Easier operation and similar power of 10 g monofilament test for screening diabetic peripheral neuropathy

Screening for Diabetic Peripheral Neuropathy: Subjective Versus Objective Measures

This study compared subjective screening modalities recommended in diabetic foot screening guidelines for the detection of diabetic peripheral neuropathy (DPN) with an objective measure, the NC-Stat DPNCheck®. We assessed 63 participants (mean age 54.5 years ± 10.5) utilising subjective screening tools (Semmes-Weinstein 10-g monofilament, 128-Hz traditional tuning fork, neurothesiometer, O'Brien 128-Hz electronic tuning fork) and compared results with the objective automated sural nerve conduction test NC-Stat DPNCheck®. A significant difference was found in the number of limbs classified with DPN between all screening tools (P < .05). Therefore, this suggests that some screening modalities are more sensitive in diagnosing DPN than others, highlighting the importance of using multiple screening tools to a comprehensive understanding of the patient's neurological status. The findings also emphasize the need to incorporate objective measures in diabetic foot screening and encourage future research to establish a gold standard tool for DPN diagnosis.

The relationship between dietary phytochemical index and novel anthropometric indices and the severity of diabetic foot ulcers in adults with type 2 diabetes: a cross-sectional study

BACKGROUND

Research on the relationship between dietary phytochemical intake and the anthropometric indices as well as the diabetic foot ulcers (DFUs) remains inconsistent. We aimed to investigate the associations of dietary phytochemical index (DPI) with the novel anthropometric indices and the severity of DFUs.

METHODS

This cross-sectional study was conducted on 339 adults with type 2 diabetes. Dietary intake was assessed using three 24-hour dietary recalls. To quantify the phytochemical content of the diet, the DPI estimation was done through an equation proposed by McCarty. The International Working Group on the Diabetic Foot (IWGDF) criteria and Wagner classification system were applied to assess DFUs. New anthropometric indices including a body shape index (ABSI), body roundness index (BRI) and abdominal volume index (AVI) were calculated based on formulas. We employed analysis of variance (ANOVA), analysis of covariance (ANCOVA) and logistic regression to explore associations between DPI and the anthropometric indices and DFU variables.

RESULTS

Our results revealed no significant association between DPI and the foot ulcer indices, following adjusting for the possible covariates. Furthermore, we also examined the relationship between diabetic neuropathy, as measured by monofilament score, and the DPI. Similarly, we did not find any substantial relationship between the DPI and monofilament score (OR: 1.18; 95% CI: 0.66-2.09; Ptrend = 0.56), as well as biochemical indices. Our analysis did not reveal any significant associations between the DPI and ABSI (OR: 0.70; 95% CI: 0.35-1.38; Ptrend = 0.30), BRI (OR: 0.80; 95% CI: 0.33-1.95; Ptrend = 0.59), and AVI (OR: 1.99; 95% CI: 0.92-4.33; Ptrend = 0.08).

CONCLUSIONS

Our study revealed no significant links between the DPI and foot ulcer indices, neuropathy measures, and anthropometric indices. These findings imply that factors beyond dietary phytochemical intake may exert greater influence on the development of foot ulcers in diabetes.

Prospective Evaluation of Vitamin C, Vitamin D, and Zinc Deficiencies in Patients with Active Foot Ulceration

