Pittsburgh Epidemiology of Diabetes Complications Study. Measuring diabetic neuropathy follow-up study results

Complications of diabetes mellitus in childhood

Complications of diabetes include retinopathy, nephropathy, neuropathy, macrovascular disease, and associated autoimmune diseases. Clinical manifestations of complications uncommonly present in childhood and adolescence. Screening during the early years can identify subclinical disease and it offers an opportunity for early intervention. The Diabetes and Complications Control Trial has provided evidence for the long-term benefits of good glycemic control in preventing and delaying the onset of microvascular complications. Complications begin to manifest during adolescence, during which time all efforts should be made to educate and support young persons in achieving optimal diabetes control.

The meaning of distal sensory loss and absent ankle reflexes in relation to age

CONTEXT

Polyneuropathy is a common disease and is more prevalent (at least 3 %) in elderly people. However, routine neurological examination of healthy elderly people may show distal sensory loss and absent tendon reflexes, which can obscure the distinction from polyneuropathy.

OBJECTIVE

To investigate the relation between age and the prevalence of distal sensory loss, absent tendon reflexes, or muscle weakness, and to ascertain above which age these neurological signs could be considered as normal in ageing.

DATA SOURCES

PubMed, Embase, the Cochrane Library, and Current Contents from 1960 until 2004. Reference lists of relevant studies were searched for additional studies, reviews or textbooks.

STUDY SELECTION

Studies reporting on neurological signs upon routine neurological examination in generally healthy adult persons were considered for inclusion. Two reviewers independently assessed study eligibility and performed study inclusion. Of 629 studies initially identified, 50 (8 %) met the inclusion criteria.

DATA EXTRACTION

Two reviewers independently performed data extraction and assessed study quality based on study design and the rigour by which confounding co-morbidity was excluded.

DATA SYNTHESIS

The 50 included studies comprised a total of 9,996 adult persons. Assuming heterogeneity between studies, the prevalence data from different studies were pooled for separate age groups with a random-effects model. In healthy persons older than 60 years the prevalence of absent vibration sense at the big toes (29 % [95 % CI 18 % to 38%]) or ankles (15 % [95 % CI 11 % to 20%]), and absent ankle reflexes (23 % [95 % CI 16 % to 30 %]) was increased.

CONCLUSIONS

Self-declared healthy adult persons younger than 60 years do not have neurological signs. After the age of 60 absent vibration sense at the big toes or ankles, and absent ankle reflexes are more prevalent, although the majority does not have these neurological signs. It seems more appropriate to apply different diagnostic criteria for polyneuropathy in adult persons younger and older than 60 years.

Distal symmetrical polyneuropathy: a definition for clinical research. A report of the American Academy of Neurology, the American Association of Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation

The objective of this report was to develop a case definition of "distal symmetrical polyneuropathy" to standardize and facilitate clinical research and epidemiologic studies. A formalized consensus process was employed to reach agreement after a systematic review and classification of evidence from the literature. The literature indicates that symptoms alone have relatively poor diagnostic accuracy in predicting the presence of polyneuropathy; signs are better predictors of polyneuropathy than symptoms; and single abnormalities on examination are less sensitive than multiple abnormalities in predicting the presence of polyneuropathy. The combination of neuropathic symptoms, signs, and electrodiagnostic findings provides the most accurate diagnosis of distal symmetrical polyneuropathy. A set of case definitions was rank ordered by likelihood of disease. The highest likelihood of polyneuropathy (useful for clinical trials) occurs with a combination of multiple symptoms, multiple signs, and abnormal electrodiagnostic studies. A modest likelihood of polyneuropathy (useful for field or epidemiologic studies) occurs with a combination of multiple symptoms and multiple signs when the results of electrodiagnostic studies are not available. A lower likelihood of polyneuropathy occurs when electrodiagnostic studies and signs are discordant. For research purposes, the best approach to defining distal symmetrical polyneuropathy is a set of case definitions rank ordered by estimated likelihood of disease. The inclusion of this formalized case definition in clinical and epidemiologic research studies will ensure greater consistency of case selection.

Distal symmetrical polyneuropathy: Definition for clinical research

The objective of this report was to develop a case definition of "distal symmetrical polyneuropathy" to standardize and facilitate clinical research and epidemiological studies. A formalized consensus process was employed to reach agreement after a systematic review and classification of evidence from the literature. The literature indicates that symptoms alone have relatively poor diagnostic accuracy in predicting the presence of polyneuropathy; signs are better predictors of polyneuropathy than symptoms; and single abnormalities on examination are less sensitive than multiple abnormalities in predicting the presence of polyneuropathy. The combination of neuropathic symptoms, signs, and electrodiagnostic findings provides the most accurate diagnosis of distal symmetrical polyneuropathy. A set of case definitions was rank ordered by likelihood of disease. The highest likelihood of polyneuropathy (useful for clinical trials) occurs with a combination of multiple symptoms, multiple signs, and abnormal electrodiagnostic studies. A modest likelihood of polyneuropathy (useful for field or epidemiological studies) occurs with a combination of multiple symptoms and multiple signs when the results of electrodiagnostic studies are not available. A lower likelihood of polyneuropathy occurs when electrodiagnostic studies and signs are discordant. For research purposes, the best approach for defining distal symmetrical polyneuropathy is a set of case definitions rank ordered by estimated likelihood of disease. The inclusion of this formalized case definition in clinical and epidemiological research studies will ensure greater consistency of case selection.

