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Çelik Kavaklılar B, Aybı Özdemir Ö, Yıldırım T, Dikmetaş Ö, Toprak H, Hekimsoy V, İşler AO, Yılmaz R, Kadayıfçılar S, Erdem Y, Erbas T, Ünlütürk U. Evaluation of Microvascular Complications in Kidney Recipients With Posttransplant Diabetes Mellitus. J Clin Endocrinol Metab 2024; 109:e1623-e1633. [PMID: 38101939 PMCID: PMC11244200 DOI: 10.1210/clinem/dgad738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 11/27/2023] [Accepted: 12/13/2023] [Indexed: 12/17/2023]
Abstract
CONTEXT The paucity of data on microvascular complications in patients with posttransplant diabetes (PTDM) is an obstacle to developing follow-up algorithms. OBJECTIVE To evaluate diabetic microvascular complications in patients with long-standing PTDM. METHODS In patients with ≥5-year history of PTDM and age-matched renal transplant recipients without PTDM (NDM), diabetic peripheral neuropathy was evaluated using the Michigan Neuropathy Screening Instrument, the CASE IV device, and in vivo corneal confocal microscopy (CCM). Cardiac autonomic neuropathy tests were performed using heart rate variability. Nephropathy screening was assessed using spot urine albumin/creatinine ratio and eGFR calculation. Diabetic retinopathy was evaluated by fundus examination and photography, and optical coherence tomography. RESULTS This study included 41 patients with PTDM and 45 NDM patients. The median follow-up was 107.5 months in the PTDM group. Peripheral neuropathy was significantly higher in the PTDM group than in the NDM group (P = .02). In the PTDM patients with peripheral neuropathy, corneal nerve fiber density examined by CCM was significantly lower than in PTDM patients without neuropathy (P = .001). Parasympathetic involvement was observed in 58.5% of the PTDM group and 22% of the NDM group (P = .001). Sympathetic involvement was present in 65.9% of the PTDM group and 29.3% of the NDM group (P = .001). Retinopathy was observed in 19.5% of patients in the PTDM group and in none of the NDM patients (P < .001). Renal functions were similar between the study groups. CONCLUSION Cardiac autonomic neuropathy and diabetic retinopathy can affect patients with PTDM at a high rate. Diabetic retinopathy is a threat to the vision of PTDM patients. Diabetic peripheral neuropathy can be detected early in PTDM patients by CCM.
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Affiliation(s)
- Başak Çelik Kavaklılar
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara 06100, Turkey
| | - Özge Aybı Özdemir
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara 06100, Turkey
| | - Tolga Yıldırım
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara 06100, Turkey
- Department of Nephrology, Hacettepe University School of Medicine, Ankara 06100, Turkey
| | - Özlem Dikmetaş
- Department of Ophthalmology, Hacettepe University School of Medicine, Ankara 06100, Turkey
| | - Hilal Toprak
- Department of Ophthalmology, Hacettepe University School of Medicine, Ankara 06100, Turkey
| | - Vedat Hekimsoy
- Department of Cardiology, Hacettepe University School of Medicine, Ankara 06100, Turkey
| | - Alperen Onur İşler
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara 06100, Turkey
- Department of Endocrinology and Metabolism, Hacettepe University School of Medicine, Ankara 06100, Turkey
| | - Rahmi Yılmaz
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara 06100, Turkey
- Department of Nephrology, Hacettepe University School of Medicine, Ankara 06100, Turkey
| | - Sibel Kadayıfçılar
- Department of Ophthalmology, Hacettepe University School of Medicine, Ankara 06100, Turkey
| | - Yunus Erdem
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara 06100, Turkey
- Department of Nephrology, Hacettepe University School of Medicine, Ankara 06100, Turkey
| | - Tomris Erbas
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara 06100, Turkey
- Department of Endocrinology and Metabolism, Hacettepe University School of Medicine, Ankara 06100, Turkey
| | - Uğur Ünlütürk
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara 06100, Turkey
- Department of Endocrinology and Metabolism, Hacettepe University School of Medicine, Ankara 06100, Turkey
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Gad H, Elgassim E, Lebbe A, MacDonald RS, Baraka A, Petropoulos IN, Ponirakis G, Ibrahim NO, Malik RA. Corneal confocal microscopy detects early nerve regeneration after pharmacological and surgical interventions: Systematic review and meta-analysis. J Peripher Nerv Syst 2024; 29:173-184. [PMID: 38887985 DOI: 10.1111/jns.12641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/30/2024] [Accepted: 06/03/2024] [Indexed: 06/20/2024]
Abstract
Corneal confocal microscopy (CCM) is an ophthalmic imaging technique that enables the identification of corneal nerve fibre degeneration and regeneration. To undertake a systematic review and meta-analysis of studies utilizing CCM to assess for corneal nerve regeneration after pharmacological and surgical interventions in patients with peripheral neuropathy. Databases (EMBASE [Ovid], PubMed, CENTRAL and Web of Science) were searched to summarize the evidence from randomized and non-randomized studies using CCM to detect corneal nerve regeneration after pharmacological and surgical interventions. Data synthesis was undertaken using RevMan web. Eighteen studies including 958 patients were included. CCM identified an early (1-8 months) and longer term (1-5 years) increase in corneal nerve measures in patients with peripheral neuropathy after pharmacological and surgical interventions. This meta-analysis confirms the utility of CCM to identify nerve regeneration following pharmacological and surgical interventions. It could be utilized to show a benefit in clinical trials of disease modifying therapies for peripheral neuropathy.
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Affiliation(s)
- Hoda Gad
- Research Department, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Einas Elgassim
- Research Department, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Ahamed Lebbe
- Research Department, Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | - Areej Baraka
- Research Department, Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | | | - Nada O Ibrahim
- Research Department, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Rayaz A Malik
- Research Department, Weill Cornell Medicine-Qatar, Doha, Qatar
- Institute of Cardiovascular Medicine, University of Manchester, Manchester, UK
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Cheung AY, Holland EJ, Lee WB, Beckman KA, Tu E, Farid M, Pepose J, Gupta PK, Fram N, Mah F, Mannis MJ. Neurotrophic keratopathy: An updated understanding. Ocul Surf 2023; 30:129-138. [PMID: 37666470 DOI: 10.1016/j.jtos.2023.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 08/10/2023] [Accepted: 09/01/2023] [Indexed: 09/06/2023]
Abstract
PURPOSE To propose an updated definition and staging system for neurotrophic keratopathy (NK) and provide consensus on diagnosis and treatment. METHODS A study group was convened to review the data pertinent to NK using a modified nominal group process. They proposed an updated definition for NK and a new 6-step staging system (Neurotrophic Keratopathy Study Group [NKSG] Classification) that can be used in conjunction with the different treatment options available currently or in the future. RESULTS NK is defined as the dysfunction of corneal innervation that results in dysregulation of corneal and/or cellular function. It is characterized by loss of corneal sensation and neuronal homeostasis, leading to eventual corneal epithelial breakdown and ultimately keratolysis if untreated. The NKSG classification emphasizes verifying corneal sensation early and distinguishes different epithelial and stromal aspects of NK with the following stages: stage 1 (altered sensation without keratopathy), stage 2 (epitheliopathy/punctate epithelial keratopathy [PEK] without stromal haze), stage 3 (persistent/recurrent epithelial defects without stromal haze), stage 4 (epitheliopathy/PEK or persistent/recurrent epithelial defects with stromal haze), stage 5 (persistent/recurrent epithelial defect with corneal ulceration), and stage 6 (corneal perforation). Treatment consists of a variety of modalities (both indirect and direct). CONCLUSIONS This updated definition and staging system will provide clinicians with the necessary information to diagnose and treat NK at an early stage before it becomes a sight-threatening disorder. It also provides a framework for evaluating current and future treatment options at distinct stages of the disease.
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Guldiken YC, Malik A, Petropoulos IN, Gad H, Elgassim E, Salivon I, Ponirakis G, Alam U, Malik RA. Where Art Thou O treatment for diabetic neuropathy: the sequel. Expert Rev Neurother 2023; 23:845-851. [PMID: 37602687 DOI: 10.1080/14737175.2023.2247163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/08/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION Having lived through a pandemic and witnessed how regulatory approval processes can evolve rapidly; it is lamentable how we continue to rely on symptoms/signs and nerve conduction as primary endpoints for clinical trials in DPN. AREAS COVERED Small (Aδ and C) fibers are key to the genesis of pain, regulate skin blood flow, and play an integral role in the development of diabetic foot ulceration but continue to be ignored. This article challenges the rationale for the FDA insisting on symptoms/signs and nerve conduction as primary endpoints for clinical trials in DPN. EXPERT OPINION Quantitative sensory testing, intraepidermal nerve fiber density, and especially corneal confocal microscopy remain an after-thought, demoted at best to exploratory secondary endpoints in clinical trials of diabetic neuropathy. If pharma are to be given a fighting chance to secure approval for a new therapy for diabetic neuropathy, the FDA needs to reassess the evidence rather than rely on 'opinion' for the most suitable endpoint(s) in clinical trials of diabetic neuropathy.
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Affiliation(s)
- Yigit Can Guldiken
- Department of Neurology, Kocaeli University Research and Application Hospital, İzmit/Kocaeli, Turkey
| | - Ayesha Malik
- Barts and The London School of Medicine and Dentistry - Medicine, London, UK
| | | | - Hoda Gad
- Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Einas Elgassim
- Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Iuliia Salivon
- Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | | | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Rayaz A Malik
- Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
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Diabetic Retinopathy: Soluble and Imaging Ocular Biomarkers. J Clin Med 2023; 12:jcm12030912. [PMID: 36769560 PMCID: PMC9917666 DOI: 10.3390/jcm12030912] [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: 12/31/2022] [Revised: 01/18/2023] [Accepted: 01/22/2023] [Indexed: 01/26/2023] Open
Abstract
Diabetic retinopathy (DR), the most common microvascular complication of diabetes mellitus, represents the leading cause of acquired blindness in the working-age population. Due to the potential absence of symptoms in the early stages of the disease, the identification of clinical biomarkers can have a crucial role in the early diagnosis of DR as well as for the detection of prognostic factors. In particular, imaging techniques are fundamental tools for screening, diagnosis, classification, monitoring, treatment planning and prognostic assessment in DR. In this context, the identification of ocular and systemic biomarkers is crucial to facilitate the risk stratification of diabetic patients; moreover, reliable biomarkers could provide prognostic information on disease progression as well as assist in predicting a patient's response to therapy. In this context, this review aimed to provide an updated and comprehensive overview of the soluble and anatomical biomarkers associated with DR.
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Dericioğlu V, Akkaya Turhan S, Erdem HE, Sevik MO, Erdil E, Sünter G, Ağan K, Toker E. In Vivo Corneal Confocal Microscopy in Multiple Sclerosis: Can it Differentiate Disease Relapse in Multiple Sclerosis? Am J Ophthalmol 2023; 250:138-148. [PMID: 36669610 DOI: 10.1016/j.ajo.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/20/2023]
Abstract
PURPOSE This study aims to investigate the role of in vivo corneal confocal microscopy (IVCCM) in the detection of corneal inflammatory activity and subbasal nerve alterations in patients with multiple sclerosis (MS) and to further determine whether IVCCM can be used to detect (acute) disease relapse. DESIGN Prospective cross-sectional study, with a subgroup follow-up. METHODS This single-center study included 58 patients with MS (MS-Relapse group [n = 27] and MS-Remission group [n = 31]), and 30 age- and sex-matched healthy control subjects. Patients with a history of optic neuritis or trigeminal symptoms were excluded. Corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), corneal nerve fiber length (CNFL), and dendritic cell (DC) density were evaluated in all patients with MS and control subjects by IVCCM. Patients in the MS-Relapse group who were in remission for ≥6 months after the MS incident underwent a repeat IVCCM. RESULTS No statistical difference was observed between the MS-Relapse and MS-Remission groups regarding age, sex, MS duration, and the number of relapses (P > .05). Compared with healthy control subjects, all subbasal nerve parameters were significantly lower (CNFD: P < .001, CNFL: P < .001, CNBD: P < .001), and the DC density was significantly higher (P = .023) in patients with MS. However, no significant difference was observed between MS-Relapse and MS-Remission groups in terms of CNFD (mean [SE] difference -2.05 [1.69] fibers/mm2 [95% confidence interval {CI} -1.32 to 5.43]; P < .227), CNFL (mean [SE] difference -1.10 [0.83] mm/mm2 [95% CI -0.56 to 2.75]; P < .190), CNBD (mean [SE] difference -3.91 [2.48] branches/mm2 [95% CI -1.05 to 8.87]; P < .120), and DC density (median [IQR], 59.38 [43.75-85.0] vs 75.0 [31.25-128.75]; P = .596). The repeat IVCCM in relapse patients (n = 16 [59.3%]) showed a significant increase in CNFD (P = .036) and CNBD (P = .018), but no change was observed in CNFL (P = .075) and DC density (P = .469). CONCLUSION Although increased inflammation and neurodegeneration can be demonstrated in patients with MS compared with healthy control subjects, a single time point evaluation of IVCCM does not seem to be sufficient to confirm the occurrence of relapse in patients with MS. However, IVCCM holds promise for demonstrating early neuroregeneration in patients with MS.