Objective: This prospective cohort study aimed to determine the relationship between serum vitamin C, D, and zinc on foot wound healing and compare time to healing in individuals who are deficient versus those who have adequate levels. Approach: One hundred adults with foot wounds were recruited from Blacktown high-risk foot service with a follow-up period of 12 months. Serum vitamin C, D, and zinc as well as routine baseline blood testing was undertaken. Wounds were measured using a three-dimensional wound camera and classified using the Wound Ischemia and Foot Infection system at regular intervals. Results: Vitamin C deficiency was present in 75% of participants, 50% had vitamin D deficiency, and 38% had zinc deficiency. Diabetes was present in 91% of participants, and 50% had a history of previous amputation. Wound chronicity (p = 0.03) and toe pressures (p = 0.04) were predictive of wound healing. Serum vitamin C, D, and zinc were not associated with significant differences in wound healing or time to wound healing. Innovation: Deficiencies in vitamin C, D, and zinc were highly prevalent in participants with active foot ulceration. Wound chronicity was predictive of healing outcomes, highlighting the importance of rapid access to best practice care. Conclusion: This cohort had high deficiency rates of vitamin C, D, and zinc consistent with previous literature; however, there was no relationship between these deficiencies and wound healing or time to heal. Large randomized controlled trials are required to comprehensively determine if adequate levels of these nutrients improve wound healing outcomes.

[Retrospective Long-Term Results After Dellon's Nerve Decompression In The Lower Leg For Polyneuropathy]

BACKGROUND

Patients affected by polyneuropathy often report pain, paraesthesia and numbness and are at risk of having an increased propensity to fall with the corresponding complications. In case of persistent symptoms after all conservative and medical treatment options have been exhausted, a nerve decompression in the lower leg as described by Dellon can lead to an improvement of the discomfort for many patients. This article presents our long-term results with Dellon's operation.

METHODS

In this retrospective study, we included 33 patients with diabetic or idiopathic polyneuropathy in whom we performed Dellon's nerve decompression in the lower leg in the years 2011-2013. In 29 out of the 33 patients, we investigated the level of pain (according to the numeric rating scale NRS 0-10), paraesthesia, numbness, Hoffman-Tinel sign, and Semmes-Weinstein monofilaments three months postoperatively. 88 months postoperatively (range 78-111 months), we were able to contact 20 of the 33 patients with a questionnaire asking about their present pain level (NRS 0-10), satisfaction with the postoperative result (NRS 0-10, 0=most satisfied, 10=not satisfied at all) and whether the patients would recommend the surgical procedure to their friends or family.

RESULTS

1. Significant pain reduction three months postoperatively, NRS 4.5 to 2.2, (p=0.000). 2. Significant reduction of paraesthesia three months postoperatively from 84.8 to 24.2% (p=0.000) 3. Significant reduction of numbness three months postoperatively from 97% to 39% (p=0.000). 4. Significant improvement of sensitivity three months postoperatively from 91% no sensitivity to 28% no sensitivity (p=0.000). 5. Significant improvement of Hoffmann-Tinel sign three months postoperatively from 76% to 13% (p=0.000). 88 months postoperatively, we saw a significant pain reduction from an average preoperative pain level of NRS 4.5 to a postoperative pain level of 2.7 (p=0.048). 88 months postoperatively, 65% of the patients would recommend the surgical procedure to their family and friends, and patient satisfaction was high (NRS 3,4).

CONCLUSION

Our long-term results show that Dellon's nerve decompression in the lower extremities leads to a marked, lasting pain reduction and a functional improvement.

Validity and Reliability of a Vibration-Based Cell Phone in Detecting Peripheral Neuropathy among Patients with a Risk of Diabetic Foot Ulcer

The aim of this study was to determine the validity and reliability of a vibration-based cell phone in detecting peripheral neuropathy among individuals with a risk of diabetic foot ulcer (DFU). The current study consisted of 3 phases: a pilot study, concurrent validity study, and interreliability study. A 128 Hz tuning fork and vibration-based cell phone using the Vibrations-Test app was compared in the primary care setting. The pilot study confirmed that the vibration-based cell phone has an adequate reliability (r > 0.70, P < .001). The concurrent validity test involved 96 participants (aged 55.78 ± 8.32 years). The Pearson correlation test found the highest correlation in the fifth metatarsal heads (r = 0.741, right feet; 0.772, left feet; P < .001). In the 4 primary care settings, the interrater reliability between nurses of the vibration-based cell phone were k = 1.000, 1.000, 1.000, and 0.720. The concurrent validity test found moderate to strong correlation results and that the interrater reliability had a strong agreement that was almost perfect. Thus, vibration-based cell phone applications can be used as screening tools for detecting neuropathy among individuals with a risk of DFU.

