demonstrated that the risk (hazard ratio, 95% confidence intervals) of DFU increased significantly with either abnormal IPM (3.319, 1.460-7.545, p = 0.004) or high (≥6) NDS (2.782, 1.546-5.007, p = 0.001) or high (≥25 volts) VPT (2.587, 1.277-5.242, p = 0.008). ROC analysis showed that all neurological modalities could discriminate participants who developed DFU (p < 0.001). IPM testing showed high sensitivity (0.86) and low specificity (0.49), while high vs. low NDS and VPT showed low sensitivity (0.40 and 0.39, respectively) and high specificity (0.87 and 0.89, respectively) for identification of patients at risk for DFU. Conclusion: Dryness of foot skin assessed by the IPM predicts the development of DFU. IPM testing has high sensitivity, whereas high NDS and VPT have high specificity in identifying subjects at risk for DFU. The IPM can be included in the screening methods for identification of the foot at risk.
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Affiliation(s)
- Georgios S. Panagoulias
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Ioanna Eleftheriadou
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Nikolaos Papanas
- Second Department of Internal Medicine, Diabetes Center, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupoli, Greece
| | - Christos Manes
- Diabetes Center, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Zdravko Kamenov
- Diabetes Outpatient Clinic, University Hospital Alexandrovska, Medical University—Sofia, Sofia, Bulgaria
| | - Dragan Tesic
- Clinic for Endocrinology, Diabetes and Diseases of Metabolism, Clinical Center of Vojvodina, Medical Faculty, University Novi Sad, Novi Sad, Serbia
| | - Stavros Bousboulas
- Diabetes Outpatient Clinic, “St. Panteleimon” General State Hospital, Nikaia, Greece
| | - Anastasios Tentolouris
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Edward B. Jude
- Tameside Hospital NHS Foundation Trust and University of Manchester, Ashton-under-Lyne, United Kingdom
| | - Nikolaos Tentolouris
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
- *Correspondence: Nikolaos Tentolouris
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Sensitivity and specificity of the Neuropad for distal sensory peripheral neuropathy (DSPN) in subjects with HIV-Infection: A case controlled observational study. INT J OSTEOPATH MED 2019. [DOI: 10.1016/j.ijosm.2018.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Petropoulos IN, Ponirakis G, Khan A, Almuhannadi H, Gad H, Malik RA. Diagnosing Diabetic Neuropathy: Something Old, Something New. Diabetes Metab J 2018; 42:255-269. [PMID: 30136449 PMCID: PMC6107364 DOI: 10.4093/dmj.2018.0056] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 05/28/2018] [Indexed: 12/13/2022] Open
Abstract
There are potentially many ways of assessing diabetic peripheral neuropathy (DPN). However, they do not fulfill U.S. Food and Drug Administration (FDA) requirements in relation to their capacity to assess therapeutic benefit in clinical trials of DPN. Over the past several decades symptoms and signs, quantitative sensory and electrodiagnostic testing have been strongly endorsed, but have consistently failed as surrogate end points in clinical trials. Therefore, there is an unmet need for reliable biomarkers to capture the onset and progression and to facilitate drug discovery in DPN. Corneal confocal microscopy (CCM) is a non-invasive ophthalmic imaging modality for in vivo evaluation of sensory C-fibers. An increasing body of evidence from multiple centers worldwide suggests that CCM fulfills the FDA criteria as a surrogate endpoint of DPN.
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Affiliation(s)
| | | | - Adnan Khan
- Division of Research, Weill Cornell Medicine Qatar, Doha, Qatar
| | | | - Hoda Gad
- Division of Research, Weill Cornell Medicine Qatar, Doha, Qatar
| | - Rayaz A Malik
- Division of Research, Weill Cornell Medicine Qatar, Doha, Qatar.
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Shivaprasad C, Amit G, Anish K, Rakesh B, Anupam B, Aiswarya Y. Clinical correlates of sudomotor dysfunction in patients with type 2 diabetes and peripheral neuropathy. Diabetes Res Clin Pract 2018. [PMID: 29524484 DOI: 10.1016/j.diabres.2018.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIMS To investigate the factors associated with abnormal electrochemical skin conductance (ESC) in patients with type 2 diabetes mellitus (T2D) and early diabetic peripheral neuropathy (DPN). METHODS We recruited 523 consecutive patients with T2D (median age: 50 [interquartile range: 16] years; median T2D duration: 4 [5] years). Sudomotor dysfunction was defined as an ESC <60 µS, and DPN as a neuropathy disability score (NDS) ≥6. Logistic regression was performed to determine the predictors of sudomotor dysfunction in patients with DPN. RESULTS The prevalence of sudomotor dysfunction was 29% for all patients and 84.5% for patients with DPN. A significant negative correlation was observed between the NDS and ESC measurements (r = -0.52, p < 0.0001). In the univariate analysis, abnormal ESC measures were associated with age, diabetes duration, glycated hemoglobin, diabetic retinopathy, insulin therapy, and foot abnormalities. In the multivariate analysis, ESC abnormalities were associated with age, diabetes duration, glycated hemoglobin levels, insulin therapy, and foot deformities. There was a robust association between foot deformities and abnormal ESC (p = 0.049; odds ratio = 16.02) in patients with DPN. CONCLUSION Sudomotor dysfunction is highly prevalent in patients with T2D, especially in those with DPN. Various diabetes-related factors were linked to lower ESC values, indicating an association between chronic hyperglycemia and sudomotor function. We also observed a strong relationship between foot deformities and ESC abnormalities. We conclude that the factors associated with DPN are also relevant to sudomotor dysfunction.