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Affiliation(s)
- Volkan Dericioğlu
- From the Department of Ophthalmology (V.D., S.A.T., H.E.E., M.O.S.), Marmara University School of Medicine, Istanbul, Turkey.
| | - Semra Akkaya Turhan
- From the Department of Ophthalmology (V.D., S.A.T., H.E.E., M.O.S.), Marmara University School of Medicine, Istanbul, Turkey
| | - Halit Eren Erdem
- From the Department of Ophthalmology (V.D., S.A.T., H.E.E., M.O.S.), Marmara University School of Medicine, Istanbul, Turkey
| | - Mehmet Orkun Sevik
- From the Department of Ophthalmology (V.D., S.A.T., H.E.E., M.O.S.), Marmara University School of Medicine, Istanbul, Turkey
| | - Esra Erdil
- and the Department of Neurology (E.E., G.S., K.A.), Marmara University School of Medicine, Istanbul, Turkey
| | - Gülin Sünter
- and the Department of Neurology (E.E., G.S., K.A.), Marmara University School of Medicine, Istanbul, Turkey
| | - Kadriye Ağan
- and the Department of Neurology (E.E., G.S., K.A.), Marmara University School of Medicine, Istanbul, Turkey
| | - Ebru Toker
- and the Department of Ophthalmology and Visual Sciences (E.T.), West Virginia University, Morgantown, West Virginia, USA
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Huo Y, Grotle AK, McCuller RK, Samora M, Stanhope KL, Havel PJ, Harrison ML, Stone AJ. Exaggerated exercise pressor reflex in male UC Davis type 2 diabetic rats is due to the pathophysiology of the disease and not aging. Front Physiol 2023; 13:1063326. [PMID: 36703927 PMCID: PMC9871248 DOI: 10.3389/fphys.2022.1063326] [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: 10/06/2022] [Accepted: 12/16/2022] [Indexed: 01/12/2023] Open
Abstract
Introduction: Studies in humans and animals have found that type 2 diabetes mellitus (T2DM) exaggerates the blood pressure (BP) response to exercise, which increases the risk of adverse cardiovascular events such as heart attack and stroke. T2DM is a chronic disease that, without appropriate management, progresses in severity as individuals grow older. Thus, it is possible that aging may also exaggerate the BP response to exercise. Therefore, the purpose of the current study was to determine the effect of the pathophysiology of T2DM on the exercise pressor reflex independent of aging. Methods: We compared changes in peak pressor (mean arterial pressure; ΔMAP), BP index (ΔBPi), heart rate (ΔHR), and HR index (ΔHRi) responses to static contraction, intermittent contraction, and tendon stretch in UCD-T2DM rats to those of healthy, age-matched Sprague Dawley rats at three different stages of the disease. Results: We found that the ΔMAP, ΔBPi, ΔHR, and ΔHRi responses to static contraction were significantly higher in T2DM rats (ΔMAP: 29 ± 4 mmHg; ΔBPi: 588 ± 51 mmHg•s; ΔHR: 22 ± 5 bpm; ΔHRi: 478 ± 45 bpm•s) compared to controls (ΔMAP: 10 ± 1 mmHg, p < 0.0001; ΔBPi: 121 ± 19 mmHg•s, p < 0.0001; ΔHR: 5 ± 2 bpm, p = 0.01; ΔHRi: 92 ± 19 bpm•s, p < 0.0001) shortly after diabetes onset. Likewise, the ΔMAP, ΔBPi, and ΔHRi to tendon stretch were significantly higher in T2DM rats (ΔMAP: 33 ± 7 mmHg; ΔBPi: 697 ± 70 mmHg•s; ΔHRi: 496 ± 51 bpm•s) compared to controls (ΔMAP: 12 ± 5 mmHg, p = 0.002; ΔBPi: 186 ± 30 mmHg•s, p < 0.0001; ΔHRi: 144 ± 33 bpm•s, p < 0.0001) shortly after diabetes onset. The ΔBPi and ΔHRi, but not ΔMAP, to intermittent contraction was significantly higher in T2DM rats (ΔBPi: 543 ± 42 mmHg•s; ΔHRi: 453 ± 53 bpm•s) compared to controls (ΔBPi: 140 ± 16 mmHg•s, p < 0.0001; ΔHRi: 108 ± 22 bpm•s, p = 0.0002) shortly after diabetes onset. Discussion: Our findings suggest that the exaggerated exercise pressor reflex and mechanoreflex seen in T2DM are due to the pathophysiology of the disease and not aging.
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Affiliation(s)
- Yu Huo
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, TX, United States
| | - Ann-Katrin Grotle
- Department of Sport, Food and Natural Sciences, Western Norway University of Applied Science, Bergen, Norway
| | - Richard K. McCuller
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, TX, United States
| | - Milena Samora
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, TX, United States
| | - Kimber L. Stanhope
- Department of Molecular Biosciences, School of Veterinary Medicine and Department of Nutrition, University of California, Davis, Davis, CA, United States
| | - Peter J. Havel
- Department of Molecular Biosciences, School of Veterinary Medicine and Department of Nutrition, University of California, Davis, Davis, CA, United States
| | - Michelle L. Harrison
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, TX, United States
| | - Audrey J. Stone
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, TX, United States,*Correspondence: Audrey J. Stone,
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Cosmo E, Midena G, Frizziero L, Bruno M, Cecere M, Midena E. Corneal Confocal Microscopy as a Quantitative Imaging Biomarker of Diabetic Peripheral Neuropathy: A Review. J Clin Med 2022; 11:5130. [PMID: 36079060 PMCID: PMC9457345 DOI: 10.3390/jcm11175130] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Distal symmetric polyneuropathy (DPN), particularly chronic sensorimotor DPN, represents one of the most frequent complications of diabetes, affecting 50% of diabetic patients and causing an enormous financial burden. Whilst diagnostic methods exist to detect and monitor this condition, they have significant limitations, mainly due to their high subjectivity, invasiveness, and non-repeatability. Corneal confocal microscopy (CCM) is an in vivo, non-invasive, and reproducible diagnostic technique for the study of all corneal layers including the sub-basal nerve plexus, which represents part of the peripheral nervous system. We reviewed the current literature on the use of CCM as an instrument in the assessment of diabetic patients, particularly focusing on its role in the study of sub-basal nerve plexus alterations as a marker of DPN. CCM has been demonstrated to be a valid in vivo tool to detect early sub-basal nerve plexus damage in adult and pediatric diabetic patients, correlating with the severity of DPN. Despite its great potential, CCM has still limited application in daily clinical practice, and more efforts still need to be made to allow the dissemination of this technique among doctors taking care of diabetic patients.
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Affiliation(s)
| | | | - Luisa Frizziero
- Department of Neuroscience-Ophthalmology, University of Padova, 35128 Padova, Italy
| | | | | | - Edoardo Midena
- IRCCS—Fondazione Bietti, 00198 Rome, Italy
- Department of Neuroscience-Ophthalmology, University of Padova, 35128 Padova, Italy
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Malik RA. Corneal confocal microscopy meets continuous glucose monitoring: a tale of two technologies. Chin Med J (Engl) 2022; 135:1891-1893. [PMID: 36148585 PMCID: PMC9746738 DOI: 10.1097/cm9.0000000000002254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Indexed: 01/26/2023] Open
Affiliation(s)
- Rayaz A. Malik
- Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha, Qatar
- Institute of Cardiovascular Science, University of Manchester, Manchester, UK
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Yu FSX, Lee PSY, Yang L, Gao N, Zhang Y, Ljubimov AV, Yang E, Zhou Q, Xie L. The impact of sensory neuropathy and inflammation on epithelial wound healing in diabetic corneas. Prog Retin Eye Res 2022; 89:101039. [PMID: 34991965 PMCID: PMC9250553 DOI: 10.1016/j.preteyeres.2021.101039] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 12/10/2021] [Accepted: 12/20/2021] [Indexed: 02/08/2023]
Abstract
Diabetic peripheral neuropathy (DPN) is the most common complication of diabetes, with several underlying pathophysiological mechanisms, some of which are still uncertain. The cornea is an avascular tissue and sensitive to hyperglycemia, resulting in several diabetic corneal complications including delayed epithelial wound healing, recurrent erosions, neuropathy, loss of sensitivity, and tear film changes. The manifestation of DPN in the cornea is referred to as diabetic neurotrophic keratopathy (DNK). Recent studies have revealed that disturbed epithelial-neural-immune cell interactions are a major cause of DNK. The epithelium is supplied by a dense network of sensory nerve endings and dendritic cell processes, and it secretes growth/neurotrophic factors and cytokines to nourish these neighboring cells. In turn, sensory nerve endings release neuropeptides to suppress inflammation and promote epithelial wound healing, while resident immune cells provide neurotrophic and growth factors to support neuronal and epithelial cells, respectively. Diabetes greatly perturbs these interdependencies, resulting in suppressed epithelial proliferation, sensory neuropathy, and a decreased density of dendritic cells. Clinically, this results in a markedly delayed wound healing and impaired sensory nerve regeneration in response to insult and injury. Current treatments for DPN and DNK largely focus on managing the severe complications of the disease. Cell-based therapies hold promise for providing more effective treatment for diabetic keratopathy and corneal ulcers.
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Affiliation(s)
- Fu-Shin X Yu
- Departments of Ophthalmology and Anatomy and Cell Biology, Wayne State University School of Medicine, Detroit, MI, 48201, USA.
| | - Patrick S Y Lee
- Departments of Ophthalmology and Anatomy and Cell Biology, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Lingling Yang
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Nan Gao
- Departments of Ophthalmology and Anatomy and Cell Biology, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Yangyang Zhang
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Alexander V Ljubimov
- Departments of Biomedical Sciences and Neurosurgery, Cedars-Sinai Medical Center, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ellen Yang
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, 60064, USA
| | - Qingjun Zhou
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Lixin Xie
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China.
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D'Souza RS, Barman R, Joseph A, Abd-Elsayed A. Evidence-Based Treatment of Painful Diabetic Neuropathy: a Systematic Review. Curr Pain Headache Rep 2022; 26:583-594. [PMID: 35716275 DOI: 10.1007/s11916-022-01061-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Painful diabetic neuropathy (PDN) manifests with pain typically in the distal lower extremities and can be challenging to treat. The authors appraised the literature for evidence on conservative, pharmacological, and neuromodulation treatment options for PDN. RECENT FINDINGS Intensive glycemic control with insulin in patients with type 1 diabetes may be associated with lower odds of distal symmetric polyneuropathy compared to patients who receive conventional insulin therapy. First-line pharmacologic therapy for PDN includes gabapentinoids (pregabalin and gabapentin) and duloxetine. Additional pharmacologic modalities that are approved by the Food and Drug Administration (FDA) but are considered second-line agents include tapentadol and 8% capsaicin patch, although studies have revealed modest treatment effects from these modalities. There is level I evidence on the use of dorsal column spinal cord stimulation (SCS) for treatment of PDN, delivering either a 10-kHz waveform or tonic waveform. In summary, this review provides an overview of treatment options for PDN. Furthermore, it provides updates on the level of evidence for SCS therapy in cases of PDN refractory to conventional medical therapy.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ross Barman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amira Joseph
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology and Perioperative Medicine, University of Wisconsin, Madison, WI, USA.
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Corneal Confocal Microscopy Identifies People with Type 1 Diabetes with More Rapid Corneal Nerve Fibre Loss and Progression of Neuropathy. J Clin Med 2022; 11:jcm11082249. [PMID: 35456342 PMCID: PMC9030140 DOI: 10.3390/jcm11082249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/03/2022] [Accepted: 04/05/2022] [Indexed: 11/23/2022] Open
Abstract
There is a need to accurately identify patients with diabetes at higher risk of developing and progressing diabetic peripheral neuropathy (DPN). Fifty subjects with Type 1 Diabetes Mellitus (T1DM) and sixteen age matched healthy controls underwent detailed neuropathy assessments including symptoms, signs, quantitative sensory testing (QST), nerve conduction studies (NCS), intra epidermal nerve fiber density (IENFD) and corneal confocal microscopy (CCM) at baseline and after 2 years of follow-up. Overall, people with type 1 diabetes mellitus showed no significant change in HbA1c, blood pressure, lipids or neuropathic symptoms, signs, QST, neurophysiology, IENFD and CCM over 2 years. However, a sub-group (n = 11, 22%) referred to as progressors, demonstrated rapid corneal nerve fiber loss (RCNFL) with a reduction in corneal nerve fiber density (CNFD) (p = 0.0006), branch density (CNBD) (p = 0.0002), fiber length (CNFL) (p = 0.0002) and sural (p = 0.04) and peroneal (p = 0.05) nerve conduction velocities, which was not related to a change in HbA1c or cardiovascular risk factors. The majority of people with T1DM and good risk factor control do not show worsening of neuropathy over 2 years. However, CCM identifies a sub-group of people with T1DM who show a more rapid decline in corneal nerve fibers and nerve conduction velocity.
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13
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Petropoulos IN, Bitirgen G, Ferdousi M, Kalteniece A, Azmi S, D'Onofrio L, Lim SH, Ponirakis G, Khan A, Gad H, Mohammed I, Mohammadi YE, Malik A, Gosal D, Kobylecki C, Silverdale M, Soran H, Alam U, Malik RA. Corneal Confocal Microscopy to Image Small Nerve Fiber Degeneration: Ophthalmology Meets Neurology. FRONTIERS IN PAIN RESEARCH 2022; 2:725363. [PMID: 35295436 PMCID: PMC8915697 DOI: 10.3389/fpain.2021.725363] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/26/2021] [Indexed: 12/13/2022] Open
Abstract
Neuropathic pain has multiple etiologies, but a major feature is small fiber dysfunction or damage. Corneal confocal microscopy (CCM) is a rapid non-invasive ophthalmic imaging technique that can image small nerve fibers in the cornea and has been utilized to show small nerve fiber loss in patients with diabetic and other neuropathies. CCM has comparable diagnostic utility to intraepidermal nerve fiber density for diabetic neuropathy, fibromyalgia and amyloid neuropathy and predicts the development of diabetic neuropathy. Moreover, in clinical intervention trials of patients with diabetic and sarcoid neuropathy, corneal nerve regeneration occurs early and precedes an improvement in symptoms and neurophysiology. Corneal nerve fiber loss also occurs and is associated with disease progression in multiple sclerosis, Parkinson's disease and dementia. We conclude that corneal confocal microscopy has good diagnostic and prognostic capability and fulfills the FDA criteria as a surrogate end point for clinical trials in peripheral and central neurodegenerative diseases.