Diagnostic accuracy of the 5.07 monofilament test for diabetes polyneuropathy: influence of age, sex, neuropathic pain and neuropathy severity

INTRODUCTION

There is a need for simple and cheap diagnostic tools for diabetic polyneuropathy (DPN). We aimed to assess the diagnostic accuracy of the 5.07/10 g monofilament test in patients referred to polyneuropathy assessments, as well as to examine how disease severity, age, sex and neuropathic pain (NP) impact diagnostic accuracy.

RESEARCH DESIGN AND METHODS

Five Norwegian university hospitals recruited patients with diabetes aged 18-70 referred to neurological outpatient clinics for polyneuropathy assessments. The 5.07/10 g Semmes-Weinstein monofilament examination (SWME) was validated against the Toronto consensus for diagnosing diabetic neuropathies; the results were stratified by age, sex and NP. Disease severity was graded by a combined nerve conduction study (NCS) Z-score, and logistic regression was applied to assess whether disease severity was a predictor of diagnostic accuracy.

RESULTS

In total, 506 patients were included in the study. Global sensitivity was 0.60 (95% CI 0.55, 0.66), specificity 0.82 (95% CI 0.75, 0.87), positive and negative predictive values were 0.86 (95% CI 0.81, 0.90) and 0.52 (95% CI 0.46, 0.58), respectively, positive and negative likelihood ratios were 3.28 (95% CI 2.37, 4.53) and 0.49 (95% CI 0.42, 0.57), respectively. The SWME was less sensitive in females (0.43), had lower specificity in patients with NP (0.56), and performed worse in patients ≥50 years. NCS-based disease severity did not affect diagnostic accuracy (OR 1.15, 95% CI 0.95, 1.40).

CONCLUSIONS

This multicenter study demonstrates poor diagnostic performance for the 5.07/10 g SWME in patients with diabetes referred to polyneuropathy assessments; it is particularly unsuited for female patients and those with NP. The diagnostic accuracy of the SWME was not influenced by NCS-based disease severity, demonstrating that it does not perform better in patients with later stages of DPN. We do not recommend the use of the 5.07/10 g monofilament in the evaluation of patients with diabetes referred to polyneuropathy assessments.

The Validity and Reliability of the SINBAD Classification System for Diabetic Foot Ulcers

ABSTRACT

Diabetic foot ulcers (DFUs) are a serious and costly complication of diabetes mellitus with a global prevalence of 6.3% and cost of £8,800 per unhealed DFU in the National Health Service. The three main types of DFU are neuropathic, ischemic, and neuroischemic, with an estimated prevalence of 35%, 15%, and 50%, respectively. Because 85% of lower-limb amputations in patients with diabetes are preceded by a DFU, the task of reducing the current and future burden of DFUs on an international level is of crucial importance. Classification of a DFU is an important and complex process with many independent variables that influence the wound severity. Correct classification of a DFU is important to prevent deterioration in the short term and lower-limb amputation in the long term. Both the accuracy of the clinician's interpretation of categorical data from a classification model and grasp of contextual risk factors can refine diagnoses. The term SINBAD is an acronym for six independent variables: site, ischemia, neuropathy, bacterial infection, area, and depth. This system uses comprehensive parameters with strict criteria to facilitate quick and accurate clinical decisions to prevent lower-limb amputation. In addition to providing quantitative measurement, SINBAD also spotlights the multifaceted characteristics of DFUs. By evaluating the validity and reliability of the SINBAD classification system, its applicability for the assessment of DFUs and prevention of lower-limb amputation can be better understood.

Factors influencing diabetes-related foot ulcer healing in Australian adults: A prospective cohort study

OBJECTIVE

Diabetes-related foot ulceration (DFU) is a common limb-threatening condition, which is complex and subsequently challenging to manage. The aim of this study was to determine the contribution of a range of clinical and social factors to the healing of diabetes-related foot ulceration in an Australian population.

