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Galiero R, Caturano A, Vetrano E, Beccia D, Brin C, Alfano M, Di Salvo J, Epifani R, Piacevole A, Tagliaferri G, Rocco M, Iadicicco I, Docimo G, Rinaldi L, Sardu C, Salvatore T, Marfella R, Sasso FC. Peripheral Neuropathy in Diabetes Mellitus: Pathogenetic Mechanisms and Diagnostic Options. Int J Mol Sci 2023; 24:ijms24043554. [PMID: 36834971 PMCID: PMC9967934 DOI: 10.3390/ijms24043554] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/01/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
Diabetic neuropathy (DN) is one of the main microvascular complications of both type 1 and type 2 diabetes mellitus. Sometimes, this could already be present at the time of diagnosis for type 2 diabetes mellitus (T2DM), while it appears in subjects with type 1 diabetes mellitus (T1DM) almost 10 years after the onset of the disease. The impairment can involve both somatic fibers of the peripheral nervous system, with sensory-motor manifestations, as well as the autonomic system, with neurovegetative multiorgan manifestations through an impairment of sympathetic/parasympathetic conduction. It seems that, both indirectly and directly, the hyperglycemic state and oxygen delivery reduction through the vasa nervorum can determine inflammatory damage, which in turn is responsible for the alteration of the activity of the nerves. The symptoms and signs are therefore various, although symmetrical painful somatic neuropathy at the level of the lower limbs seems the most frequent manifestation. The pathophysiological aspects underlying the onset and progression of DN are not entirely clear. The purpose of this review is to shed light on the most recent discoveries in the pathophysiological and diagnostic fields concerning this complex and frequent complication of diabetes mellitus.
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Affiliation(s)
- Raffaele Galiero
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Alfredo Caturano
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Erica Vetrano
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Domenico Beccia
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Chiara Brin
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Maria Alfano
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Jessica Di Salvo
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Raffaella Epifani
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Alessia Piacevole
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Giuseppina Tagliaferri
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Maria Rocco
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Ilaria Iadicicco
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Giovanni Docimo
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Luca Rinaldi
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Teresa Salvatore
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
| | - Ferdinando Carlo Sasso
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, I-80138 Naples, Italy
- Correspondence: ; Tel.: +39-08-1566-5010
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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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Kristianto H. Analysis of risk factors responsible for neuropathy in patients with type 2 diabetes mellitus with diabetic foot during the COVID-19 pandemic. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2023; 28:85-91. [DOI: 10.4103/ijnmr.ijnmr_180_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 09/10/2022] [Accepted: 10/19/2022] [Indexed: 01/26/2023]
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Selvarajah D, Kar D, Khunti K, Davies MJ, Scott AR, Walker J, Tesfaye S. Diabetic peripheral neuropathy: advances in diagnosis and strategies for screening and early intervention. Lancet Diabetes Endocrinol 2019; 7:938-948. [PMID: 31624024 DOI: 10.1016/s2213-8587(19)30081-6] [Citation(s) in RCA: 206] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 12/13/2022]
Abstract
Diabetic peripheral neuropathy (DPN) is a common complication of both type 1 and 2 diabetes. It is a leading cause of lower-limb amputation and disabling neuropathic pain. Amputations in patients with diabetes have a devastating effect on quality of life and are associated with an alarmingly low life expectancy (on average only 2 years from the amputation). Amputation also places a substantial financial burden on health-care systems and society in general. With the introduction of national diabetes eye screening programmes, the prevalence of blindness in working-age adults is falling. This is not the case, however, with diabetes related amputations. In this Review, we appraise innovative point-of-care devices that enable the early diagnosis of DPN and assess the evidence for early risk factor-based management strategies to reduce the incidence and slow the progression of DPN. We also propose a framework for screening and early multifactorial interventions as the best prospect for preventing or halting DPN and its devastating sequelae.