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Affiliation(s)
- Channabasappa Shivaprasad
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India.
| | - Goel Amit
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India
| | - Kolly Anish
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India
| | - Boppana Rakesh
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India
| | - Biswas Anupam
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India
| | - Yalamanchi Aiswarya
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India
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Maser RE, James Lenhard M, Pohlig RT, Babu Balagopal P. Osteopontin and clusterin levels in type 2 diabetes mellitus: differential association with peripheral autonomic nerve function. Neurol Sci 2017; 38:1645-1650. [PMID: 28638999 PMCID: PMC5709198 DOI: 10.1007/s10072-017-3019-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 06/03/2017] [Indexed: 12/27/2022]
Abstract
Osteopontin (OPN) and clusterin are secreted glycoproteins potentially associated with nerve function. Sudomotor dysfunction is associated with the development of foot ulcerations. The purpose of this study was to investigate the potential relationship of OPN and clusterin with sudomotor function (i.e., autonomic nerves that control sweating) in participants with type 2 diabetes mellitus (T2DM). Sudomotor function was assessed using SUDOSCAN® which measures electrochemical skin conductance (ESC) of the hands and feet. Demographics (e.g., age, gender, race, body mass index (BMI)), HbA1c, 25-hydroxyvitamin D, creatinine, OPN, and clusterin were also determined for the participants. Fifty individuals with T2DM (age = 59±11 years; 23/27 male/female; 13 African Americans) participated in this study. Lower ESC for the hands and feet were observed in African Americans versus Caucasians/Asians (p < 0.05). No significant ESC differences were observed for good [HbA1c <7%] versus poor [HbA1c ≥7%] glycemic control. With regard to gender, ESC values were lower for the hands for females (p < 0.05). In linear regression with ESC for the hands or feet as the dependent variable, increased OPN levels, but not clusterin, were independently associated with reduced sudomotor function while adjusting for age, gender, race, BMI, and glycemic control (ESC hands model R 2 = 0.504, p < 0.001; ESC feet model R 2 = 0.534, p < 0.001). The association between OPN and reduced sudomotor function found in our study warrants further investigation to delineate the underlying mechanisms and determine if OPN is neuroprotective, involved in the pathogenesis of sudomotor dysfunction, or simply a bystander.
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Affiliation(s)
- Raelene E Maser
- Department of Medical Laboratory Sciences, University of Delaware, 305F Willard Hall Education Building, Newark, DE, 19716, USA.
- Diabetes and Metabolic Research Center, Christiana Care Health System, Newark, DE, 19713, USA.
| | - M James Lenhard
- Diabetes and Metabolic Research Center, Christiana Care Health System, Newark, DE, 19713, USA
- Diabetes and Metabolic Diseases Center, Christiana Care Health System, Wilmington, DE, 19801, USA
| | - Ryan T Pohlig
- Biostatistics Core Facility, University of Delaware, Newark, DE, 19716, USA
| | - P Babu Balagopal
- Biomedical Research & Analysis Laboratory, Nemours Children's Specialty Care & Mayo Clinic College of Medicine, Jacksonville, FL, 32207, USA
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Sheshah E, Madanat A, Al-Greesheh F, AL-Qaisi D, AL-Harbi M, Aman R, AL-Ghamdi AA, AL-Madani K. Electrochemical skin conductance to detect sudomotor dysfunction, peripheral neuropathy and the risk of foot ulceration among Saudi patients with diabetes mellitus. J Diabetes Metab Disord 2016; 15:29. [PMID: 27500133 PMCID: PMC4974704 DOI: 10.1186/s40200-016-0252-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 08/02/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Sudomotor dysfunction is manifested clinically as abnormal sweating leading to dryness of feet skin and increased risk of foot ulceration. The aim of this study was to test the performance of foot electrochemical skin conductance (ESC) to detect diabetic peripheral neuropathy and the risk of foot ulceration against traditional methods in Saudi patients with diabetes mellitus. METHODS This cross-sectional study was conducted on 296 Saudi patients with diabetes mellitus. Painful neuropathic symptoms were evaluated using the neuropathy symptom score (NSS). The risk of foot ulceration and diabetic peripheral neuropathy were determined using the neuropathy disability score (NDS). Vibration perception threshold (VPT) was assessed using neurothesiometer. Neurophysiological assessment of the right and left sural, peroneal and tibial nerves was performed in 222 participants. Diabetic peripheral neuropathy was defined according to the definition of the American Academy of Neurology. ESC was measured with Sudoscan. RESULTS Feet-ESC decreased as the scores of sensory and motor function tests increased. Feet-ESC decreased as the NSS, NDS and severity of diabetic peripheral neuropathy increased. Sensitivity of feet-ESC < 50μS to detect diabetic peripheral neuropathy assessed by VPT ≥ 25 V, NDS ≥ 3, NDS ≥ 6 was 90.1, 61 and 63.8 % respectively and specificity 77, 85 and 81.9 % respectively. Sensitivity of feet-ESC < 70μS to detect diabetic peripheral neuropathy assessed by VPT ≥ 25 V, NDS ≥ 3, NDS ≥ 6 was 100, 80.6 and 80.9 % respectively. Sensitivity and specificity of feet-ESC < 70μS to detect confirmed-diabetic peripheral neuropathy were 67.5 and 58.9 % respectively. CONCLUSION Sudoscan a simple and objective tool can be used to detect diabetic peripheral neuropathy and the risk of foot ulceration among patients with diabetes mellitus. Prospective studies to confirm our results are warranted.