RESEARCH DESIGN AND METHODS

This was a prospective cohort study of individuals with diabetes-related foot ulceration (DFU). Age, sex, medical history, medications, dietary supplementation (e.g. vitamin C intake) and smoking history were elicited at baseline. The index of relative socio-economic disadvantage (IRSD) was calculated. The Australian Eating Survey and International Physical Activity Questionnaire-short were administered. Wound history, size, grade, time to healing and infection were captured and monitored over 6 months. Logistic regression was performed to determine the relationship between healing and diet quality, toe systolic pressure, wound size at, IRSD, infection and previous amputation.

RESULTS

A total of 117 participants were included. The majority were male n = 96 (82%), socio-economically disadvantaged (mean IRSD 965, SD 60), and obese (BMI 36 kg/m2 , SD 11) with a long history of diabetes (20 years, SD 11). Wounds were predominantly neuropathic (n = 85, 73%) and classified 1A (n = 63, 54%) on the University of Texas wound classification system with few infections (n = 23, 16%). Dietary supplementation was associated with 4.36 increased odds of healing (95% 1.28-14.84, p = 0.02), and greater levels of socio-economic advantage were also associated with increased odds of healing (OR 1.01, 95% CI 1.01-1.02, p = 0.03).

CONCLUSIONS

In this cohort study of predominantly neuropathic, non-infected DFU, individuals who had greater levels of socio-economic advantage had significantly greater odds of DFU healing. Diet quality was poor in most participants, with individuals taking supplementation significantly more likely to heal.

Differences in Cognitive Function in Women and Men with Diabetic Peripheral Neuropathy with or without Pain

The aim of this study was to analyse the differences in cognitive function between women and men with type-2 diabetes mellitus (DMT2) and diabetic peripheral neuropathy (DPN) with and without diabetic neuropathic pain (DNP), and the factors associated with cognitive function in each sex. A cross-sectional study of 149 patients with DMT2 and DPN was performed. Sociodemographic and clinical variables, Test Your Memory (TYM) for cognitive assessment, anxiety and depression (HADS), quality of life (SF-12v2) and sleep characteristics (MOS-sleep) were measured. A high percentage of women presented cognitive impairment (50% vs. 36.1%) and they scored lower on the TYM (mean = 40.77; SD = 6.03 vs. mean = 42.49; SD = 6.05). Women with DNP scored lower on calculation tasks (3.17 vs. 3.52) than men with DNP, while women without DNP scored lower on retrograde memory (2.70 vs. 3.74), executive function (3.83 vs. 4.25) and similarities (2.51 vs. 3.12) than men without DNP. Being older (B = -0.181) and presenting cardiovascular risk factors (B = -5.059) were associated with worse cognitive function in women, while in men this was associated with older age (B = -0.154), a longer duration of diabetes (B = -0.319) and the presence of depression (B = -0.363). Women with and without DNP obtained worse results in cognitive function. However, the presence of pain had a greater impact on the different dimensions in men.

Increased pulse wave velocity is related to impaired working memory and executive function in older adults with metabolic syndrome