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Affiliation(s)
| | - Gulfidan Bitirgen
- Department of Ophthalmology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Maryam Ferdousi
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Alise Kalteniece
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Shazli Azmi
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom.,Centre for Diabetes, Endocrinology and Metabolism, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Luca D'Onofrio
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Sze Hway Lim
- Department of Neurology, Salford Royal National Health System (NHS) Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | | | - Adnan Khan
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Hoda Gad
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Ibrahim Mohammed
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | - Ayesha Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - David Gosal
- Department of Neurology, Salford Royal National Health System (NHS) Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | - Christopher Kobylecki
- Department of Neurology, Salford Royal National Health System (NHS) Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | - Monty Silverdale
- Department of Neurology, Salford Royal National Health System (NHS) Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | - Handrean Soran
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine, Clinical Sciences Centre, Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool University Hospital National Health System (NHS) Foundation Trust, Liverpool, United Kingdom
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar.,Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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14
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Al-Bazz DY, Nelson AJ, Burgess J, Petropoulos IN, Nizza J, Marshall A, Brown E, Cuthbertson DJ, Marshall AG, Malik RA, Alam U. Is Nerve Electrophysiology a Robust Primary Endpoint in Clinical Trials of Treatments for Diabetic Peripheral Neuropathy? Diagnostics (Basel) 2022; 12:731. [PMID: 35328284 PMCID: PMC8947384 DOI: 10.3390/diagnostics12030731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 12/10/2022] Open
Abstract
There is currently no FDA-approved disease-modifying therapy for diabetic peripheral neuropathy (DPN). Nerve conduction velocity (NCV) is an established primary endpoint of disease-modifying therapies in DPN and clinical trials have been powered with an assumed decline of 0.5 m/s/year. This paper sought to establish the time-dependent change in NCV associated with a placebo, compared to that observed in the active intervention group. A literature search identified twenty-one double-blind, randomised controlled trials in DPN of ≥1 year duration conducted between 1971 and 2021. We evaluated changes in neurophysiology, with a focus on peroneal motor and sural sensory NCV and amplitude in the placebo and treatment groups. There was significant variability in the change and direction of change (reduction/increase) in NCV in the placebo arm, as well as variability influenced by the anatomical site of neurophysiological measurement within a given clinical trial. A critical re-evaluation of efficacy trials should consider placebo-adjusted effects and present the placebo-subtracted change in NCV rather than assume a universal annual decline of 0.5 m/s/year. Importantly, endpoints such as corneal confocal microscopy (CCM) have demonstrated early nerve repair, whilst symptoms and NCV have not changed, and should thus be considered as a viable alternative.
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Affiliation(s)
- Dalal Y. Al-Bazz
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (A.J.N.); (J.B.); (J.N.); (A.M.); (A.G.M.)
| | - Andrew J. Nelson
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (A.J.N.); (J.B.); (J.N.); (A.M.); (A.G.M.)
| | - Jamie Burgess
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (A.J.N.); (J.B.); (J.N.); (A.M.); (A.G.M.)
| | - Ioannis N. Petropoulos
- Research Division, Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha 24144, Qatar; (I.N.P.); (R.A.M.)
| | - Jael Nizza
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (A.J.N.); (J.B.); (J.N.); (A.M.); (A.G.M.)
| | - Anne Marshall
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (A.J.N.); (J.B.); (J.N.); (A.M.); (A.G.M.)
| | - Emily Brown
- Obesity and Endocrinology Research Group, Institute of Life Course and Medical Sciences, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (E.B.); (D.J.C.)
| | - Daniel J. Cuthbertson
- Obesity and Endocrinology Research Group, Institute of Life Course and Medical Sciences, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (E.B.); (D.J.C.)
| | - Andrew G. Marshall
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (A.J.N.); (J.B.); (J.N.); (A.M.); (A.G.M.)
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester M13 9WL, UK
| | - Rayaz A. Malik
- Research Division, Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha 24144, Qatar; (I.N.P.); (R.A.M.)
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester M13 9WL, UK
| | - Uazman Alam
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (A.J.N.); (J.B.); (J.N.); (A.M.); (A.G.M.)
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester, Manchester M13 9PL, UK
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15
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Malik RA, Efron N. Corneal Confocal Microscopy and the Nervous System: Introduction to the Special Issue. J Clin Med 2022; 11:jcm11061475. [PMID: 35329801 PMCID: PMC8953792 DOI: 10.3390/jcm11061475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/05/2022] [Indexed: 12/07/2022] Open
Affiliation(s)
- Rayaz A. Malik
- Weill Cornell Medicine-Qatar, Research Division, Qatar Foundation, Education City, Doha 24144, Qatar;
| | - Nathan Efron
- School of Optometry and Vision Science, Queensland University of Technology, Kelvin Grove, QLD 4059, Australia
- Correspondence:
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16
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Singleton JR, Foster-Palmer S, Marcus RL. Exercise as Treatment for Neuropathy in the Setting of Diabetes and Prediabetic Metabolic Syndrome: A Review of Animal Models and Human Trials. Curr Diabetes Rev 2022; 18:e230921196752. [PMID: 34561989 DOI: 10.2174/1573399817666210923125832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/21/2021] [Accepted: 05/17/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Peripheral neuropathy is among the most common complications of diabetes, but a phenotypically identical distal sensory predominant, painful axonopathy afflicts patients with prediabetic metabolic syndrome, exemplifying a spectrum of risk and continuity of pathogenesis. No pharmacological treatment convincingly improves neuropathy in the setting of metabolic syndrome, but evolving data suggest that exercise may be a promising alternative. OBJECTIVE The aim of the study was to review in depth the current literature regarding exercise treatment of metabolic syndrome neuropathy in humans and animal models, highlight the diverse mechanisms by which exercise exerts beneficial effects, and examine adherence limitations, safety aspects, modes and dose of exercise. RESULTS Rodent models that recapitulate the organismal milieu of prediabetic metabolic syndrome and the phenotype of its neuropathy provide a strong platform to dissect exercise effects on neuropathy pathogenesis. In these models, exercise reverses hyperglycemia and consequent oxidative and nitrosative stress, improves microvascular vasoreactivity, enhances axonal transport, ameliorates the lipotoxicity and inflammatory effects of hyperlipidemia and obesity, supports neuronal survival and regeneration following injury, and enhances mitochondrial bioenergetics at the distal axon. Prospective human studies are limited in scale but suggest exercise to improve cutaneous nerve regenerative capacity, neuropathic pain, and task-specific functional performance measures of gait and balance. Like other heath behavioral interventions, the benefits of exercise are limited by patient adherence. CONCLUSION Exercise is an integrative therapy that potently reduces cellular inflammatory state and improves distal axonal oxidative metabolism to ameliorate features of neuropathy in metabolic syndrome. The intensity of exercise need not improve cardinal features of metabolic syndrome, including weight, glucose control, to exert beneficial effects.
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Affiliation(s)
| | | | - Robin L Marcus
- Department Physical Therapy and Athletic Training, University of Utah, UT, United States
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17
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Abstract
Diabetic painless and painful peripheral neuropathy remains the most frequent complication of diabetes mellitus, but the pathophysiology remains undescribed, there are no robust clinical endpoints and no efficient treatment exists. This hampers good clinical practice, fruitful clinical research and successful pharmacological trials, necessary for the development of early detection, prevention and treatment. This chapter supplies an update on background and treatment of diabetic peripheral neuropathy. Goals and perspectives for future clinical and scientific approaches are also described.
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Affiliation(s)
- Johan Røikjer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Faculty of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Ejskjaer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark.
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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18
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Verdugo RJ, Matamala JM, Inui K, Kakigi R, Valls-Solé J, Hansson P, Bernhard Nilsen K, Lombardi R, Lauria G, Petropoulos IN, Malik RA, Treede RD, Baumgärtner U, Jara PA, Campero M. Review of techniques useful for the assessment of sensory small fiber neuropathies: Report from an IFCN expert group. Clin Neurophysiol 2022; 136:13-38. [DOI: 10.1016/j.clinph.2022.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 02/09/2023]
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19
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Wu PY, Wu JH, Hsieh YT, Chen LCC, Cheng T, Wu PY, Hsieh BJ, Huang WL, Huang SL, Chen WL. Comparing the results of manual and automated quantitative corneal neuroanalysing modules for beginners. Sci Rep 2021; 11:18208. [PMID: 34521890 PMCID: PMC8440557 DOI: 10.1038/s41598-021-97567-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/24/2021] [Indexed: 11/11/2022] Open
Abstract
This study aimed to evaluate the reliability of in vivo confocal microscopic neuroanalysis by beginners using manual and automated modules. Images of sub-basal corneal nerve plexus (SCNP) from 108 images of 18 healthy participants were analyzed by 7 beginner observers using manual (CCMetrics, [CCM]) and automated (ACCMetrics, [ACCM]) module. SCNP parameters analyzed included corneal nerve fiber density (NFD), corneal nerve branch density (NBD), corneal nerve fiber length (NFL), and tortuosity coefficient (TC). The intra-observer repeatability, inter-observer reliability, inter-module agreement, and left–right eye symmetry level of SCNP parameters were examined. All observers showed good intra-observer repeatability using CCM (intraclass correlation coefficient [ICC] > 0.60 for all), except when measuring TC. Two observers demonstrated especially excellent repeatability in analyzing NFD, NBD, and NFL using manual mode, indicating the quality of interpretation may still be observer-dependent. Among all SCNP parameters, NFL had the best inter-observer reliability (Spearman’s rank-sum correlation coefficient [SpCC] and ICC > 0.85 for the 3 original observers) and left–right symmetry level (SpCC and ICC > 0.60). In the additional analysis of inter-observer reliability using results by all 7 observers, only NFL showed good inter-observer reliability (ICC = 0.79). Compared with CCM measurements, values of ACCM measurements were significantly lower, implying a poor inter-module agreement. Our result suggested that performance of quantitative corneal neuroanalysis by beginners maybe acceptable, with NFL being the most reliable parameter, and automated method cannot fully replace manual work.
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Affiliation(s)
- Po-Ying Wu
- Department of General Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jo-Hsuan Wu
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California, San Diego, USA
| | - Yi-Ting Hsieh
- Department of Ophthalmology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Lin Chih-Chieh Chen
- Graduate Institute of Photonics and Optoelectronics, National Taiwan University, Taipei, Taiwan.,Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan
| | - Ting Cheng
- Department of Ophthalmology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Po-Yi Wu
- Department of Ophthalmology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Bing-Jun Hsieh
- Department of Ophthalmology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Wei-Lun Huang
- Department of Ophthalmology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Sheng-Lung Huang
- Graduate Institute of Photonics and Optoelectronics, National Taiwan University, Taipei, Taiwan.,Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan
| | - Wei-Li Chen
- Department of Ophthalmology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan. .,Advanced Ocular Surface and Corneal Nerve Regeneration Center, National Taiwan University Hospital, Taipei, Taiwan. .,Department of Ophthalmology, College of Medicine, National Taiwan University, Taipei, Taiwan.
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20
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Cozzini T, Piona C, Marchini G, Merz T, Brighenti T, Bonetto J, Marigliano M, Olivieri F, Maffeis C, Pedrotti E. In vivo confocal microscopy study of corneal nerve alterations in children and youths with Type 1 diabetes. Pediatr Diabetes 2021; 22:780-786. [PMID: 33934464 PMCID: PMC8360056 DOI: 10.1111/pedi.13219] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/13/2021] [Accepted: 04/16/2021] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To determine whether children and youths with Type 1 diabetes (T1D) have early alterations of the corneal subbasal nerve plexus detectable with in vivo confocal microscopy (IVCM) and to investigate the role of longitudinally measured major risk factors for diabetes complications associated with these alterations. METHODS One hundred and fifty children and youths with T1D and 51 age-matched controls were enrolled and underwent IVCM. Corneal nerve fiber length (CNFL), corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), corneal fiber total branch density (CTBD), and corneal fiber fractal dimension (CNFrD) were measured. Risk factors for diabetes complications (blood pressure, BMI, HbA1c, lipoproteins, urinary albumin-creatinine ratio) were recorded at IVCM and longitudinally since T1D onset. Unpaired t-test was used to compare variables between the groups. Multiple regression models were calculated using IVCM parameters as dependent variables and risk factors as independent variables. RESULTS All IVCM parameters, except CTBD, were significantly lower in the T1D patients. Glycometabolic control (HbA1c, visit-to-visit HbA1c variability, and mean HbA1c), and blood pressure were inversely correlated with IVCM parameters. Multiple regression showed that part of the variability in CNFL, CNFD, CTBD, and CNFraD was explained by HbA1c, blood pressure percentiles and age at IVCM examination, independent of diabetes duration, BMI percentile and LDL cholesterol. Comparable results were obtained using the mean value of risk factors measured longitudinally since T1D onset. CONCLUSIONS Early signs of corneal nerve degeneration were found in children and youths with T1D. Glycometabolic control and blood pressure were the major risk factors for these alterations.
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Affiliation(s)
- Tiziano Cozzini
- Department of Neuroscience, Biomedicine and Movement SciencesEye Clinic, University of VeronaVeronaItaly
| | - Claudia Piona
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric DiabetesUniversity City Hospital of VeronaVeronaItaly
| | - Giorgio Marchini
- Department of Neuroscience, Biomedicine and Movement SciencesEye Clinic, University of VeronaVeronaItaly
| | - Tommaso Merz
- Department of Neuroscience, Biomedicine and Movement SciencesEye Clinic, University of VeronaVeronaItaly
| | - Tommaso Brighenti
- Department of Neuroscience, Biomedicine and Movement SciencesEye Clinic, University of VeronaVeronaItaly
| | - Jacopo Bonetto
- Department of Neuroscience, Biomedicine and Movement SciencesEye Clinic, University of VeronaVeronaItaly
| | - Marco Marigliano
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric DiabetesUniversity City Hospital of VeronaVeronaItaly
| | - Francesca Olivieri
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric DiabetesUniversity City Hospital of VeronaVeronaItaly
| | - Claudio Maffeis
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric DiabetesUniversity City Hospital of VeronaVeronaItaly
| | - Emilio Pedrotti
- Department of Neuroscience, Biomedicine and Movement SciencesEye Clinic, University of VeronaVeronaItaly
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21
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Abstract
PURPOSE OF REVIEW Hyperlipidaemia is associated with the development of neuropathy. Indeed, a mechanistic link between altered lipid metabolism and peripheral nerve dysfunction has been demonstrated in a number of experimental and clinical studies. Furthermore, post hoc analyses of clinical trials of cholesterol and triglyceride-lowering pharmacotherapy have shown reduced rates of progression of diabetic neuropathy. Given, there are currently no FDA approved disease-modifying therapies for diabetic neuropathy, modulation of lipids may represent a key therapeutic target for the treatment of diabetic nerve damage. This review summarizes the current evidence base on the role of hyperlipidaemia and lipid lowering therapy on the development and progression of peripheral neuropathy. RECENT FINDINGS A body of literature supports a detrimental effect of dyslipidaemia on nerve fibres resulting in somatic and autonomic neuropathy. The case for an important modulating role of hypertriglyceridemia is stronger than for low-density lipoprotein cholesterol (LDL-C) in relation to peripheral neuropathy. This is reflected in the outcomes of clinical trials with the different therapeutic agents targeting hyperlipidaemia reporting beneficial or neutral effects with statins and fibrates. The potential concern with the association between proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor therapy and cognitive decline raised the possibility that extreme LDL-C lowering may result in neurodegeneration. However, studies in murine models and data from small observational studies indicate an association between increased circulating PCSK9 levels and small nerve fibre damage with a protective effect of PCSK9i therapy against small fibre neuropathy. Additionally, weight loss with bariatric surgery leads to an improvement in peripheral neuropathy and regeneration of small nerve fibres measured with corneal confocal microscopy in people with obesity with or without type 2 diabetes. These improvements correlate inversely with changes in triglyceride levels. SUMMARY Hyperlipidaemia, particularly hypertriglyceridemia, is associated with the development and progression of neuropathy. Lipid modifying agents may represent a potential therapeutic option for peripheral neuropathy. Post hoc analyses indicate that lipid-lowering therapies may halt the progression of neuropathy or even lead to regeneration of nerve fibres. Well designed randomized controlled trials are needed to establish if intensive targeted lipid lowering therapy as a part of holistic metabolic control leads to nerve fibre regeneration and improvement in neuropathy symptoms.