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Affiliation(s)
- Eman Sheshah
- Diabetes Care Center, King Salman Hospital (MOH), Ayesha Bint Abi Baker St., PO Box: 15169, Riyadh, 11444 Kingdom of Saudi Arabia
| | - Amal Madanat
- Diabetes Care Center, King Salman Hospital (MOH), Ayesha Bint Abi Baker St., PO Box: 15169, Riyadh, 11444 Kingdom of Saudi Arabia
| | - Fahad Al-Greesheh
- Diabetes Care Center, King Salman Hospital (MOH), Ayesha Bint Abi Baker St., PO Box: 15169, Riyadh, 11444 Kingdom of Saudi Arabia
| | - Dalal AL-Qaisi
- Diabetes Care Center, King Salman Hospital (MOH), Ayesha Bint Abi Baker St., PO Box: 15169, Riyadh, 11444 Kingdom of Saudi Arabia
| | - Mohammad AL-Harbi
- Diabetes Care Center, King Salman Hospital (MOH), Ayesha Bint Abi Baker St., PO Box: 15169, Riyadh, 11444 Kingdom of Saudi Arabia
| | - Reem Aman
- Diabetes Care Center, King Salman Hospital (MOH), Ayesha Bint Abi Baker St., PO Box: 15169, Riyadh, 11444 Kingdom of Saudi Arabia
| | - Abdul Aziz AL-Ghamdi
- Diabetes Care Center, King Salman Hospital (MOH), Ayesha Bint Abi Baker St., PO Box: 15169, Riyadh, 11444 Kingdom of Saudi Arabia
| | - Khaled AL-Madani
- Diabetes Care Center, King Salman Hospital (MOH), Ayesha Bint Abi Baker St., PO Box: 15169, Riyadh, 11444 Kingdom of Saudi Arabia
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Yotsu RR, Pham NM, Oe M, Nagase T, Sanada H, Hara H, Fukuda S, Fujitani J, Yamamoto-Honda R, Kajio H, Noda M, Tamaki T. Comparison of characteristics and healing course of diabetic foot ulcers by etiological classification: neuropathic, ischemic, and neuro-ischemic type. J Diabetes Complications 2014; 28:528-35. [PMID: 24846054 DOI: 10.1016/j.jdiacomp.2014.03.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 03/07/2014] [Accepted: 03/24/2014] [Indexed: 02/07/2023]
Abstract
AIMS To identify differences in the characteristics of patients with diabetic foot ulcers (DFUs) according to their etiological classification and to compare their healing time. METHODS Over a 4.5-year period, 73 patients with DFUs were recruited. DFUs were etiologically classified as being of neuropathic, ischemic, or neuro-ischemic origin. Descriptive analyses were performed to characterize study subjects, foot-related factors, and healing outcome and time. Duration of healing was assessed using the Kaplan-Meier method. Healing time among the three types was compared using the log rank test. RESULTS The number of patients manifesting neuropathic, ischemic, and neuro-ischemic ulcers was 30, 20, and 14, respectively. Differences were identified for age, diabetes duration, body mass index, hypertension, and estimated glomerular filtration rate. Patients with neuro-ischemic ulcers had better ankle-brachial index, skin perfusion pressure (SPP), and transcutaneous oxygen pressure values compared to those with ischemic ulcers. The average time in which 50% of patients had healed wounds was 70, 113, and 233 days for neuropathic, neuro-ischemic, and ischemic ulcers, respectively. Main factors associated with healing were age and SPP values. CONCLUSIONS Based on the etiological ulcer type, DFU healing course and several patient factors differed. Failure to consider the differences in DFU etiology may have led to heterogeneity of results in previous studies on DFUs.