Risks for sensorimotor peripheral neuropathy and autonomic neuropathy in non-insulin-dependent diabetes mellitus (NIDDM)

Identification of risk factors for development of diabetic sensorimotor peripheral neuropathy (DSPN) and diabetic autonomic neuropathy (DNA) may help to prevent or modify these complications. The ABCD Trial, a prospective study of diabetic complications, has identified risk factors of the presence and staging of peripheral neuropathy based on neurological symptom scores, neurological disability scores, autonomic function testing and quantitative sensory examination. DSPN is independently associated with diabetes duration [odds ratio (OR) = 1.5 per 10 years], body weight (OR = 1.1 per 5 kg), age (OR = 1.8 per 10 years), retinopathy (OR = 2.3), overt albuminuria (OR = 2.5), height (OR = 1.2 per 10 cm), duration of hypertension (OR = 1.1 per 10 years), insulin use (OR = 1.4), and race/ethnicity [African American vs. non-Hispanic white (OR = 0.4) and Hispanic vs. non-Hispanic white (OR = 0.8)]. DAN is independently associated with diabetes duration (OR = 1.2 per 10 years), body weight (OR = 1.1 per 5 kg), glycosylated hemoglobin (OR = 1.1 per 2.5%), overt albuminuria (OR = 1.6), and retinopathy (OR = 1.8).

Diabetic cystopathy presenting as primary acute urinary retention in a previously undiagnosed young male diabetic patient

Lower genito-urinary problems are part of the polyneuropathy of diabetes. Cystopathy affects 40%-85% of diabetic patients, although less than half are symptomatic. We report on a 42-year-old patient who was not known to be diabetic, and who presented to the urologists with primary acute urinary retention. His underlaying disease was detected by a test for random blood glucose. More common causes were excluded with careful clinical and radiological examinations. He was managed with insulin and self-catheterization. Diabetes should be considered as a differential diagnosis in relatively young men who present with unexplained acute urinary retention.

Factors associated with impaired vibration perception in Mauritians with normal and abnormal glucose tolerance. Mauritius NCD Study Group

Vibration perception threshold (VPT) was measured in 1185 Indian, Creole, and Chinese men and women in Mauritius, where the current prevalence of diabetes mellitus in adults aged 25-74 years is estimated to be 13%. Vibration perception threshold was measured using a biothesiometer, at seven sites in the hand, wrist, foot, and ankle, during a population survey in 76% of 574 known diabetic patients (KDM), 79% of 525 newly diagnosed diabetic patients (NDM), 18% of 1121 subjects with impaired glucose tolerance (IGT), and in 127 normal subjects. The association of VPT with glucose tolerance and other risk factors was assessed in order to identify individuals most at risk of foot ulceration and to determine whether risk factors and normal levels for VPT in these ethnic groups were consistent with those reported for Caucasians. After adjusting for age and height, geometric mean VPT at six of seven sites increased significantly with worsening glucose tolerance and increasing duration of diabetes in both men and women, VPT also increased significantly with level of fasting plasma glucose in men, but not women. Smoking and alcohol consumption had no effect on VPT, and body-mass index (BMI) was positively associated only at some sites. Chinese subjects had lower VPTs than Indians or Creoles. In multiple linear regression models, age, male gender, duration of diabetes, ethnic group, and height (lower extremity sites) were significantly associated with VPT among diabetic subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective study of sensory function in patients with type 2 diabetes

Sensory function was prospectively examined in 201 Type 2 diabetic patients over a 2-year period. Quantitative sensory testing for vibration, cool, warm, and pressure perception at the hallux was performed at baseline, 1-month, 1-year, and 2-year visits. There were statistically significant increments of thresholds for all sensory modalities from the baseline visit to the 1-year visit (p < 0.001) and from the 1-year visit to the 2-year visit (p < 0.001). Thirty percent of 77 subjects considered to be at low risk for foot ulceration at baseline progressed to a higher risk category at the 2-year visit. There were no significant differences in mean glycosylated haemoglobin, height, sex distribution, age, or diabetes duration when patients who had a faster progression of insensitivity were compared with patients who had a slower progression. There was a high degree of autocorrelation between baseline and 2-year visits for all sensory modalities (r = 0.83 to r = 0.88, p < 0.001 for all). Also, changes in sensory thresholds from the baseline to 2-year visits for one modality tended to correlate with other modalities (r = 0.36 to r = 0.70, p < 0.001 for all). These data indicate that an appreciable proportion of Type 2 diabetic patients are at risk for a marked rate of decline of sensory function, and suggest a need for at least yearly quantitative sensory testing.