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Affiliation(s)
- Zohaib Iqbal
- Faculty of Biology, Medicine and Health, University of Manchester
- Department of Endocrinology, Diabetes and Metabolism, Peter Mount Building, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Bilal Bashir
- Department of Endocrinology, Diabetes and Metabolism, Peter Mount Building, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Maryam Ferdousi
- Faculty of Biology, Medicine and Health, University of Manchester
- Department of Endocrinology, Diabetes and Metabolism, Peter Mount Building, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Alise Kalteniece
- Faculty of Biology, Medicine and Health, University of Manchester
| | - Uazman Alam
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Rayaz A Malik
- Faculty of Biology, Medicine and Health, University of Manchester
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Handrean Soran
- Faculty of Biology, Medicine and Health, University of Manchester
- Department of Endocrinology, Diabetes and Metabolism, Peter Mount Building, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
- Weill-Cornell Medicine-Qatar, Doha, Qatar
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22
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Zhang Y, Fan D, Zhang Y, Zhang S, Wang H, Liu Z, Wang H. Using corneal confocal microscopy to compare Mecobalamin intramuscular injections vs oral tablets in treating diabetic peripheral neuropathy: a RCT. Sci Rep 2021; 11:14697. [PMID: 34282267 PMCID: PMC8290034 DOI: 10.1038/s41598-021-94284-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/18/2021] [Indexed: 02/04/2023] Open
Abstract
This randomized controlled study used corneal confocal microscopy (CCM) to compare the efficacy of Mecobalamin intramuscular injections vs oral tablets in treating mild to moderate diabetic peripheral neuropathy (DPN) by detecting early nerve fiber repair. Enrolled patients were randomized approximately 1:1 to receive Mecobalamin intramuscular injections (0.5 mg/day, 3 times/week) or Mecobalamin oral tablets (1.5 mg/day) for 8 weeks. Primary outcome was change of inferior whorl length (IWL) from baseline. Secondary outcomes included changes of corneal nerve fibre length (CNFL), corneal nerve fibre density (CNFD), corneal nerve branch density (CNBD) and the Survey of Autonomic Symptoms (SAS). 15 (93.75%) patients in the injection group and 17 (89.47%) patients in the tablet group completed the study. The injection treatment significantly improved patients' IWL from baseline (21.64 ± 3.00 mm/mm2 vs 17.64 ± 4.83 mm/mm2, P < 0.01) while the tablet treatment didn't. Additionally, the injection treatment led to significantly improved CNFL, CNBD and SAS from baseline (all P < 0.05) while the tablet treatment did not. No patient experienced any adverse events. In conclusion, CCM is sensitive enough to detect the superior efficacy of 8-week Mecobalamin intramuscular injection treatment for DPN compared to the oral tablet treatment.ClinicalTrials.gov registration number: NCT04372316 (30/04/2020).
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Affiliation(s)
- Yuanjin Zhang
- Neurology Department, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China
- Beijing Municipal Key Laboratory of Biomarker and Translational Research in Neurodegenerative Disease, Beijing, China
| | - Dongsheng Fan
- Neurology Department, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China.
- Beijing Municipal Key Laboratory of Biomarker and Translational Research in Neurodegenerative Disease, Beijing, China.
| | - Yixuan Zhang
- Neurology Department, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China
- Beijing Municipal Key Laboratory of Biomarker and Translational Research in Neurodegenerative Disease, Beijing, China
| | - Shuo Zhang
- Neurology Department, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China
- Beijing Municipal Key Laboratory of Biomarker and Translational Research in Neurodegenerative Disease, Beijing, China
| | - Haikun Wang
- Department of Ophthalmology, Peking University Third Hospital, Beijing, China
| | - Ziyuan Liu
- Department of Ophthalmology, Peking University Third Hospital, Beijing, China
| | - Hongli Wang
- Neurology Department, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191, China
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Ferdousi M, Azmi S, Kalteniece A, Khan SU, Petropoulos IN, Ponirakis G, Alam U, Asghar O, Marshall A, Soran H, Boulton AJM, Augustine T, Malik RA. No evidence of improvement in neuropathy after renal transplantation in patients with end stage kidney disease. J Peripher Nerv Syst 2021; 26:269-275. [PMID: 34085731 DOI: 10.1111/jns.12456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/20/2021] [Accepted: 02/24/2021] [Indexed: 11/29/2022]
Abstract
To assess the impact of renal transplantation on peripheral nerve damage in patients with chronic kidney disease (CKD). Fifteen patients with CKD (eGFR <15 mL/min/1.73 m2 ) underwent longitudinal assessment after renal transplantation (age: 56.88 ± 2.53 years, eGFR: 46.82 ± 4.86) and were compared with 15 age-matched controls (age: 58.25 ± 2.18 years, eGFR: 86.0 ± 2.0). The neuropathy symptom profile (NSP), neuropathy disability score (NDS), vibration perception threshold (VPT), cold and warm sensation threshold (CST and WST), cold and heat induced pain (CIP and HIP), deep breathing heart rate variability (DB-HRV), nerve conduction studies and corneal confocal microscopy (CCM) to quantify small nerve fibre pathology, were undertaken within 1-month of renal transplantation (baseline) and at 6, 12 and 24 months of follow up. There was no significant difference in NSP (P = .1), NDS (P = .3), VPT (P = .6), CST (P = .2), CIP (P = .08), HIP (P = .1), DB-HRV (P = .9) and sural (P = .4) and peroneal (P = .1) nerve amplitude between patients with CKD and controls at baseline. However, sural (P = .04), peroneal (P = .002) and tibial (P = .007) nerve conduction velocity and tibial nerve amplitude (P = .03) were significantly lower, WST (P = .02) was significantly higher and corneal nerve fibre density (P = .004) was significantly lower in patients with CKD compared with controls. There was no significant change in NSP, NDS, quantitative sensory testing, DB-HRV, nerve conduction or CCM parameters 24 months after renal transplantation. There is evidence of small and large fibre neuropathy in patients with CKD, but no change up to 24 months after successful renal transplantation.
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Affiliation(s)
- Maryam Ferdousi
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Shazli Azmi
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Alise Kalteniece
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Saif Ullah Khan
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | | | - Georgios Ponirakis
- Weill Cornell Medicine-Qatar, Research Division, Qatar Foundation, Doha, Qatar
| | - Uazman Alam
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Omar Asghar
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Andrew Marshall
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Handrean Soran
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Andrew J M Boulton
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Titus Augustine
- Department of Transplant and Endocrine Surgery, Central Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - Rayaz A Malik
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK.,Weill Cornell Medicine-Qatar, Research Division, Qatar Foundation, Doha, Qatar
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Takahashi K, Mizukami H, Osonoi S, Ogasawara S, Hara Y, Kudoh K, Takeuchi Y, Sasaki T, Daimon M, Yagihashi S. Inhibitory effects of xanthine oxidase inhibitor, topiroxostat, on development of neuropathy in db/db mice. Neurobiol Dis 2021; 155:105392. [PMID: 34000416 DOI: 10.1016/j.nbd.2021.105392] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/03/2021] [Accepted: 05/10/2021] [Indexed: 02/07/2023] Open
Abstract
Inflammation and oxidative stress contribute to the pathophysiology of diabetic neuropathy. According to recent evidence, the modulation of macrophage polarization in peripheral nerves represents a potential therapeutic target for diabetic neuropathy. Xanthine oxidase, which is a form of xanthin oxidoreductase, is the rate-limiting enzyme that catalyzes the degradation of hypoxanthine and xanthine into uric acid. Activation of xanthine oxidase promotes oxidative stress and macrophage activation. A preclinical study reported the beneficial effects of xanthine oxidase inhibitors on peripheral nerve dysfunction in experimental models of diabetes. However, the detailed mechanisms remain unknown. In this study, we examined the effect of the xanthine oxidase inhibitor topiroxostat on macrophage polarization and peripheral neuropathy in an obese diabetic model, db/db mice. First, the effects of xanthine oxidase inhibitors on cultured macrophages and dorsal root ganglion neurons exposed to xanthine oxidase were assessed. Furthermore, five-week-old db/db mice were administered the xanthine oxidase inhibitors topiroxostat [1 mg/kg/day (dbT1) or 2 mg/kg/day (dbT2)] or febuxostat [1 mg/kg (dbF)]. Glucose metabolism and body weight were evaluated during the experimental period. At 4 and 8 weeks of treatment, peripheral nerve functions such as nerve conduction velocities, thermal thresholds and pathology of skin and sciatic nerves were evaluated. The mRNA expression of molecules related to inflammation and oxidative stress was also measured in sciatic nerves. Untreated db/db mice and the nondiabetic db strain (db/m) were studied for comparison. An in vitro study showed that topiroxostat suppressed macrophage activation and proinflammatory but not anti-inflammatory polarization, and prevented the reduction in neurite outgrowth from neurons exposed to xanthine oxidase. Neuropathic changes exemplified by delayed nerve conduction and reduced intraepidermal nerve fiber density developed in db/db mice. These deficits were significantly prevented in the treated group, most potently in dbT2. Protective effects were associated with the suppression of macrophage infiltration, cytokine expression, and oxidative stress in the sciatic nerve and decreased plasma xanthine oxidoreductase activity. Our results revealed the beneficial effects of the xanthine oxidase inhibitor topiroxostat on neuropathy development in a mouse model of type 2 diabetes. The suppression of proinflammatory macrophage activation and oxidative stress-induced damage were suggested to be involved in this process.
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Affiliation(s)
- Kazuhisa Takahashi
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan; Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Hiroki Mizukami
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan.
| | - Sho Osonoi
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan; Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Saori Ogasawara
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Yutaro Hara
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan; Department of Gastroenterological Surgery and Pediatric Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Kazuhiro Kudoh
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Yuki Takeuchi
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan; Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Takanori Sasaki
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Makoto Daimon
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Soroku Yagihashi
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
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25
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Petropoulos IN, Ponirakis G, Ferdousi M, Azmi S, Kalteniece A, Khan A, Gad H, Bashir B, Marshall A, Boulton AJM, Soran H, Malik RA. Corneal Confocal Microscopy: A Biomarker for Diabetic Peripheral Neuropathy. Clin Ther 2021; 43:1457-1475. [PMID: 33965237 DOI: 10.1016/j.clinthera.2021.04.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/05/2021] [Accepted: 04/08/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE Diagnosing early diabetic peripheral neuropathy remains a challenge due to deficiencies in currently advocated end points. The cornea is densely innervated with small sensory fibers, which are structurally and functionally comparable to intraepidermal nerve fibers. Corneal confocal microscopy is a method for rapid, noninvasive scanning of the living cornea with high resolution and magnification. METHODS This narrative review presents the framework for the development of biomarkers and the literature on the use and adoption of corneal confocal microscopy as an objective, diagnostic biomarker in experimental and clinical studies of diabetic peripheral neuropathy. A search was performed on PubMed and Google Scholar based on the terms "corneal confocal microscopy," "diabetic neuropathy," "corneal sensitivity," and "clinical trials." FINDINGS A substantial body of evidence underpins the thesis that corneal nerve loss predicts incident neuropathy and progresses with the severity of diabetic peripheral neuropathy. Corneal confocal microscopy also identifies early corneal nerve regeneration, strongly arguing for its inclusion as a surrogate end point in clinical trials of disease-modifying therapies. IMPLICATIONS There are sufficient diagnostic and prospective validation studies to fulfill the US Food and Drug Administration criteria for a biomarker to support the inclusion of corneal confocal microscopy as a primary end point in clinical trials of disease-modifying therapies in diabetic neuropathy.
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Affiliation(s)
| | | | - Maryam Ferdousi
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Shazli Azmi
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Centre for Diabetes, Endocrinology and Metabolism, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Alise Kalteniece
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Adnan Khan
- Research Division, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Hoda Gad
- Research Division, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Bilal Bashir
- Centre for Diabetes, Endocrinology and Metabolism, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Andrew Marshall
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom; Clinical Neurophysiology, The Walton Centre, Liverpool, United Kingdom; Division of Neuroscience and Experimental Psychology, Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Andrew J M Boulton
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Centre for Diabetes, Endocrinology and Metabolism, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Handrean Soran
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Rayaz A Malik
- Research Division, Weill Cornell Medicine-Qatar, Doha, Qatar; Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom.
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26
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Bondugulapati LNR, Narayen N. Corneal confocal microscopy: potential usage in the context of diabetes mellitus. PRACTICAL DIABETES 2021. [DOI: 10.1002/pdi.2328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- LN Rao Bondugulapati
- Consultant Physician in Diabetes & Endocrinology, Endocrine Unit, Maelor Hospital, Wrexham, UK
| | - Nitesh Narayen
- Consultant Ophthalmologist, Cataract, Cornea and Refractive Surgeon, Director – Nvision Eye Care, Hyderabad, India
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27
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Celiker H, Erekul G, Turhan SA, Kokar S, Yavuz DG, Gunduz OH, Tavakoli M, Toker E. Early detection of neuropathy in patients with type 2 diabetes with or without microalbuminuria in the absence of peripheral neuropathy and retinopathy. J Fr Ophtalmol 2021; 44:485-493. [PMID: 33648764 DOI: 10.1016/j.jfo.2020.09.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Our goal is early detection of neuropathy in patients with type 2 diabetes with or without microalbuminuria in the absence of diabetic retinopathy and peripheral neuropathy by using in vivo corneal confocal microscopy (IVCCM). METHODS A total of 60 type-2 diabetic patients, assigned to either a diabetes mellitus (DM) with microalbuminuria group (DM/MA+, n=30) or a DM without microalbuminuria group (DM/MA-, n=30), and 30 age-matched control subjects were enrolled in this study. All cases underwent evaluation of blood glucose level, HbA1c, lipid fractions, body mass index (BMI), and corneal sensitivity (CS). Corneal nerve fiber length (NFL), nerve fiber density (NFD), nerve branch density (NBD), and tortuosity coefficient (TC) were quantified by IVCCM. None of the patients had peripheral neuropathy or retinopathy. RESULTS Compared with the healthy subjects, NFL and NFD were reduced in both diabetic groups (P<0.0001), while NBD was significantly reduced in the DM/MA+ group. Between the diabetic groups, NFL, NFD, and NBD were significantly higher in the DM/MA- group (all P's<0.001). CS was significantly lower in DM/MA+ compared with DM/MA- and controls (both P's<0.0001). NFD and NFL were inversely correlated with age, triglyceride level, and BMI. CONCLUSION These results indicate that significant damage to small nerves, quantified using IVCCM, can be detected in the absence of retinopathy, peripheral neuropathy or microalbuminuria in type 2 diabetic patients. The severity of corneal nerve involvement may further increase in the presence of nephropathy. This feature may also be valuable for early detection of microvascular complications of DM, allowing for the prevention of progression of life threatening microvascular complications.