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Affiliation(s)
- Rie Roselyne Yotsu
- Department of Dermatology, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Ngoc Minh Pham
- Department of Epidemiology and Prevention, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Makoto Oe
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Takeshi Nagase
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hiromi Sanada
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hisao Hara
- Division of Cardiovascular Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shoji Fukuda
- Department of Cardiovascular Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Junko Fujitani
- Department of Rehabilitation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ritsuko Yamamoto-Honda
- Department of Diabetes and Metabolic Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiroshi Kajio
- Department of Diabetes and Metabolic Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mitsuhiko Noda
- Department of Diabetes and Metabolic Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takeshi Tamaki
- Department of Dermatology, National Center for Global Health and Medicine, Tokyo, Japan
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Charnogursky GA, Emanuele NV, Emanuele MA. Neurologic Complications of Diabetes. Curr Neurol Neurosci Rep 2014; 14:457. [DOI: 10.1007/s11910-014-0457-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Clinical and diagnostic features of small fiber damage in diabetic polyneuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2014; 126:275-90. [DOI: 10.1016/b978-0-444-53480-4.00019-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Verrotti A, Prezioso G, Scattoni R, Chiarelli F. Autonomic neuropathy in diabetes mellitus. Front Endocrinol (Lausanne) 2014; 5:205. [PMID: 25520703 PMCID: PMC4249492 DOI: 10.3389/fendo.2014.00205] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 11/17/2014] [Indexed: 12/14/2022] Open
Abstract
Diabetic autonomic neuropathy (DAN) is a serious and common complication of diabetes, often overlooked and misdiagnosed. It is a systemic-wide disorder that may be asymptomatic in the early stages. The most studied and clinically important form of DAN is cardiovascular autonomic neuropathy defined as the impairment of autonomic control of the cardiovascular system in patients with diabetes after exclusion of other causes. The reported prevalence of DAN varies widely depending on inconsistent definition, different diagnostic method, different patient cohorts studied. The pathogenesis is still unclear and probably multifactorial. Once DAN becomes clinically evident, no form of therapy has been identified, which can effectively stop or reverse it. Prevention strategies are based on strict glycemic control with intensive insulin treatment, multifactorial intervention, and lifestyle modification including control of hypertension, dyslipidemia, stop smoking, weight loss, and adequate physical exercise. The present review summarizes the latest knowledge regarding clinical presentation, epidemiology, pathogenesis, and management of DAN, with some mention to childhood and adolescent population.
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Affiliation(s)
| | | | | | - Francesco Chiarelli
- Department of Pediatrics, University of Chieti, Chieti, Italy
- *Correspondence: Francesco Chiarelli, Department of Pediatrics, University of Chieti, Via dei Vestini 5, Chieti 66013, Italy e-mail:
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Barshes NR, Sigireddi M, Wrobel JS, Mahankali A, Robbins JM, Kougias P, Armstrong DG. The system of care for the diabetic foot: objectives, outcomes, and opportunities. Diabet Foot Ankle 2013; 4:21847. [PMID: 24130936 PMCID: PMC3796020 DOI: 10.3402/dfa.v4i0.21847] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 08/07/2013] [Accepted: 08/29/2013] [Indexed: 01/13/2023]
Abstract
Most cases of lower extremity limb loss in the United States occur among people with diabetes who have a diabetic foot ulcer (DFU). These DFUs and the associated limb loss that may occur lead to excess healthcare costs and have a large negative impact on mobility, psychosocial well-being, and quality of life. The strategies for DFU prevention and management are evolving, but the implementation of these prevention and management strategies remains challenging. Barriers to implementation include poor access to primary medical care; patient beliefs and lack of adherence to medical advice; delays in DFU recognition; limited healthcare resources and practice heterogeneity of specialists. Herein, we review the contemporary outcomes of DFU prevention and management to provide a framework for prioritizing quality improvement efforts within a resource-limited healthcare environment.
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Affiliation(s)
- Neal R Barshes
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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Aubert CE, Le Doeuff J, Lajou J, Barthelemy O, Hartemann A, Bourron O. Influence of peripheral arterial occlusive disease on the Neuropad(®) test performance in patients with diabetes. Diabet Med 2013; 30:e178-84. [PMID: 23398465 DOI: 10.1111/dme.12150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 12/13/2012] [Accepted: 02/05/2013] [Indexed: 02/06/2023]
Abstract
AIMS The specificity of the Neuropad(®) test to screen for peripheral neuropathy is moderate, but this test has several advantages, such as self-use, educative value and good sensitivity. Use of the Neuropad is usually contra-indicated in the presence of peripheral arterial occlusive disease, a condition associated with skin dryness. The aim of this study was to assess the influence of peripheral arterial occlusive disease on the performance of the Neuropad for screening peripheral neuropathy, and to compare it with the monofilament test. METHODS We included 200 patients with diabetes. Peripheral neuropathy was defined by a neuropathy disability score ≥ 6. The Neuropad was determined as normal or abnormal at 10 and 20 min, respectively, and its performance was compared in patients with and without peripheral arterial occlusive disease diagnosed by colour duplex ultrasonography. The performances of the Neuropad and of the monofilament test were compared. RESULTS Prevalences of peripheral neuropathy and of peripheral arterial occlusive disease were 15.8 and 44%, respectively. At 10 min, sensitivity and negative predictive value were high (93.8 and 95.1%), while specificity and positive predictive value were poor (23.2 and 18.9%). The Neuropad performance was not significantly different between patients with and without arteriopathy. Between 10 and 20 min, there was significant loss of sensitivity and gain in specificity. The Neuropad at 10 min was more sensitive but less specific than the monofilament test. CONCLUSIONS The reliability of the Neuropad is not significantly different in the presence or absence of peripheral arterial occlusive disease.