Age-related vascular alterations promote the pathogenesis of vascular cognitive impairment (VCI). Cardiovascular risk factors that accelerate vascular aging exacerbate VCI. Metabolic syndrome (MetS) constitutes a cluster of critical cardiovascular risk factors (abdominal obesity, hypertension, elevated triglycerides, elevated fasting glucose, reduced HDL cholesterol), which affects nearly 37% of the adult US population. The present study was designed to test the hypotheses that MetS exacerbates cognitive impairment and that arterial stiffening moderates the association between cognitive dysfunction and MetS in older adults. MetS was defined by the NCEP ATP III guidelines. Cognitive function (digit span and trail-making tests) and brachial-ankle pulse wave velocity (baPWV; a non-invasive clinical measurement of arterial stiffness) were assessed in older adults with MetS and age- and sex-matched controls. Multiple linear regression models were applied to test for the main effects of MetS, baPWV, and their interaction on cognitive performance. Fifty-three participants with MetS (age: 68 ± 8 years) and 39 age-matched individuals without MetS (age: 66 ± 9 years) were enrolled into the study. In adjusted multivariable regression analyses of the digit span backward length score, both MetS (ß = 1.97, p = 0.048) and MetS by baPWV interaction (ß =  - 0.001, p = 0.026) were significant predictors. In participants with MetS, higher baPWV was associated with poorer performance on digit span backward length score, a test of working memory (R =  - 0.44, p = 0.0012), but there was no association in those without MetS (R = 0.035, p = 0.83). MetS was negatively associated with performance on the digit span backward length score, baPWV was negatively associated with multiple neuropsychological outcomes, and baPWV moderated the association between digit span backward length score and MetS, as individuals with both MetS and higher baPWV had the most impaired cognitive function. Our findings add to the growing body of evidence that individuals with MetS and higher baPWV may be prone to VCI.

Effectiveness of Semmes Weinstein 10 gm monofilament in diabetic peripheral neuropathy taking nerve conduction and autonomic function study as reference tests

Context

Diabetic peripheral neuropathy (DPN) if detected early can reduce the burden on the health system and prevent the development of diabetic foot ulcers and amputation.

Aim

To study the effectiveness of Semmes Weinstein 10 gm monofilament in detecting DPN taking nerve conduction studies (NCS) and autonomic function testing (AFT) as reference tests.

Settings and Design

Observational and comparative cross-sectional study conducted in the Physiology department AIIMS, Bhopal in collaboration with the Medicine department of the institute.

Methods and Material

A total of 72 diagnosed type-2 diabetes mellitus patients were examined using Semmes Weinstein 10 gm monofilament, DPN was confirmed using NCS (Nihon Kohden Neuropack XI machine) and autonomic neuropathy was confirmed using AFT (Ewing's battery and Power lab) with heart rate variability (HRV). Diagnostic value of Semmes Weinstein 10 gm monofilament taking NCS and AFT as reference test was calculated.

Statistical Analysis Used

Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) were calculated using the standard formula.

Results

Sensitivity, specificity, PPV, and NPV using monofilament are 69.23%, 20%, 69.23% and 20% respectively taking NCS as reference test and 70.59%, 0, 92.30%, and 0 respectively taking AFT as reference test.

Conclusions

Semmes Weinstein 10 gm monofilament is not the ideal screening test for the diagnosis of DPN. Sole clinical use of monofilament should be discouraged.

Factors related to cognitive function in type-2 diabetes and neuropathic pain patients, the role of mood and sleep disorders in this relationship

To compare cognitive function in patients with diabetes mellitus type-2 (T2DM) both with and without diabetic neuropathic pain (DNP). To analyse the relationship between mood and sleep disorders, quality of life and cognitive function in patients with DNP. Cross-sectional study conducted in patients with T2DM and neuropathy. The presence of DNP, cognitive function, mood status, sleep quality, health-related quality of life, pain intensity and phenotype of pain were measured. Descriptive, bivariate and multivariate analyses were performed. A total of 149 patients (71 with DNP) were included. Patients with and without DNP presented similar scores on the TYM (41.46; SD = 6.70 vs. 41.97; SD = 5.50) and those with DNP had a slightly higher frequency of cognitive impairment (TYM score ≤ 41: 40.8% vs. 43.6%). The patients without DNP performed better in the verbal fluency dimension (mean = 3.53; SD = 0.98 vs. mean = 3.82; SD = 0.66). Being older (B = − 0.258) and under treatment with insulin (B = − 2.919) were related with greater cognitive impairment. Obesity (OR = 17.277) and a longer duration of diabetes (OR = 1.317) were also related to greater risk of cognitive impairment. Impaired cognitive function in patients with DNP is more related to T2DM factors than pain factors. The presence of depression and a worse quality of life were related to a greater risk of cognitive impairment. Identifying and controlling these factors should be an essential intervention for maintaining the cognitive function in patients with T2DM and DNP.