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Affiliation(s)
- Hande Celiker
- Department of Ophthalmology, Marmara University School of Medicine, Istanbul, Turkey.
| | - Gozde Erekul
- Department of Ophthalmology, Marmara University School of Medicine, Istanbul, Turkey
| | - Semra Akkaya Turhan
- Department of Ophthalmology, Marmara University School of Medicine, Istanbul, Turkey
| | - Serdar Kokar
- Section of Pain Medicine, Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey
| | - Dilek Gogas Yavuz
- Section of Endocrinology and Metabolism, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Osman Hakan Gunduz
- Section of Pain Medicine, Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey
| | - Mitra Tavakoli
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Ebru Toker
- Department of Ophthalmology, Marmara University School of Medicine, Istanbul, Turkey
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28
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Adam S, Azmi S, Ho JH, Liu Y, Ferdousi M, Siahmansur T, Kalteniece A, Marshall A, Dhage SS, Iqbal Z, D'Souza Y, Natha S, Kalra PA, Donn R, Ammori BJ, Syed AA, Durrington PN, Malik RA, Soran H. Improvements in Diabetic Neuropathy and Nephropathy After Bariatric Surgery: a Prospective Cohort Study. Obes Surg 2021; 31:554-563. [PMID: 33104989 PMCID: PMC7847862 DOI: 10.1007/s11695-020-05052-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 10/10/2020] [Accepted: 10/13/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE There are limited data on the impact of bariatric surgery on microvascular complications of type 2 diabetes (T2D), particularly diabetic neuropathy. We assessed microvascular complications (especially neuropathy) in obese patients with T2D before and 12 months after bariatric surgery. MATERIALS AND METHODS This was a prospective observational cohort study. Measurements of neuropathy symptom profile (NSP), neuropathy disability score (NDS), vibration (VPT), cold (CPT) and warm (WPT) perception thresholds, nerve conduction studies (NCS) and corneal confocal microscopy (CCM) to quantify corneal nerve fibre density (CNFD), branch density (CNBD) and fibre length (CNFL); urinary albumin/creatinine ratio (uACR), estimated glomerular filtration rate (eGFRcyst-creat) and retinal grading were taken. RESULTS Twenty-six (62% female; median age 52 years) obese patients with T2D were recruited. Body mass index (BMI) (47.2 to 34.5 kg/m2; p < 0.001) decreased post-operatively. There were improvements in CNFD (27.1 to 29.2/mm2; p = 0.005), CNBD (63.4 to 77.8/mm2; p = 0.008), CNFL (20.0 to 20.2/mm2; p = 0.001), NSP (3 to 0/38; p < 0.001) and eGFRcyst-creat (128 to 120 ml/min; p = 0.015) post-bariatric surgery. Changes in (Δ) triglycerides were independently associated with ΔCNFL (β = - 0.53; p = 0.024) and Δsystolic blood pressure (β = 0.62;p = 0.017), and %excess BMI loss (β = - 0.004; p = 0.018) were associated with ΔeGFRcyst-creat. There was no significant change in NDS, VPT, CPT, WPT, NCS, uACR or retinopathy status. Glomerular hyperfiltration resolved in 42% of the 12 patients with this condition pre-operatively. CONCLUSION Bariatric surgery results in improvements in small nerve fibres and glomerular hyperfiltration in obese people with T2D, which were associated with weight loss, triglycerides and systolic blood pressure, but with no change in retinopathy or uACR at 12 months.
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Affiliation(s)
- Safwaan Adam
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- The Christie NHS Foundation Trust, Manchester, UK
| | - Shazli Azmi
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Jan H Ho
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Yifen Liu
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Maryam Ferdousi
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Tarza Siahmansur
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alise Kalteniece
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Andrew Marshall
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Shaishav S Dhage
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- The Christie NHS Foundation Trust, Manchester, UK
| | - Zohaib Iqbal
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Yvonne D'Souza
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Salim Natha
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Philip A Kalra
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Salford Royal NHS Foundation Trust, Salford, UK
| | - Rachelle Donn
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Basil J Ammori
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Salford Royal NHS Foundation Trust, Salford, UK
| | - Akheel A Syed
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Salford Royal NHS Foundation Trust, Salford, UK
| | - Paul N Durrington
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Rayaz A Malik
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Weill-Cornell Medicine-Qatar, Doha, Qatar
| | - Handrean Soran
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
- Manchester University NHS Foundation Trust, Manchester, UK.
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Early Detection of Diabetic Peripheral Neuropathy: A Focus on Small Nerve Fibres. Diagnostics (Basel) 2021; 11:diagnostics11020165. [PMID: 33498918 PMCID: PMC7911433 DOI: 10.3390/diagnostics11020165] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/14/2021] [Accepted: 01/20/2021] [Indexed: 02/07/2023] Open
Abstract
Diabetic peripheral neuropathy (DPN) is the most common complication of both type 1 and 2 diabetes. As a result, neuropathic pain, diabetic foot ulcers and lower-limb amputations impact drastically on quality of life, contributing to the individual, societal, financial and healthcare burden of diabetes. DPN is diagnosed at a late, often pre-ulcerative stage due to a lack of early systematic screening and the endorsement of monofilament testing which identifies advanced neuropathy only. Compared to the success of the diabetic eye and kidney screening programmes there is clearly an unmet need for an objective reliable biomarker for the detection of early DPN. This article critically appraises research and clinical methods for the diagnosis or screening of early DPN. In brief, functional measures are subjective and are difficult to implement due to technical complexity. Moreover, skin biopsy is invasive, expensive and lacks diagnostic laboratory capacity. Indeed, point-of-care nerve conduction tests are convenient and easy to implement however questions are raised regarding their suitability for use in screening due to the lack of small nerve fibre evaluation. Corneal confocal microscopy (CCM) is a rapid, non-invasive, and reproducible technique to quantify small nerve fibre damage and repair which can be conducted alongside retinopathy screening. CCM identifies early sub-clinical DPN, predicts the development and allows staging of DPN severity. Automated quantification of CCM with AI has enabled enhanced unbiased quantification of small nerve fibres and potentially early diagnosis of DPN. Improved screening tools will prevent and reduce the burden of foot ulceration and amputations with the primary aim of reducing the prevalence of this common microvascular complication.
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30
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Carmichael J, Fadavi H, Ishibashi F, Shore AC, Tavakoli M. Advances in Screening, Early Diagnosis and Accurate Staging of Diabetic Neuropathy. Front Endocrinol (Lausanne) 2021; 12:671257. [PMID: 34122344 PMCID: PMC8188984 DOI: 10.3389/fendo.2021.671257] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/17/2021] [Indexed: 12/14/2022] Open
Abstract
The incidence of both type 1 and type 2 diabetes is increasing worldwide. Diabetic peripheral neuropathy (DPN) is among the most distressing and costly of all the chronic complications of diabetes and is a cause of significant disability and poor quality of life. This incurs a significant burden on health care costs and society, especially as these young people enter their peak working and earning capacity at the time when diabetes-related complications most often first occur. DPN is often asymptomatic during the early stages; however, once symptoms and overt deficits have developed, it cannot be reversed. Therefore, early diagnosis and timely intervention are essential to prevent the development and progression of diabetic neuropathy. The diagnosis of DPN, the determination of the global prevalence, and incidence rates of DPN remain challenging. The opinions vary about the effectiveness of the expansion of screenings to enable early diagnosis and treatment initiation before disease onset and progression. Although research has evolved over the years, DPN still represents an enormous burden for clinicians and health systems worldwide due to its difficult diagnosis, high costs related to treatment, and the multidisciplinary approach required for effective management. Therefore, there is an unmet need for reliable surrogate biomarkers to monitor the onset and progression of early neuropathic changes in DPN and facilitate drug discovery. In this review paper, the aim was to assess the currently available tests for DPN's sensitivity and performance.
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Affiliation(s)
- Josie Carmichael
- Diabetes and Vascular Research Centre, National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, United Kingdom
| | - Hassan Fadavi
- Peripheral Neuropathy Group, Imperial College, London, United Kingdom
| | - Fukashi Ishibashi
- Internal Medicine, Ishibashi Medical and Diabetes Centre, Hiroshima, Japan
| | - Angela C Shore
- Diabetes and Vascular Research Centre, National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, United Kingdom
| | - Mitra Tavakoli
- Diabetes and Vascular Research Centre, National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, United Kingdom
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31
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Performance analysis of noninvasive electrophysiological methods for the assessment of diabetic sensorimotor polyneuropathy in clinical research: a systematic review and meta-analysis with trial sequential analysis. Sci Rep 2020; 10:21770. [PMID: 33303857 PMCID: PMC7730399 DOI: 10.1038/s41598-020-78787-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/12/2020] [Indexed: 12/13/2022] Open
Abstract
Despite the availability of various clinical trials that used different diagnostic methods to identify diabetic sensorimotor polyneuropathy (DSPN), no reliable studies that prove the associations among diagnostic parameters from two different methods are available. Statistically significant diagnostic parameters from various methods can help determine if two different methods can be incorporated together for diagnosing DSPN. In this study, a systematic review, meta-analysis, and trial sequential analysis (TSA) were performed to determine the associations among the different parameters from the most commonly used electrophysiological screening methods in clinical research for DSPN, namely, nerve conduction study (NCS), corneal confocal microscopy (CCM), and electromyography (EMG), for different experimental groups. Electronic databases (e.g., Web of Science, PubMed, and Google Scholar) were searched systematically for articles reporting different screening tools for diabetic peripheral neuropathy. A total of 22 studies involving 2394 participants (801 patients with DSPN, 702 controls, and 891 non-DSPN patients) were reviewed systematically. Meta-analysis was performed to determine statistical significance of difference among four NCS parameters, i.e., peroneal motor nerve conduction velocity, peroneal motor nerve amplitude, sural sensory nerve conduction velocity, and sural sensory nerve amplitude (all p < 0.001); among three CCM parameters, including nerve fiber density, nerve branch density, and nerve fiber length (all p < 0.001); and among four EMG parameters, namely, time to peak occurrence (from 0 to 100% of the stance phase) of four lower limb muscles, including the vastus lateralis (p < 0.001), tibialis anterior (p = 0.63), lateral gastrocnemius (p = 0.01), and gastrocnemius medialis (p = 0.004), and the vibration perception threshold (p < 0.001). Moreover, TSA was conducted to estimate the robustness of the meta-analysis. Most of the parameters showed statistical significance between each other, whereas some were statistically nonsignificant. This meta-analysis and TSA concluded that studies including NCS and CCM parameters were conclusive and robust. However, the included studies on EMG were inconclusive, and additional clinical trials are required.
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Pellegrini M, Sebastiani S, Tucci L, Giannaccare G, Moscatiello S, Laffi G, Pagotto U, Di Dalmazi G, Versura P. Association between alterations of corneal sub-basal nerve plexus analyzed with in vivo confocal microscopy and long-term glycemic variability. Eur J Ophthalmol 2020; 31:2294-2299. [DOI: 10.1177/1120672120964126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Purpose: The effect of long-term glycemic variability upon corneal sub-basal nerve plexus (CSNP) morphology analyzed by in vivo confocal microscopy (IVCM) has been poorly investigated in the setting of type 1 diabetes mellitus (T1DM). Our purpose was to analyze the association between morphometric parameters of CSNP and new markers of glycemic variability in a population of patients with T1DM. Methods: Forty patients with T1DM underwent: assessment of diabetic neuropathy (DN); analysis of subcutaneous advanced glycated end-products; IVCM scans of CSNP. The fully automated software ACCMetrics was employed to analyze IVCM images and calculate seven corneal nerve parameters. Data of diabetes duration, mean and standard deviation (SD) of either last-year and all-time glycated hemoglobin (HbA1C) were retrieved. Results: Diabetes duration and all-time SD of HbA1C were independently associated with CNFD (R = –0.26, p = 0.01; R = –0.27, p = 0.047 respectively), CNFL (R = –0.12; p = 0.01; R = –0.17, p = 0.01 respectively) and CNFrD (R = –0.001, p = 0.009; R = –0.002, p = 0.007 respectively). The analysis of the association among IVCM parameters and specific subtypes of DN showed that altered cold sensitivity was independently associated with CNFD (B = –0.24, p = 0.01), CNFL (B = –0.46, p = 0.01) and CNFrD (B = –28.65, p = 0.03). Conclusions: All-time SD of HbA1C and disease duration were found to be independent predictors of damage to CSNP in patients with T1DM.
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Affiliation(s)
- Marco Pellegrini
- Ophthalmology Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Stefano Sebastiani
- Ophthalmology Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
- Department of Ophthalmology, Infermi Hospital, Rimini, Italy
| | - Lorenzo Tucci
- Endocrinology Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giuseppe Giannaccare
- Ophthalmology Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
- Department of Ophthalmology, University of “Magna Graecia”, Catanzaro, Italy
| | | | - Gilberto Laffi
- Diabetes Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Uberto Pagotto
- Endocrinology Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
- Diabetes Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Guido Di Dalmazi
- Endocrinology Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Piera Versura
- Ophthalmology Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
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Zharkikh E, Dremin V, Zherebtsov E, Dunaev A, Meglinski I. Biophotonics methods for functional monitoring of complications of diabetes mellitus. JOURNAL OF BIOPHOTONICS 2020; 13:e202000203. [PMID: 32654427 DOI: 10.1002/jbio.202000203] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/02/2020] [Accepted: 07/04/2020] [Indexed: 06/11/2023]
Abstract
The prevalence of diabetes complications is a significant public health problem with a considerable economic cost. Thus, the timely diagnosis of complications and prevention of their development will contribute to increasing the length and quality of patient life, and reducing the economic costs of their treatment. This article aims to review the current state-of-the-art biophotonics technologies used to identify the complications of diabetes mellitus and assess the quality of their treatment. Additionally, these technologies assess the structural and functional properties of biological tissues, and they include capillaroscopy, laser Doppler flowmetry and hyperspectral imaging, laser speckle contrast imaging, diffuse reflectance spectroscopy and imaging, fluorescence spectroscopy and imaging, optical coherence tomography, optoacoustic imaging and confocal microscopy. Recent advances in the field of optical noninvasive diagnosis suggest a wider introduction of biophotonics technologies into clinical practice and, in particular, in diabetes care units.