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Affiliation(s)
- C E Aubert
- Diabetes and Metabolic Diseases Department, AP-HP, Pitié-Salpêtrière Hospital, Paris, France.
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27
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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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28
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Morales-Vidal S, Morgan C, McCoyd M, Hornik A. Diabetic peripheral neuropathy and the management of diabetic peripheral neuropathic pain. Postgrad Med 2012; 124:145-53. [PMID: 22913903 DOI: 10.3810/pgm.2012.07.2576] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Diabetic peripheral neuropathy (DPN) affects approximately half of patients with diabetes. Neuropathic pain is a major complaint of patients with diabetic polyneuropathy. Diabetic peripheral neuropathy can also lead to autonomic dysfunction. This article provides an outline of the clinical subtypes, pathophysiological features, and diagnosis of DPN. Disease-modifying treatments are reviewed, with particular attention paid to DPN pain management.
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Affiliation(s)
- Sarkis Morales-Vidal
- Department of Neurology, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL 60153, USA.
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29
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Monteiro-Soares M, Boyko EJ, Ribeiro J, Ribeiro I, Dinis-Ribeiro M. Predictive factors for diabetic foot ulceration: a systematic review. Diabetes Metab Res Rev 2012; 28:574-600. [PMID: 22730196 DOI: 10.1002/dmrr.2319] [Citation(s) in RCA: 191] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Improving ability to predict and prevent diabetic foot ulceration is imperative because of the high personal and financial costs of this complication. We therefore conducted a systematic review in order to identify all studies of factors associated with DFU and assess whether available DFU risk stratification systems incorporate those factors of highest potential value. We performed a search in PubMed for studies published through April 2011 that analysed the association between independent variables and DFU. Articles were selected by two investigators-independently and blind to each other. Divergences were solved by a third investigator. A total of 71 studies were included that evaluated the association between diabetic foot ulceration and more than 100 independent variables. The variables most frequently assessed were age, gender, diabetes duration, BMI, HbA(1c) and neuropathy. Diabetic foot ulceration prevalence varied greatly among studies. The majority of the identified variables were assessed by only two or fewer studies. Diabetic neuropathy, peripheral vascular disease, foot deformity and previous diabetic foot ulceration or lower extremity amputation - which are the most common variables included in risk stratification systems - were consistently associated with diabetic foot ulceration development. Existing diabetic foot ulceration risk stratification systems often include variables shown repeatedly in the literature to be strongly predictive of this outcome. Improvement of these risk classification systems though is impaired because of deficiencies noted, including a great lack of standardization in outcome definition and variable selection and measurement.
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Affiliation(s)
- M Monteiro-Soares
- Endocrinology, Diabetes and Metabolism Department-Diabetic Foot Team, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Portugal.
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30
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Luo KR, Chao CC, Hsieh PC, Lue JH, Hsieh ST. Effect of glycemic control on sudomotor denervation in type 2 diabetes. Diabetes Care 2012; 35:612-6. [PMID: 22301122 PMCID: PMC3322711 DOI: 10.2337/dc11-1607] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Sudomotor symptoms are a common component of diabetic autonomic neuropathy, but the pathology of sudomotor innervation and its relationship with glycemic control have remained obscured. RESEARCH DESIGN AND METHODS We enrolled 42 patients (26 males and 16 females aged 56.64 ± 12.67 years) with diabetic neuropathy defined by symmetric distally predominant sensory symptoms, abnormal nerve conduction studies, and reduced intraepidermal nerve fiber density in the leg. Skin biopsies of the distal leg were immunostained with antiprotein gene product 9.5 for nerve fibers and counterstained with Congo red for sweat glands. Sweat gland innervation index (SGII) was quantified with a new computerized area-based morphometric system. RESULTS Protein gene product 9.5(+) nerve terminals surrounded secretory coils of the sweat glands in the skin of control subjects. Sudomotor denervation was present in diabetic patients, manifesting as depletion of periglandular nerve fibers with lower SGII compared with 42 age- and sex-matched control subjects (2.54 ± 1.87 vs. 4.68 ± 1.51%, P < 0.001). The SGII was correlated with HbA(1c) (P = 0.011) and was lower in patients with anhidrosis of the feet compared with those with normal sweating of the feet (0.82 ± 0.69 vs. 3.00 ± 1.81%, P = 0.001). Sudomotor denervation was concordant with cardiac autonomic dysfunction as assessed with reduced heart rate variability (P = 0.003). CONCLUSIONS Sudomotor denervation is a significant presentation of diabetic neuropathy, and the SGII was associated with HbA(1c). A skin biopsy offers a structural assessment of sudomotor innervation.