Prevalence of diabetic peripheral neuropathy in patients with type 2 diabetes mellitus at a tertiary referral centre in Singapore

Background:

There is a lack of data regarding prevalence estimates of diabetic peripheral neuropathy (DPN) in Singapore. This study aimed to investigate the prevalence of DPN and risk factors in patients who present to a diabetic foot screening clinic and are considered low to medium risk in developing foot complications due to their type 2 diabetes mellitus.

Methods:

A one-year retrospective analysis was conducted at Ng Teng Fong General Hospital. Patients who underwent diabetic foot screening and endocrinologist review in the Diabetes and Endocrinology Specialist Outpatient Clinic during the period January 2019–December 2019 were included in this study. DPN was defined by the patient’s inability to detect ⩾1 out of 10 sites using the 10 g monofilament. Significantly associated risk factors with DPN were analysed using a multivariable logistic regression model.

Results:

Data from 479 patients were analysed. Prevalence of DPN was 28% (95% confidence interval (CI) 24.0–32.2). DPN was significantly associated with age >65 years (odds ratio (OR)=5.44, 95% CI 2.87–10.32), Indian ethnicity (OR=1.99, 95% CI 1.04–3.80), insulin use (OR=1.65, 95% CI 1.03– 2.64), diabetic retinopathy (OR=2.36, 95% CI 1.47–3.78) and stroke (OR=2.44, 95% CI 1.03–5.77).

Conclusion:

Prevalence of DPN in this study’s population sample was 28%, and the significant risk factors are age, Indian ethnicity, insulin use, diabetic retinopathy and stroke.

Non-invasive assessment of vibration perception and protective sensation in people with diabetes mellitus: inter- and intra-rater reliability

BACKGROUND

Testing of protective sensation and vibration perception are two of the most commonly used non-invasive methods of screening for diabetes-related peripheral neuropathy (DPN). However, there is limited research investigating the reliability of these tests in people with diabetes. The aim of this study was to determine the inter- and intra-rater reliability of methods used to test vibration perception and protective sensation in a community-based population of adults with type 2 diabetes.

METHODS

Three podiatrists with varying clinical experience tested four- and 10-site, 10 g monofilament and vibration perception threshold (VPT). In a separate cohort, the reliability of a graduated tuning fork as well as two methods of conventional tuning fork (on/off method and dampening method) was undertaken by a new graduate podiatrist and podiatrist with one-year's clinical experience. The intra- (Cohen's К) and inter-rater (Cohen's or Fleiss' К) reliability of each test was determined.

RESULTS

Fifty participants (66% male, 100% type 2, 32% with DPN) underwent monofilament and neurothesiometer testing with 44 returning for the retest. Twenty-four participants (63% male, 100% type 2, 4% with DPN) underwent tuning fork testing and returned for retest. All tests demonstrated acceptable inter-rater reliability ranging from moderate (10-site monofilament, К: 0.54, CI: 0.38-0.70, p = 0.02) to substantial (graduated tuning fork, К: 0.68, CI: 0.41-0.95, p < 0.01). The 10-site monofilament (К: 0.44-0.77) outperformed the 4-site test (К: 0.34-0.67) and the dampened tuning fork method (К: 0.41-0.49) showed lower intra-rater reliability compared to both conventional (К: 0.52-0.57) and graduated methods (К: 0.50-0.57).

CONCLUSION

We support the current recommendations of using more than one test to screen and monitor progression of DPN. Four- and 10-site 10 g monofilament testing have similarly acceptable levels of reliability and the neurothesiometer is the most reliable method of assessing vibration perception function. Use of a graduated tuning fork was slightly more reliable than other methods of tuning fork application however all had substantial reliability. Years of clinical experience only marginally affected test reliability overall and due to subjective nature of the tests we suggest that testing should be performed regularly and repetitively.