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Affiliation(s)
- Elena Zharkikh
- Research & Development Center of Biomedical Photonics, Orel State University, Orel, Russia
| | - Viktor Dremin
- Research & Development Center of Biomedical Photonics, Orel State University, Orel, Russia
- School of Engineering and Applied Science, Aston University, Birmingham, UK
| | - Evgeny Zherebtsov
- Research & Development Center of Biomedical Photonics, Orel State University, Orel, Russia
- Optoelectronics and Measurement Techniques unit, University of Oulu, Oulu, Finland
| | - Andrey Dunaev
- Research & Development Center of Biomedical Photonics, Orel State University, Orel, Russia
| | - Igor Meglinski
- School of Engineering and Applied Science, Aston University, Birmingham, UK
- Optoelectronics and Measurement Techniques unit, University of Oulu, Oulu, Finland
- Interdisciplinary Laboratory of Biophotonics, National Research Tomsk State University, Tomsk, Russia
- Institute of Engineering Physics for Biomedicine (PhysBio), National Research Nuclear University-MEPhI, Moscow, Russia
- School of Life and Health Sciences, Aston University, Birmingham, UK
- Department of Histology, Cytology and Embryology, Institute of Clinical Medicine N.V. Sklifosovsky, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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Ocular surface diabetic disease: A neurogenic condition? Ocul Surf 2020; 19:218-223. [PMID: 33010441 DOI: 10.1016/j.jtos.2020.09.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 09/14/2020] [Accepted: 09/22/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE To investigate clinical and inflammatory changes in the ocular surface of insulin-dependent type I diabetic patients. METHODS Two hundred and nine eyes of 106 patients with diagnosis of type I diabetes were recruited in a prospective observational study. Ocular surface clinical assessment, corneal sensitivity and tear film stability tests were performed to evaluate ocular surface system function. Ocular Surface Disease Index (OSDI) questionnaire was administered to all enrolled subjects. Conjunctival impression cytology specimens were also collected to detect neuromediators and inflammatory molecules. Duration of disease, HbA1c levels and diabetic retinopathy stage were recorded. RESULTS Corneal sensitivity assessed by Cochet-Bonnet esthesiometer was reduced in patients with more chronic disease, higher HbA1c levels and proliferative diabetic retinopathy. Tear break-up time (TBUT) was reduced in subjects with long-standing diabetes or with more severe retinopathy. OSDI questionnaire scores showed direct correlation with increased HbA1c values. Significant increase of NPY, STAT-5 and ICAM-1 was found in diabetic patients compared to healthy controls. A direct correlation between NPY concentration and ICAM-1 values in patients with type I diabetes was demonstrated. CONCLUSIONS Patients with long-standing type I diabetes showed chronic inflammation of the ocular surface, due to neurogenic dysregulation of para-inflammatory homeostatic mechanisms. These patients with ocular surface system failure complained of ocular discomfort but had modest reduction of corneal sensitivity and no signs of neurotrophic keratopathy. Disease duration, increased HbA1c levels and severe diabetic retinopathy appear the most critical factors.
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Kudoh K, Mizukami H, Itabashi C, Fuke N, Osonoi S, Takeuchi Y, Wada K, Igawa A, Ogasawara S, Ishibashi Y, Hakamada K, Yagihashi S, Nakaji S. Lipopolysaccharide-binding protein is a distinctive biomarker of abnormal pain threshold in the general Japanese population. BMJ Open Diabetes Res Care 2020; 8:8/1/e001739. [PMID: 33099510 PMCID: PMC7590358 DOI: 10.1136/bmjdrc-2020-001739] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 09/01/2020] [Accepted: 09/07/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Small fiber neuropathy (SFN) is an early manifestation in diabetic polyneuropathy (DPN); however, the mechanisms are not fully understood. In diabetes, SFN is presumed to be common in individuals with overt DPN, enhancing activation of polyol pathway, oxidative stress, advanced glycation end products (AGEs), and inflammation. We explored the relationship between clinicohematological factors related to DPN and pain sensation in the Japanese population. RESEARCH DESIGN AND METHODS We conducted a population-based study, recruiting 1030 individuals (average age 54.4±0.5 years), in 2017, to participate in our Iwaki project. After initial screening by fasting blood glucose and glycohemoglobin A1c (HbA1c) measurements, the subjects were categorized into control (n=894), type 2 diabetes (n=81), and impaired fasting glucose (n=55) groups. Clinical data were gathered, and relationships between pain threshold from intraepidermal electrical stimulation (PINT) and DPN were examined by analysis of variance, post hoc test, and χ2 tests to study correlations among and between groups of the clinical data and DPN. RESULTS Univariate linear regression analyses showed significant correlations between PINT and serum lipopolysaccharide-binding protein (LBP) level (ß=0.1025, p=0.001). Adjustments for the clinical measurements confirmed a positive correlation (ß=0.070, p=0.034). Logistic regression analysis revealed high LBP value (>6.7 mg/dL) as a significant risk factor toward abnormal PINT (≥0.35 mA). LBP significantly correlated with the high-sensitivity C reactive protein, inflammation marker, elevated similarly in both pre-diabetic and overt-diabetic groups, compared with controls, but it did not correlate with a decreased Achilles tendon reflex. In contrast, urine 8-hydroxy-2'-deoxyguanosine, oxidative stress marker, and pentosidine, AGEs, markedly increased in individuals with type 2 diabetes with high HbA1c. CONCLUSIONS Individuals with high LBP exhibited an elevated PINT in the Japanese population. Low level of inflammation evoked by metabolic endotoxemia is possibly implicated in the pathophysiology of SFN from pre-diabetic stage.
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Affiliation(s)
- Kazuhiro Kudoh
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hiroki Mizukami
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Chieko Itabashi
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Nobuo Fuke
- Innovation Division, KAGOME Co, Ltd, Tochigi, Japan
| | - Sho Osonoi
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuki Takeuchi
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kanichiro Wada
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Akiko Igawa
- Department of Gastrointestinal Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Saori Ogasawara
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kenichi Hakamada
- Department of Gastrointestinal Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Soroku Yagihashi
- Department of Pathology and Molecular Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shigeyuki Nakaji
- Department of Social Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Corneal nerves in diabetes-The role of the in vivo corneal confocal microscopy of the subbasal nerve plexus in the assessment of peripheral small fiber neuropathy. Surv Ophthalmol 2020; 66:493-513. [PMID: 32961210 DOI: 10.1016/j.survophthal.2020.09.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 02/06/2023]
Abstract
The cornea's intense innervation is responsible for corneal trophism and ocular surface hemostasis maintenance. Corneal diabetic neuropathy affects subbasal nerve plexus, with progressive alteration of nerves' morphology and density. The quantitative analysis of nerve fibers can be performed with in vivo corneal confocal microscopy considering the main parameters such as corneal nerve fibers length, corneal nerve fibers density, corneal nerve branching density, tortuosity coefficient, and beadings frequency. As the nerve examination permits the detection of early changes occurring in diabetes, the invivo corneal confocal microscopy becomes, over time, an important tool for diabetic polyneuropathy assessment and follow-up. In this review, we summarize the actual evidence about corneal nerve changes in diabetes and the relationship between the grade of alterations and the duration and severity of the disease. We aim at understanding how diabetes impacts corneal nerves and how it correlates with sensorimotor peripheral polyneuropathy and retinal complications. We also attempt to analyze the safety of the most common surgical procedures such as cataract and refractive surgery in diabetic patients and to highlight the specific risk factors. We believe that information about the corneal nerve fibers' condition obtained from the in vivo subbasal nerve plexus investigation may be crucial in monitoring peripheral small fiber polyneuropathy and that it will help with decision-making in ophthalmic surgery in diabetic patients.
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Azmi S, Alam U, Burgess J, Malik RA. State-of-the-art pharmacotherapy for diabetic neuropathy. Expert Opin Pharmacother 2020; 22:55-68. [PMID: 32866410 DOI: 10.1080/14656566.2020.1812578] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The global epidemic of diabetes has led to an epidemic of diabetes complications. Diabetic neuropathy is the most common microvascular complication, of which diabetic peripheral neuropathy (DPN) and autonomic neuropathy (AN) are the most prevalent, affecting ~50% of patients. DPN results in pain with a poor quality of life and a loss of sensation with an increased risk of foot ulceration. Autonomic neuropathy can cause significant morbidity in a minority and is associated with increased mortality. The cornerstone of treatment to prevent or limit the progression of DPN/AN is multifactorial risk factor modification including treatment of glycemia, lipids and blood pressure. Whilst, there are no FDA-approved disease-modifying therapies, there are a number of therapies to relieve symptoms in DPN and AN. AREAS COVERED The authors discuss current approved therapies for painful diabetic neuropathy and autonomic neuropathy. They also address the potential role of improving risk factors to limit the development and progression of diabetic neuropathy and new pathogenetic and pain-relieving treatments. EXPERT OPINION The FDA-approved Pregabalin and Duloxetine over 25 years ago and Tapentadol, 6 years ago for painful diabetic neuropathy. There are currently no FDA-approved disease-modifying treatments for diabetic neuropathy which has been attributed to inappropriate models of the disease with limited translational capacity and major limitations of trial designs and endpoints in clinical trials.
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Affiliation(s)
- Shazli Azmi
- Institute of Cardiovascular Science, University of Manchester and Manchester NHS Foundation Trust , Manchester, UK
| | - Uazman Alam
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester , Manchester, UK.,Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool , Liverpool, UK.,Department of Diabetes and Endocrinology, Liverpool University Hospital NHS Foundation Trust , Liverpool, UK
| | - Jamie Burgess
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool , Liverpool, UK
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar , Doha, Qatar
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Petropoulos IN, Al-Mohammedi A, Chen X, Ferdousi M, Ponirakis G, Kemp H, Chopra R, Hau S, Schargus M, Vollert J, Sturm D, Bharani T, Kleinschnitz C, Stettner M, Peto T, Maier C, Rice ASC, Malik RA. The Utility of Corneal Nerve Fractal Dimension Analysis in Peripheral Neuropathies of Different Etiology. Transl Vis Sci Technol 2020; 9:43. [PMID: 32934893 PMCID: PMC7463182 DOI: 10.1167/tvst.9.9.43] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 08/10/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose Quantification of corneal confocal microscopy (CCM) images has shown a significant reduction in corneal nerve fiber length (CNFL) in a range of peripheral neuropathies. We assessed whether corneal nerve fractal dimension (CNFrD) analysis, a novel metric to quantify the topological complexity of corneal subbasal nerves, can differentiate peripheral neuropathies of different etiology. Methods Ninety patients with peripheral neuropathy, including 29 with diabetic peripheral neuropathy (DPN), 34 with chronic inflammatory demyelinating polyneuropathy (CIDP), 13 with chemotherapy-induced peripheral neuropathy (CIPN), 14 with human immunodeficiency virus-associated sensory neuropathy (HIV-SN), and 20 healthy controls (HCs), underwent CCM for estimation of corneal nerve fiber density (CNFD), CNFL, corneal nerve branch density (CNBD), CNFrD, and CNFrD adjusted for CNFL (ACNFrD). Results In patients with DPN, CIDP, CIPN, or HIV-SN compared to HCs, CNFD (P = 0.004-0.0001) and CNFL (P = 0.05-0.0001) were significantly lower, with a further significant reduction among subgroups. CNFrD was significantly lower in patients with CIDP compared to HCs and patients with HIV-SN (P = 0.02-0.0009) and in patients with DPN compared to HCs and patients with HIV-SN, CIPN, or CIDP (P = 0.001-0.0001). ACNFrD was lower in patients with CIPN, CIDP, or DPN compared to HCs (P = 0.03-0.0001) and in patients with DPN compared to those with HIV-SN, CIPN, or CIDP (P = 0.01-0.005). Conclusions CNFrD can detect a distinct pattern of corneal nerve loss in patients with DPN or CIDP compared to those with CIPN or HIV-SN and controls. Translational Relevance Various peripheral neuropathies are characterized by a comparable degree of corneal nerve loss. Assessment of corneal nerve topology by CNFrD could be useful in differentiating neuropathies based on the pattern of loss.
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Affiliation(s)
| | | | - Xin Chen
- School of Computer Science, University of Nottingham, Nottingham, UK
| | - Maryam Ferdousi
- Institute of Cardiovascular Science, University of Manchester, Manchester, UK
| | | | - Harriet Kemp
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Reena Chopra
- NIHR Moorfields Clinical Research Facility, Moorfields Eye Hospital, London, UK
| | - Scott Hau
- NIHR Moorfields Clinical Research Facility, Moorfields Eye Hospital, London, UK
| | - Marc Schargus
- Department of Ophthalmology, University Eye Hospital, Dusseldorf, Germany
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Division of Neurophysiology, Center of Biomedicine and Medical Technology Mannheim (CBTM), Medical Faculty Mannheim, Ruprecht-Karls University, Heidelberg, Germany
| | - Dietrich Sturm
- BG Universitätsklinikum Bergmannsheil GmbH, Department of Neurology, Ruhr University, Bochum, Germany
| | - Tina Bharani
- Division of Research, Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | - Mark Stettner
- Department of Neurology, Essen University Hospital, Essen, Germany
| | - Tunde Peto
- Queen's University Belfast, Belfast, Northern Ireland
| | - Christoph Maier
- BG Universitätsklinikum Bergmannsheil GmbH, Department of Pain Medicine, Ruhr University, Bochum, Germany
| | - Andrew S C Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Rayaz A Malik
- Division of Research, Weill Cornell Medicine-Qatar, Doha, Qatar
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Røikjer J, Mørch CD, Ejskjaer N. Diabetic Peripheral Neuropathy: Diagnosis and Treatment. Curr Drug Saf 2020; 16:2-16. [PMID: 32735526 DOI: 10.2174/1574886315666200731173113] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/04/2020] [Accepted: 06/16/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Diabetic peripheral neuropathy (DPN) is traditionally divided into large and small fibre neuropathy (SFN). Damage to the large fibres can be detected using nerve conduction studies (NCS) and often results in a significant reduction in sensitivity and loss of protective sensation, while damage to the small fibres is hard to reliably detect and can be either asymptomatic, associated with insensitivity to noxious stimuli, or often manifests itself as intractable neuropathic pain. OBJECTIVE To describe the recent advances in both detection, grading, and treatment of DPN as well as the accompanying neuropathic pain. METHODS A review of relevant, peer-reviewed, English literature from MEDLINE, EMBASE and Cochrane Library between January 1st 1967 and January 1st 2020 was used. RESULTS We identified more than three hundred studies on methods for detecting and grading DPN, and more than eighty randomised-controlled trials for treating painful diabetic neuropathy. CONCLUSION NCS remains the method of choice for detecting LFN in people with diabetes, while a gold standard for the detection of SFN is yet to be internationally accepted. In the recent years, several methods with huge potential for detecting and grading this condition have become available including skin biopsies and corneal confocal microscopy, which in the future could represent reliable endpoints for clinical studies. While several newer methods for detecting SFN have been developed, no new drugs have been accepted for treating neuropathic pain in people with diabetes. Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors and anticonvulsants remain first line treatment, while newer agents targeting the proposed pathophysiology of DPN are being developed.