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Affiliation(s)
- Kai-Ren Luo
- Department of Anatomy and Cell Biology, College of Medicine, National Taiwan University, Taipei, Taiwan
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31
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Malik RA, Veves A, Tesfaye S, Smith G, Cameron N, Zochodne D, Lauria G. Small fibre neuropathy: role in the diagnosis of diabetic sensorimotor polyneuropathy. Diabetes Metab Res Rev 2011; 27:678-84. [PMID: 21695760 DOI: 10.1002/dmrr.1222] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 06/06/2011] [Indexed: 12/15/2022]
Abstract
Small fibres constitute 70-90% of peripheral nerve fibres and regulate several key functions such as tissue blood flow, temperature and pain perception as well as sweating, all of which are highly relevant to the clinical presentation and adverse outcomes associated with foot ulcerations in patients with diabetes. Recent studies demonstrated significant abnormalities in the small fibres in subjects with impaired glucose tolerance and diabetes, despite normal electrophysiology, suggesting that the earliest nerve fibre damage is to the small fibres. Unfortunately, guidelines and consensus statements focus on large fibres and continue to advocate electrophysiology as a diagnostic modality and as a primary end point for the assessment of therapeutic benefit. (In part, this reflects the difficulties in quantifying small fibre dysfunction and damage.) We have therefore critically assessed currently available techniques that measure small fibre dysfunction in diabetic neuropathy, using quantitative sensory and sudomotor testing. We have assessed the role of identifying structural damage by quantifying intraepidermal nerve fibre density in skin biopsies and corneal nerve morphology using corneal confocal microscopy. Finally, we propose a definition for diabetic neuropathy that incorporates small fibre damage.
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Affiliation(s)
- R A Malik
- Division of Cardiovascular Medicine, University of Manchester, Manchester, UK.
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32
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Kempler P, Amarenco G, Freeman R, Frontoni S, Horowitz M, Stevens M, Low P, Pop-Busui R, Tahrani AA, Tesfaye S, Várkonyi T, Ziegler D, Valensi P. Management strategies for gastrointestinal, erectile, bladder, and sudomotor dysfunction in patients with diabetes. Diabetes Metab Res Rev 2011; 27:665-77. [PMID: 21748841 DOI: 10.1002/dmrr.1223] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 06/06/2011] [Indexed: 02/06/2023]
Abstract
There are substantial advances in understanding disordered gastrointestinal autonomic dysfunction in diabetes. It occurs frequently. The underlying pathogenesis is complex involving defects in multiple interacting cell types of the myenteric plexus as well. These defects may be irreversible or reversible. Gastrointestinal symptoms represent a major and generally underestimated source of morbidity for escalating health care costs in diabetes. Acute changes in glycaemia are both determinants and consequences of altered gastrointestinal motility. 35-90% of diabetic men have moderate-to-severe erectile dysfunction (ED). ED shares common risk factors with CVD. Diagnosis is based on medical/sexual history, including validated questionnaires. Physical examination and laboratory testing must be tailored to patient's complaints and risk factors. Treatment is based on PDE5-inhibitors (PDE5-I). Other explorations may be useful in patients who do not respond to PDE5-I. Patients at high cardiovascular risk should be stabilized by their cardiologists before sexual activity is considered or ED treatment is recommended. Estimates on bladder dysfunction prevalence are 43-87% of type 1 and 25% of type 2 diabetic patients, respectively. Common symptoms include dysuria, frequency, urgency, nocturia and incomplete bladder emptying. Diagnosis should use validated questionnaire for lower urinary tract symptoms. The type of bladder dysfunction is readily characterized with complete urodynamic testing. Sudomotor dysfunction is a cause of dry skin and is associated with foot ulcerations. Sudomotor function can be assessed by thermoregulatory sweat testing, quantitative sudomotor axon reflex test, sympathetic skin response, quantitative direct/indirect axon reflex testing and the indicator plaster.
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Affiliation(s)
- P Kempler
- I Department of Medicine, Semmelweis University, Budapest, Hungary.
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Argiana V, Eleftheriadou I, Tentolouris N. Screening for the high-risk foot of ulceration: tests of somatic and autonomic nerve function. Curr Diab Rep 2011; 11:294-301. [PMID: 21494779 DOI: 10.1007/s11892-011-0192-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Diabetic foot ulcers affect almost 5% of the patients with diabetes and carry a huge physical, emotional, and financial burden. Almost 80% of amputations in patients with diabetes are preceded by a foot ulcer. The need for simple screening methods for prevention of foot ulcers and amputations is indisputable. Simple tests such as monofilament, tuning fork, vibration perception threshold determination, ankle reflexes, and pinprick sensation alone or in combination have been studied prospectively and can be used for identification of patients at risk. Newer tests examining sudomotor dysfunction and skin dryness have been introduced in recent years. In cross-sectional studies sudomotor dysfunction assessed by either sympathetic skin response or NEUROPAD™ (Miro Verbandstoffe GmbH, Wiehl-Drabenderhöhe, Germany) testing has been consistently associated with foot ulceration. In addition, NEUROPAD™ testing is simple, reproducible, and widely available and has a high sensitivity for the diagnosis of clinical or subclinical diabetic polyneuropathy. Prospective studies are required to establish whether sudomotor dysfunction can predict foot ulcers and if simple methods assessing sudomotor dysfunction (eg, NEUROPAD™ testing) can be included in the screening tests for the prevention of this complication.