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Affiliation(s)
- Dinesh Selvarajah
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.
| | - Debasish Kar
- Derbyshire Community Health Services NHS Foundation Trust, Bakewell, UK; Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Adrian R Scott
- Academic Unit of Diabetes and Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jeremy Walker
- Department of Podiatry Services, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Solomon Tesfaye
- Academic Unit of Diabetes and Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Abbott CA, Chatwin KE, Foden P, Hasan AN, Sange C, Rajbhandari SM, Reddy PN, Vileikyte L, Bowling FL, Boulton AJM, Reeves ND. Innovative intelligent insole system reduces diabetic foot ulcer recurrence at plantar sites: a prospective, randomised, proof-of-concept study. LANCET DIGITAL HEALTH 2019; 1:e308-e318. [PMID: 33323253 DOI: 10.1016/s2589-7500(19)30128-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prevention of diabetic foot ulcer recurrence in high risk patients, using current standard of care methods, remains a challenge. We hypothesised that an innovative intelligent insole system would be effective in reducing diabetic foot ulcer recurrence in such patients. METHODS In this prospective, randomised, proof-of-concept study, patients with diabetes, and with peripheral neuropathy and a recent history of plantar foot ulceration were recruited from two multidisciplinary outpatient diabetic foot clinics in the UK, and were randomly assigned to either intervention or control. All patients received an insole system, which measured plantar pressure continuously during daily life. The intervention group received audiovisual alerts via a smartwatch linked to the insole system and offloading instructions when aberrant pressures were detected; the control group did not receive any alerts. The primary outcome was plantar foot ulcer occurrence within 18 months. This trial is registered with ISRCTN, ISRCTN05585501, and is closed to accrual and complete. FINDINGS Between March 18, 2014, and Dec 20, 2016, 90 patients were recruited and consented to the study, and 58 completed the study. At follow-up, ten ulcers from 8638 person-days were recorded in the control group and four ulcers from 11 835 person-days in the intervention group: a 71% reduction in ulcer incidence in the intervention group compared with the control group (incidence rate ratio 0·29, 95% CI, 0·09-0·93; p=0·037). The number of patients who ulcerated was similar between groups (six of 26 [control group] vs four of 32 [intervention group]; p=0·29); however, individual plantar sites ulcerated more often in the control group (ten of 416) than in the intervention group (four of 512; p=0·047). In an exploratory analysis of good compliers (n=40), ulcer incidence was reduced by 86% in the intervention group versus control group (incidence rate ratio 0·14, 95% CI 0·03-0·63; p=0·011). In the exploratory analysis, plantar callus severity (change from baseline to 6 months) was greater in re-ulcerating patients (6·5, IQR 4·0-8·3) than non-re-ulcerating patients (2·0, 0·0-4·8; p=0·040). INTERPRETATION To our knowledge, this study is the first to show that continuous plantar pressure monitoring and dynamic offloading guidance, provided by an innovative intelligent insole system, can lead to a reduction in diabetic foot ulcer site recurrence. FUNDING Diabetes UK and Orpyx Medical Technologies.
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Affiliation(s)
- Caroline A Abbott
- Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK.
| | - Katie E Chatwin
- Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
| | - Philip Foden
- Medical Statistics Department, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Ahmad N Hasan
- Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK; Institute of Medical Science and Technology, University Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Chandbi Sange
- Diabetes Centre, Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, UK
| | - Satyan M Rajbhandari
- Diabetes Centre, Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, UK
| | - Prabhav N Reddy
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Loretta Vileikyte
- Department of Medicine, Manchester Royal Infirmary, Manchester, UK; Diabetes Research Institute, University of Miami, Miami, FL, USA
| | - Frank L Bowling
- Division of Diabetes, Endocrinology & Gastroenterology University of Manchester, Manchester, UK
| | - Andrew J M Boulton
- Department of Medicine, Manchester Royal Infirmary, Manchester, UK; Diabetes Research Institute, University of Miami, Miami, FL, USA
| | - Neil D Reeves
- Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
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