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Affiliation(s)
- Johan Røikjer
- Department of Health Science and Technology, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | - Carsten Dahl Mørch
- Department of Health Science and Technology, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | - Niels Ejskjaer
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Fogagnolo P, Melardi E, Tranchina L, Rossetti L. Topical citicoline and vitamin B12 versus placebo in the treatment of diabetes-related corneal nerve damage: a randomized double-blind controlled trial. BMC Ophthalmol 2020; 20:315. [PMID: 32738875 PMCID: PMC7395393 DOI: 10.1186/s12886-020-01584-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 07/28/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND To evaluate the effects of topical citicoline and vitamin B12 (Cit-B12: OMK2, Omikron Italia srl, Italy) on corneal innervation of patients with diabetic neuropathy. METHODS This prospective, randomized, double blind, placebo-controlled study included 30 patients randomised with a 2:1 ratio to Cit-B12 or placebo 3 times daily for 18 months. At baseline and at months 4, 8, 12, 18 patients underwent the Ocular Surface Disease Index questionnaire (OSDI), tear break-up time, evaluation of corneal and conjunctival staining, Schirmer I test, Cochet-Bonnet esthesiometry, and confocal biomicroscopy of corneal sub-basal plexus (SBP). Fiber lenght density (FLD) was calculated using NeuronJ and expressed in mm/mm2. Raw data and differences from baseline were analysed in the two groups. RESULTS 29/30 patients concluded the study. The two groups had similar FLD at baseline; it progressively improved up to month 18 in both groups (Cit-B12, p < 0.0001; controls, < 0.0001-0.03); improvement at month 18 vs baseline was higher in Cit-B12 than placebo (33% vs 15%, p = 0.04). A progressive amelioration of corneal sensitivity (baseline, 28 ± 18 mm; month 18, 52 ± 10 mm, p < 0.0001), conjunctival staining (P = 0.04) and OSDI questionnaire (P = 0.05) were shown on Cit-B12 group alone. Both treatments were well tolerated and adherence during the study was high. CONCLUSIONS Cit-B12 ameliorated both morphology and function of corneal nerves in patients with diabetes, thus suggesting a neuroregenerative effect. TRIAL REGISTRATION Trial registration NCT03906513 , retrospectively registered on 08 April 2019.
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Affiliation(s)
- Paolo Fogagnolo
- Eye Clinic, Università degli Studi di Milano; ASST Santi Paolo e Carlo, San Paolo Hospital, Via di Rudini', 8, 20142, Milan, Italy.
| | - Ettore Melardi
- Eye Clinic, Università degli Studi di Milano; ASST Santi Paolo e Carlo, San Paolo Hospital, Via di Rudini', 8, 20142, Milan, Italy
| | - Laura Tranchina
- Eye Clinic, Università degli Studi di Milano; ASST Santi Paolo e Carlo, San Paolo Hospital, Via di Rudini', 8, 20142, Milan, Italy.,ASST Rhodense, Garbagnate Milanese Hospital, Milan, Italy
| | - Luca Rossetti
- Eye Clinic, Università degli Studi di Milano; ASST Santi Paolo e Carlo, San Paolo Hospital, Via di Rudini', 8, 20142, Milan, Italy
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Gad H, Al-Jarrah B, Saraswathi S, Petropoulos IN, Ponirakis G, Khan A, Singh P, Al Khodor S, Elawad M, Almasri W, Abdelrahman H, Elawwa A, Khalifa A, Shamekh A, Al-Khalaf F, Petrovski G, Al Zyoud M, Al Maadheed M, Hendaus MA, Hussain K, Akobeng AK, Malik RA. Corneal nerve loss in children with type 1 diabetes mellitus without retinopathy or microalbuminuria. J Diabetes Investig 2020; 11:1594-1601. [PMID: 32491258 PMCID: PMC7610109 DOI: 10.1111/jdi.13313] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/18/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022] Open
Abstract
Aims/Introduction Corneal confocal microscopy is a rapid, non‐invasive ophthalmic technique to identify subclinical neuropathy. The aim of this study was to quantify corneal nerve morphology in children with type 1 diabetes mellitus compared with age‐matched healthy controls using corneal confocal microscopy. Materials and Methods A total of 20 participants with type 1 diabetes mellitus (age 14 ± 2 years, diabetes duration 4.08 ± 2.91 years, glycated hemoglobin 9.3 ± 2.1%) without retinopathy or microalbuminuria and 20 healthy controls were recruited from outpatient clinics. Corneal confocal microscopy was undertaken, and corneal nerve fiber density (n/mm2), corneal nerve branch density (n/mm2), corneal nerve fiber length (mm/mm2), corneal nerve fiber tortuosity and inferior whorl length (mm/mm2) were quantified manually. Results Corneal nerve fiber density (22.73 ± 8.84 vs 32.92 ± 8.59; P < 0.001), corneal nerve branch density (26.19 ± 14.64 vs 47.34 ± 20.01; P < 0.001), corneal nerve fiber length (13.26 ± 4.06 vs 19.52 ± 4.54; P < 0.001) and inferior whorl length (15.50 ± 5.48 vs 23.42 ± 3.94; P < 0.0001) were significantly lower, whereas corneal nerve fiber tortuosity (14.88 ± 5.28 vs 13.52 ± 3.01; P = 0.323) did not differ between children with type 1 diabetes mellitus and controls. Glycated hemoglobin correlated with corneal nerve fiber tortuosity (P < 0.006) and aspartate aminotransferase correlated with corneal nerve fiber density (P = 0.039), corneal nerve branch density (P = 0.003) and corneal nerve fiber length (P = 0.037). Conclusion Corneal confocal microscopy identifies significant subclinical corneal nerve loss, especially in the inferior whorl of children with type 1 diabetes mellitus without retinopathy or microalbuminuria.
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Affiliation(s)
- Hoda Gad
- Medicine Department, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Bara Al-Jarrah
- Gastroenterology Department, Sidra Medicine, Doha, Qatar
| | | | | | | | - Adnan Khan
- Medicine Department, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Parul Singh
- Research Department, Sidra Medicine, Doha, Qatar
| | | | - Mamoun Elawad
- Gastroenterology Department, Sidra Medicine, Doha, Qatar
| | - Wesam Almasri
- Gastroenterology Department, Sidra Medicine, Doha, Qatar
| | | | - Ahmed Elawwa
- Endocrinology Department, Sidra Medicine, Doha, Qatar
| | - Amel Khalifa
- Endocrinology Department, Sidra Medicine, Doha, Qatar
| | - Ahmed Shamekh
- Endocrinology Department, Sidra Medicine, Doha, Qatar
| | | | | | | | | | | | | | | | - Rayaz A Malik
- Medicine Department, Weill Cornell Medicine-Qatar, Doha, Qatar.,Institute of Cardiovascular Medicine, University of Manchester, Manchester, UK
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Ponirakis G, Abdul-Ghani MA, Jayyousi A, Almuhannadi H, Petropoulos IN, Khan A, Gad H, Migahid O, Megahed A, DeFronzo R, Mahfoud Z, Hassan M, Al Hamad H, Ramadan M, Alam U, Malik RA. Effect of treatment with exenatide and pioglitazone or basal-bolus insulin on diabetic neuropathy: a substudy of the Qatar Study. BMJ Open Diabetes Res Care 2020; 8:8/1/e001420. [PMID: 32576561 PMCID: PMC7312325 DOI: 10.1136/bmjdrc-2020-001420] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/28/2020] [Accepted: 05/13/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION To assess the effect of exenatide and pioglitazone or basal-bolus insulin on diabetic peripheral neuropathy (DPN) in patients with poorly controlled type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS This is a substudy of the Qatar Study, an open-label, randomized controlled trial. 38 subjects with poorly controlled T2D were studied at baseline and 1-year follow-up and 18 control subjects were assessed at baseline only. A combination of exenatide (2 mg/week) and pioglitazone (30 mg/day) or glargine with aspart insulin were randomly assigned to patients to achieve an HbA1c <53 mmol/mol (<7%). DPN was assessed with corneal confocal microscopy (CCM), DN4, vibration perception and sudomotor function. RESULTS Subjects with T2D had reduced corneal nerves, but other DPN measures were comparable with the control group. In the combination treatment arm (n=21), HbA1c decreased by 35.2 mmol/mol (3.8 %) (p<0.0001), body weight increased by 5.6 kg (p<0.0001), corneal nerve branch density increased (p<0.05), vibration perception worsened (p<0.05), and DN4 and sudomotor function showed no change. In the insulin treatment arm, HbA1c decreased by 28.7 mmol/mol (2.7 %) (p<0.0001), body weight increased by 4.6 kg (p<0.01), corneal nerve branch density and fiber length increased (p≤0.01), vibration perception improved (p<0.01), and DN4 and sudomotor function showed no change. There was no association between the change in CCM measures with change in HbA1c, weight or lipids. CONCLUSIONS Treatment with exenatide and pioglitazone or basal-bolus insulin results in corneal nerve regeneration, but no change in neuropathic symptoms or sudomotor function over 1 year.
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Affiliation(s)
- Georgios Ponirakis
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
- Manchester Metropolitan University, Manchester, Greater Manchester, UK
| | | | - Amin Jayyousi
- Department of Diabetes and Endocrinology, Hamad Medical Corporation, Doha, Ad Dawhah, Qatar
| | | | | | - Adnan Khan
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Hoda Gad
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Osama Migahid
- Department of Diabetes and Endocrinology, Hamad Medical Corporation, Doha, Ad Dawhah, Qatar
| | - Ayman Megahed
- Department of Diabetes and Endocrinology, Hamad Medical Corporation, Doha, Ad Dawhah, Qatar
| | - Ralph DeFronzo
- University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ziyad Mahfoud
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Mona Hassan
- Department of Diabetes and Endocrinology, Hamad Medical Corporation, Doha, Ad Dawhah, Qatar
| | - Hanadi Al Hamad
- Department of Geriatrics and Long Term Care, Qatar Rehabilitation Institute, Doha, Qatar
| | - Marwan Ramadan
- Department of Geriatrics and Long Term Care, Qatar Rehabilitation Institute, Doha, Qatar
| | - Uazman Alam
- Aintree University Hospitals NHS Foundation Trust, Liverpool, Liverpool, UK
| | - Rayaz A Malik
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
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Tear Levels of IGFBP-3: A Potential Biomarker for Diabetic Nerve Changes in the Cornea. Eye Contact Lens 2020; 46:319-325. [DOI: 10.1097/icl.0000000000000700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Musiał M, Wiench R, Kolonko A, Choręza P, Niedzielski D, Machorowska-Pieniążek A, Skaba D, Więcek A, Owczarek A, Niedzielska I, Król R, Ziaja J. Simultaneously Transplanted Pancreas Improves Salivation and Reduces Oral Fungal Infections Incidence in Type 1 Diabetic Renal Transplant Recipients. Transplant Proc 2020; 52:2067-2073. [PMID: 32305203 DOI: 10.1016/j.transproceed.2020.01.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 01/22/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Long-lasting diabetes mellitus may lead to numerous pathologies in the oral cavity. The aim of the study was to assess the condition of the oral cavity, caries intensity, salivary parameters, and incidence of oral fungal infections in patients with type 1 diabetes (T1D) and end-stage renal disease (ESRD) after kidney transplantation (KTx) or simultaneous kidney and pancreas transplantation (SPK). METHODS Twenty-one patients after SPK, 18 T1D patients after KTx, and 14 kidney recipients without diabetes (control group) were included in the study. Donor sources complied with Helsinki Congress and the Declaration of Istanbul. RESULTS Approximal plague index in SPK (80% [68%-90%]) was comparable to KTx (80% [37.5%-92.5%]) but higher than in control group (46% [35%-50%]). All 3 groups did not differ in terms of decayed-missing-filled tooth index: 22.3 ± 4.8 vs 22.5 ± 4.5 vs 19.1 ± 4.9, respectively. Normal saliva resting secretion and consistency were more common in SPK (71.4% and 52%, respectively) than in KTx (27.8% and 50.0%, respectively). Stimulated saliva volume in the SPK, KTx and controls, pH value, and buffering capacity were comparable. In KTx higher incidence of Candida albicans infection (55.6%) compared with SPK (23.8%) and controls (no infection) was observed. CONCLUSIONS Simultaneously transplanted pancreas improves salivation and reduces the incidence of oral fungal infections in T1D kidney recipients. The severity of caries is higher and oral hygiene is worse in T1D kidney recipients compared with patients after KTx without diabetes.