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Affiliation(s)
- Vasiliki Argiana
- 1st Department of Propaedeutic and Internal Medicine, Athens University Medical School, Athens, Greece
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34
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Abstract
The prevalence of diabetic polyneuropathy (DPN) can approach 50% in subjects with longer-duration diabetes. The most common neuropathies are generalized symmetrical chronic sensorimotor polyneuropathy and autonomic neuropathy. It is important to recognize that 50% of subjects with DPN may have no symptoms and only careful clinical examination may reveal the diagnosis. DPN, especially painful diabetic peripheral neuropathy, is associated with poor quality of life. Although there is a better understanding of the pathophysiology of DPN and the mechanisms of pain, treatment remains challenging and is limited by variable efficacy and side effects of therapies. Intensification of glycemic control remains the cornerstone for the prevention or delay of DPN but optimization of other traditional cardiovascular risk factors may also be of benefit. The management of DPN relies on its early recognition and needs to be individually based on comorbidities and tolerability to medications. To date, most pharmacological strategies focus upon symptom control. In the management of pain, tricyclic antidepressants, selective serotonin noradrenaline reuptake inhibitors, and anticonvulsants alone or in combination are current first-line therapies followed by use of opiates. Topical agents may offer symptomatic relief in some patients. Disease-modifying agents are still in development and to date, antioxidant α-lipoic acid has shown the most promising effect. Further development and testing of therapies based upon improved understanding of the complex pathophysiology of this common and disabling complication is urgently required.
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Affiliation(s)
| | - Martin J Stevens
- Heart of England NHS Foundation Trust, Birmingham, UK
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
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35
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Gin H, Baudoin R, Raffaitin CH, Rigalleau V, Gonzalez C. Non-invasive and quantitative assessment of sudomotor function for peripheral diabetic neuropathy evaluation. DIABETES & METABOLISM 2011; 37:527-32. [PMID: 21715211 DOI: 10.1016/j.diabet.2011.05.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 05/03/2011] [Accepted: 05/04/2011] [Indexed: 10/18/2022]
Abstract
AIMS Perturbation of pain sensation is considered one of the major initiating risk factors for diabetic foot ulcer. Sweat dysfunction leading to abnormal skin conditions, including dryness and fissures, can increase foot ulcer risk. The aim of this study was to evaluate Sudoscan™, a new, quick, non-invasive and quantitative method of measuring sudomotor dysfunction as a co-indicator of the severity of diabetic polyneuropathy (DPN). METHODS A total of 142 diabetic patients (age 62±18 years, diabetes duration 13±14 years, HbA(1c) 8.9±2.5%) were measured for vibration perception threshold (VPT), using a biothesiometer, and for sudomotor dysfunction, using electrochemical sweat conductance (ESC) based on the electrochemical reaction between sweat chloride and electrodes in contact with the hands and feet. Retinopathy status was also assessed, as well as reproducibility between two ESC measurements and the effect of glycaemia levels. RESULTS ESC measurements in the feet of patients showed a descending trend from 66±17 μS to 43±39 μS, corresponding to an ascending trend in VPT threshold from <15 V to >25 V (P=0.001). Correlation between VPT and ESC was -0.45 (P<0.0001). Foot ESC was lower in patients with fissures, while VPT was comparable. Both VPT and foot ESC correlated with retinopathy status. Bland-Altman plots indicated good reproducibility between two measurements, and between low and high glycaemia levels. CONCLUSION Sudoscan™ is a reproducible technique with results that are not influenced by blood glucose levels. Sweating status may be a quantitative indicator of the severity of polyneuropathy that may be useful for the early prevention of foot skin lesions.
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Affiliation(s)
- H Gin
- Service de diabétologie, hôpital Haut-Lévêque, 33604 Pessac, France.
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36
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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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37
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Sehgal VN, Bhattacharya SN, Verma P. Juvenile, insulin-dependent diabetes mellitus, type 1-related dermatoses. J Eur Acad Dermatol Venereol 2010; 25:625-36. [DOI: 10.1111/j.1468-3083.2010.03912.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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38
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Tesfaye S, Boulton AJM, Dyck PJ, Freeman R, Horowitz M, Kempler P, Lauria G, Malik RA, Spallone V, Vinik A, Bernardi L, Valensi P. Diabetic neuropathies: update on definitions, diagnostic criteria, estimation of severity, and treatments. Diabetes Care 2010; 33:2285-93. [PMID: 20876709 PMCID: PMC2945176 DOI: 10.2337/dc10-1303] [Citation(s) in RCA: 1622] [Impact Index Per Article: 115.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Preceding the joint meeting of the 19th annual Diabetic Neuropathy Study Group of the European Association for the Study of Diabetes (NEURODIAB) and the 8th International Symposium on Diabetic Neuropathy in Toronto, Canada, 13-18 October 2009, expert panels were convened to provide updates on classification, definitions, diagnostic criteria, and treatments of diabetic peripheral neuropathies (DPNs), autonomic neuropathy, painful DPNs, and structural alterations in DPNs.
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Affiliation(s)
- Solomon Tesfaye
- Diabetes Research Unit, Sheffield Teaching Hospitals, Sheffield, UK.
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39
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Vatankhah N, Noudeh YJ, Khamseh ME, Baradaran HR. Screening people with type 2 diabetes at risk for foot ulceration in Iran. Diabetes Technol Ther 2010; 12:731-6. [PMID: 20707739 DOI: 10.1089/dia.2010.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Foot screening is one of the most effective means of preventing foot complications in diabetes. Therefore the aim of this study was to perform a screening program for people with type 2 diabetes at risk of foot complications. METHODS Physical examinations consisting of vascular, neurological, musculoskeletal, and dermatologic examinations were performed. We used a Semmes-Weinstein monofilament and a 128-Hz tuning fork to test peripheral neuropathy. The study population was categorized based on Scottish Intercollegiate Guidelines into three groups of low, medium, and high risk for diabetes foot disease. RESULTS Of a total of 148 people with type 2 diabetes, 4.7% had an active foot ulcer, and 41.9% were classed as low risk, 40.6% as medium risk, and 12.8% as high risk. CONCLUSIONS Considering the potential of developing risk of foot disease in people with diabetes, it is recommended that foot screening should be performed by primary care practitioners and specialists to detect foot disease in an early stage. Foot screening program for people with diabetes should also be taken into account by health policy makers in national guidelines.
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Affiliation(s)
- Nasibeh Vatankhah
- Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran.
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40
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Electrical Skin Resistance and Thermal Findings in Patients With Lumbar Disc Herniation. J Clin Neurophysiol 2010; 27:303-7. [DOI: 10.1097/wnp.0b013e3181eaad66] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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41
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Papanas N, Papatheodorou K, Papazoglou D, Kotsiou S, Maltezos E. Association between foot temperature and sudomotor dysfunction in type 2 diabetes. J Diabetes Sci Technol 2010; 4:803-7. [PMID: 20663441 PMCID: PMC2909509 DOI: 10.1177/193229681000400406] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Increased foot skin temperature has been described as a feature of diabetic neuropathy. The aim of this present study was to investigate the association between foot temperature and sudomotor dysfunction in type 2 diabetes mellitus. PATIENTS AND METHODS This study included 51 patients (group A: 25 men, mean age 61.14 +/- 6.11 years) without sudomotor dysfunction and 52 patients (group B: 25 men, mean age 59.54 +/- 6.18 years) with sudomotor dysfunction. Sudomotor dysfunction was defined as time until complete Neuropad color change from blue to pink exceeding 600 s in at least one foot. Time until complete color change of the test was also recorded. Foot skin temperature was measured with a handheld infrared thermometer on the plantar aspect of the foot at the level of the first metatarsal head. RESULTS On both feet, temperature was significantly higher in group B than in group A (right foot, group A versus group B, 30.62 +/- 1.13 degrees C versus 32.12 +/- 1.06 degrees C, p < .001; left foot, group A versus group B, 30.65 +/- 1.06 degrees C versus 32.19 +/- 1.10 degrees C, p < .001). There was a significant positive correlation between time to complete Neuropad color change and foot skin temperature (right foot, r = 0.742, p < .001; left foot, r = 0.758, p < .001), which was confirmed in both groups. CONCLUSIONS Patients with sudomotor dysfunction have significantly higher foot temperature than those without sudomotor dysfunction. Foot temperature is positively correlated with severity of sudomotor dysfunction, as evaluated by the time to complete Neuropad color change.
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Affiliation(s)
- Nikolaos Papanas
- Outpatient Clinic of the Diabetic Foot, Second Department of Internal Medicine, Democritus University of Thrace, Greece, Alexandroupolis, Greece.
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Tentolouris N, Voulgari C, Liatis S, Kokkinos A, Eleftheriadou I, Makrilakis K, Marinou K, Katsilambros N. Moisture status of the skin of the feet assessed by the visual test neuropad correlates with foot ulceration in diabetes. Diabetes Care 2010; 33:1112-4. [PMID: 20150296 PMCID: PMC2858186 DOI: 10.2337/dc09-2027] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine the association between the moisture status of the skin of the feet with foot ulceration in subjects with diabetes. RESEARCH DESIGN AND METHODS A total of 379 subjects with diabetes were examined. Assessment of peripheral neuropathy was based on neuropathy symptom score, neuropathy disability score, vibration perception threshold, and the 10-g monofilament perception. The moisture status of the skin of the feet was assessed using the visual test Neuropad. RESULTS Patients with foot ulceration had more severe peripheral neuropathy and more often an abnormal Neuropad response. Multivariate logistic regression analysis demonstrated that the odds of foot ulceration increased with measures of neuropathy but increased also with an abnormal Neuropad response. CONCLUSIONS An abnormal Neuropad response correlates with foot ulceration in subjects with diabetes. This finding, if confirmed prospectively, suggests that the Neuropad test may be included in the screening tests for the prediction of foot ulceration.
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Affiliation(s)
- Nicholas Tentolouris
- First Department of Propaedeutic Medicine, Laiko General Hospital, Athens University Medical School, Athens, Greece.
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