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Affiliation(s)
- Mikołaj Musiał
- Department of Orthodontics, Medical University of Silesia, Katowice, Poland.
| | - Rafał Wiench
- Department of Periodontal Diseases and Oral Mucosa, Medical University of Silesia, Katowice, Poland
| | - Aureliusz Kolonko
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Piotr Choręza
- Department of Statistics, Department of Instrumental Analysis, Faculty of Pharmaceutical Sciences, Medical University of Silesia, Katowice, Poland
| | - Damian Niedzielski
- Department of Craniomaxillofacial Surgery, Medical University of Silesia, Katowice, Poland
| | | | - Dariusz Skaba
- Department of Periodontal Diseases and Oral Mucosa, Medical University of Silesia, Katowice, Poland
| | - Andrzej Więcek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Aleksander Owczarek
- Department of Statistics, Department of Instrumental Analysis, Faculty of Pharmaceutical Sciences, Medical University of Silesia, Katowice, Poland
| | - Iwona Niedzielska
- Department of Craniomaxillofacial Surgery, Medical University of Silesia, Katowice, Poland
| | - Robert Król
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
| | - Jacek Ziaja
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
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Rosenberger DC, Blechschmidt V, Timmerman H, Wolff A, Treede RD. Challenges of neuropathic pain: focus on diabetic neuropathy. J Neural Transm (Vienna) 2020; 127:589-624. [PMID: 32036431 PMCID: PMC7148276 DOI: 10.1007/s00702-020-02145-7] [Citation(s) in RCA: 128] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/19/2020] [Indexed: 02/07/2023]
Abstract
Neuropathic pain is a frequent condition caused by a lesion or disease of the central or peripheral somatosensory nervous system. A frequent cause of peripheral neuropathic pain is diabetic neuropathy. Its complex pathophysiology is not yet fully elucidated, which contributes to underassessment and undertreatment. A mechanism-based treatment of painful diabetic neuropathy is challenging but phenotype-based stratification might be a way to develop individualized therapeutic concepts. Our goal is to review current knowledge of the pathophysiology of peripheral neuropathic pain, particularly painful diabetic neuropathy. We discuss state-of-the-art clinical assessment, validity of diagnostic and screening tools, and recommendations for the management of diabetic neuropathic pain including approaches towards personalized pain management. We also propose a research agenda for translational research including patient stratification for clinical trials and improved preclinical models in relation to current knowledge of underlying mechanisms.
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Affiliation(s)
- Daniela C Rosenberger
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience (MCTN), Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Vivian Blechschmidt
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience (MCTN), Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Hans Timmerman
- Department of Anesthesiology, Pain Center, University Medical Center of Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - André Wolff
- Department of Anesthesiology, Pain Center, University Medical Center of Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Rolf-Detlef Treede
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience (MCTN), Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany.
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Coppey L, Davidson E, Shevalye H, Obrosov A, Torres M, Yorek MA. Progressive Loss of Corneal Nerve Fibers and Sensitivity in Rats Modeling Obesity and Type 2 Diabetes Is Reversible with Omega-3 Fatty Acid Intervention: Supporting Cornea Analyses as a Marker for Peripheral Neuropathy and Treatment. Diabetes Metab Syndr Obes 2020; 13:1367-1384. [PMID: 32425569 PMCID: PMC7189026 DOI: 10.2147/dmso.s247571] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/31/2020] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To determine whether cornea nerve fiber density and/or corneal function are valid markers for early detection and treatment of peripheral neuropathy in rats modeling prediabetes and type 2 diabetes. METHODS High-fat feeding combined without or with low-dose streptozotocin was used to create rat models for prediabetes and type 2 diabetes that were longitudinally studied for loss of structure and function of sensory nerves in the cornea and skin as well as nerve conduction velocity and vascular reactivity of epineurial arterioles. There were three time points examined in each of the three conditions with 12 rats per group. The latest time point (24 weeks of high-fat diet with or without 16 weeks of hyperglycemia) was used to examine reversibility of neuro and vascular pathology following 16 weeks of treatment with menhaden oil, a natural source of long-chain omega-3 polyunsaturated fatty acids. The number of rats in the intervention study ranged from 6 to 17. RESULTS Our longitudinal study demonstrated that vascular and neural dysfunction associated with obesity or type 2 diabetes occur early and are progressive. Decrease in cornea nerve fiber length and function were valid markers of disease in both the pre-diabetic and diabetic rat models and were more sensitive than decrease in intraepidermal nerve fiber density of the skin and thermal nociception of the hindpaw. Late intervention with menhaden oil significantly reversed both vascular and peripheral nerve damage induced by chronic obesity or type 2 diabetes. CONCLUSION These studies provide support for examination of corneal structure and function as an early marker of peripheral neuropathy in prediabetes and type 2 diabetes. Furthermore, we demonstrate that omega-3 polyunsaturated fatty acids derived from fish oil are an effective treatment for peripheral neuropathy that occurs with chronic obesity or type 2 diabetes.
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Affiliation(s)
- Lawrence Coppey
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Eric Davidson
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Hanna Shevalye
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Alexander Obrosov
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Michael Torres
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Mark A Yorek
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
- Department of Veterans Affairs, Iowa City Health Care System, Iowa City, IA, USA
- Veterans Affairs Center for the Prevention and Treatment of Visual Loss, Iowa City, IA, USA
- Fraternal Order of Eagles Diabetes Research Center, University of Iowa, Iowa City, IA, USA
- Correspondence: Mark A Yorek Department of Veterans Affairs, Iowa City Health Care System, Iowa City, IA52246Tel +1-319-338-0581 ext. 7696Fax +1-319-339-7162 Email
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Avetisov SE, Chernenkova NA, Surnina ZV, Akhmedzhanova LT, Fokina AS, Strokov IA. [Early diagnosis of diabetic polyneuropathy based on the results of corneal nerve fibers examination]. Vestn Oftalmol 2020; 136:155-162. [PMID: 33063958 DOI: 10.17116/oftalma2020136052155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
UNLABELLED Laser corneal confocal microscopy (CCM) is a method of objective visualization of thin corneal nerve fibers (CNF), the structure of which changes in patients with diabetes mellitus (DM). PURPOSE To conduct comparative analysis of the results of CNF assessment using CCM and other known neurological instrumental techniques as well as evaluate their applicability to the early diagnosis of diabetic polyneuropathy (DPN). MATERIAL AND METHODS We examined a total of 46 patients (85 eyes) with type 1 DM and either subclinical (24 patients), or clinical-stage DPN (22 patients) and 50 patients (87 eyes) with type 2 DM (subclinical DPN in 27 patients and clinical-stage DPN in 23 patients). The control group consisted of 34 healthy volunteers (68 eyes). All patients underwent standard ophthalmological examination, CCM with nerve tortuosity assessment (including calculation of coefficients of CNF orientation anisotropy, KΔL, and symmetry, Ksym) and interocular asymmetry, electroneuromyography (ENMG), and quantitative sensory testing (QST). RESULTS Analysis of the CCM results revealed a reliable decrease in the average KΔL values in patients with type 1 and type 2 DM compared with the control group. In the group of patients with type 1 DM and subclinical DPN, correlations were revealed between the CNF tortuosity coefficients and a number of ENMG parameters, such as the M-response amplitude of the peroneal nerve (r=0.73, p≤0.02), M-response amplitude of the tibial nerve (r=0.58, p≤0.01), residual latency (r= -0.62, p≤0.05), and peroneal nerve conduction velocity (r=0.57, p≤0.01). Ksym values correlated with the warm sensitivity threshold (r=0.6, p≤0.008). Among patients with type 2 DM and subclinical DPN, the KΔL coefficient correlated with the peroneal nerve conduction velocity (r=0.46, p≤0.02), M-response amplitude of the tibial nerve (r=0.6, p≤0.04), and residual latency of the peroneal nerve (r=-0.56, p≤0.05). CONCLUSION The state of thin corneal nerves correlates with functional changes in the peripheral nerves. Pathological changes in CNF in patients with DM can be detected at an early (subclinical) stage of DPN using laser CCM and a program for corneal nerve tortuosity analysis.
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Affiliation(s)
- S E Avetisov
- Research Institute of Eye Diseases, Moscow, Russia
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - N A Chernenkova
- Research Institute of Eye Diseases, Moscow, Russia
- Research Center of Neurology, Moscow, Russia
| | - Z V Surnina
- Research Institute of Eye Diseases, Moscow, Russia
| | - L T Akhmedzhanova
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - A S Fokina
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - I A Strokov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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C-Fiber Assays in the Cornea vs. Skin. Brain Sci 2019; 9:brainsci9110320. [PMID: 31718074 PMCID: PMC6896162 DOI: 10.3390/brainsci9110320] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/07/2019] [Accepted: 11/08/2019] [Indexed: 12/11/2022] Open
Abstract
C-fibers are unmyelinated nerve fibers that transmit high threshold mechanical, thermal, and chemical signals that are associated with pain sensations. This review examines current literature on measuring altered peripheral nerve morphology and discusses the most relevant aspects of corneal microscopy, especially whether corneal imaging presents significant method advantages over skin biopsy. Given its relative merits, corneal confocal microscopy would seem to be a more practical and patient-centric approach than utilizing skin biopsies.
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Abstract
PURPOSE The purpose of this study was to establish an age-dependent normative range and factors affecting the migration rate of the corneal subbasal nerve plexus in a healthy control population. METHODS Corneal nerve migration rate was measured in 60 healthy participants grouped by age: A, aged 20 to 39 years (n = 20); B, 40 to 59 years (n = 20); and C, 60 to 79 years (n = 20). Laser-scanning corneal confocal microscopy was performed on the right eye of all participants at baseline and again after 3 weeks. Fully automated software was used to montage the frames. Distinctive nerve landmarks were manually reidentified between the two montages, and a software program was developed to measure the migration of these landmark points to determine corneal nerve migration rate in micrometers per week (μm/wk). RESULTS The mean ± SD age of all participants in the study was 47.5 ± 15.5 years; 62% of participants were male. The average corneal nerve migration rates of groups A, B, and C were 42.0 ± 14.0, 42.3 ± 15.5, and 42.0 ± 10.8 μm/wk, respectively (P = .99). There was no difference in corneal nerve migration rate between male (41.1 ± 13.5 μm/wk) and female (43.7 ± 13.2 μm/wk) participants (P = .47). There was no significant correlation between age (P = .97), smoking (P = .46), alcohol use (P = .61), and body mass index (P = .49, respectively) with corneal nerve migration rate. However, exercise frequency correlated significantly (P = .04) with corneal nerve migration rate. CONCLUSIONS Corneal nerve migration rate varies in healthy individuals and is not affected by age, sex, or body mass index but is related to physical activity.
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Azmi S, Jeziorska M, Ferdousi M, Petropoulos IN, Ponirakis G, Marshall A, Alam U, Asghar O, Atkinson A, Jones W, Boulton AJM, Brines M, Augustine T, Malik RA. Early nerve fibre regeneration in individuals with type 1 diabetes after simultaneous pancreas and kidney transplantation. Diabetologia 2019; 62:1478-1487. [PMID: 31175373 PMCID: PMC6647173 DOI: 10.1007/s00125-019-4897-y] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 04/15/2019] [Indexed: 01/17/2023]
Abstract
AIMS/HYPOTHESIS The study aimed to assess the impact on neuropathy of simultaneous pancreas and kidney transplantation (SPK) in individuals with type 1 diabetes. METHODS This longitudinal observational study examined neuropathic symptoms, deficits, quantitative sensory testing, neurophysiology, corneal confocal microscopy and skin biopsy results in 32 healthy (non-diabetic) control participants, 29 individuals with type 1 diabetes and severe diabetic peripheral neuropathy [DPN] and 36 individuals with type 1 diabetes after SPK. RESULTS Following SPK, HbA1c, eGFR, triacylglycerols and HDL improved significantly (all p < 0.05). Compared with the DPN group, which remained unchanged over the 36 month study period, corneal confocal microscopy assessments improved over 36 months following SPK, with increasing corneal nerve fibre density of 5/mm2 (95% CI 1.8, 8.2; p = 0.003) and corneal nerve fibre length of 3.2 mm/mm2 (95% CI 0.9, 5.5; p = 0.006). The Neuropathy Symptom Profile and peroneal nerve conduction velocity also improved significantly by 36 months compared with DPN (2.5; 95% CI 0.7, 4.3; p = 0.008 and 4.7 m/s; 95% CI 2.2, 7.4; p = 0.0004, respectively), but with a temporal delay compared with the corneal confocal microscopy assessments. Intraepidermal nerve fibre density did not change following SPK; however, mean dendritic length improved significantly at 12 (p = 0.020) and 36 (p = 0.019) months. In contrast, there were no changes in the Neuropathy Disability Score, quantitative sensory testing or cardiac autonomic function assessments. Except for a small decrease in corneal nerve fibre density in the healthy control group, there were no changes in any other neuropathy measure in the healthy control or DPN groups over 36 months. CONCLUSIONS/INTERPRETATION SPK is associated with early and maintained small nerve fibre regeneration in the cornea and skin, followed by an improvement in neuropathic symptoms and peroneal nerve conduction velocity.
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Affiliation(s)
- Shazli Azmi
- Institute of Cardiovascular Sciences, University of Manchester and Central Manchester NHS Foundation Trust, Core Technology Facility, Grafton Street, Manchester, M13 9NT, UK
| | - Maria Jeziorska
- Institute of Cardiovascular Sciences, University of Manchester and Central Manchester NHS Foundation Trust, Core Technology Facility, Grafton Street, Manchester, M13 9NT, UK
| | - Maryam Ferdousi
- Institute of Cardiovascular Sciences, University of Manchester and Central Manchester NHS Foundation Trust, Core Technology Facility, Grafton Street, Manchester, M13 9NT, UK
| | - Ioannis N Petropoulos
- Department of Medicine, Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, Doha, Qatar
| | - Georgios Ponirakis
- Department of Medicine, Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, Doha, Qatar
| | - Andrew Marshall
- Department of Clinical Neurophysiology, Central Manchester NHS Foundation Trust, Manchester, UK
| | - Uazman Alam
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Omar Asghar
- Institute of Cardiovascular Sciences, University of Manchester and Central Manchester NHS Foundation Trust, Core Technology Facility, Grafton Street, Manchester, M13 9NT, UK
| | - Andrew Atkinson
- Institute of Cardiovascular Sciences, University of Manchester and Central Manchester NHS Foundation Trust, Core Technology Facility, Grafton Street, Manchester, M13 9NT, UK
| | - Wendy Jones
- Institute of Cardiovascular Sciences, University of Manchester and Central Manchester NHS Foundation Trust, Core Technology Facility, Grafton Street, Manchester, M13 9NT, UK
| | - Andrew J M Boulton
- Institute of Cardiovascular Sciences, University of Manchester and Central Manchester NHS Foundation Trust, Core Technology Facility, Grafton Street, Manchester, M13 9NT, UK
| | | | - Titus Augustine
- Department of Transplant and Endocrine Surgery, Central Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - Rayaz A Malik
- Institute of Cardiovascular Sciences, University of Manchester and Central Manchester NHS Foundation Trust, Core Technology Facility, Grafton Street, Manchester, M13 9NT, UK.
- Department of Medicine, Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, Doha, Qatar.
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