2,606 research outputs found

    Diabetic peripheral neuropathy : advances in diagnosis and strategies for screening and early intervention

    Get PDF
    Diabetic peripheral neuropathy (DPN) is a common complication of both type 1 and 2 diabetes. It is a leading cause of lower-limb amputation and disabling neuropathic pain. Amputations in patients with diabetes have a devastating effect on quality of life and are associated with an alarmingly low life expectancy (on average only 2 years from the amputation). Amputation also places a substantial financial burden on health-care systems and society in general. With the introduction of national diabetes eye screening programmes, the prevalence of blindness in working-age adults is falling. This is not the case, however, with diabetes related amputations. In this Review, we appraise innovative point-of-care devices that enable the early diagnosis of DPN and assess the evidence for early risk factor-based management strategies to reduce the incidence and slow the progression of DPN. We also propose a framework for screening and early multifactorial interventions as the best prospect for preventing or halting DPN and its devastating sequelae

    One-stop microvascular screening service: an effective model for the early detection of diabetic peripheral neuropathy and the high-risk foot.

    Get PDF
    AIMS: To evaluate the feasibility of a one-stop microvascular screening service for the early diagnosis of diabetic distal symmetrical polyneuropathy, painful distal symmetrical polyneuropathy and the at-risk diabetic foot. METHODS: People with diabetes attending retinal screening in hospital and community settings had their feet examined by a podiatrist. Assessment included: Toronto Clinical Neuropathy Score evaluation; a 10-g monofilament test; and two validated, objective and quick measures of neuropathy obtained using the point-of-care devices 'DPN-Check', a hand-held device that measures sural nerve conduction velocity and amplitude, and 'Sudoscan', a device that measures sudomotor function. The diagnostic utility of these devices was assessed against the Toronto Clinical Neuropathy Score as the 'gold standard'. RESULTS: A total of 236 consecutive people attending the retinal screening service, 18.9% of whom had never previously had their feet examined, were evaluated. The prevalence of distal symmetrical polyneuropathy, assessed using the Toronto Clinical Neuropathy Score, was 30.9%, and was underestimated by 10-g monofilament test (14.4%). The prevalence of distal symmetrical polyneuropathy using DPN-check was 51.5% (84.3% sensitivity, 68.3% specificity), 38.2% using Sudoscan foot electrochemical skin conductance (77.4% sensitivity, 68.3% specificity), and 61.9% using abnormality in either of the results (93.2% sensitivity, 52.8% specificity). The results of both devices correlated with Toronto Clinical Neuropathy Score (P<0.001). A new diagnosis of painful distal symmetrical polyneuropathy was made in 59 participants (25%), and 56.6% had moderate- or high-risk foot. Participants rated the service very highly. CONCLUSIONS: Combined, eye, foot and renal screening is feasible, has a high uptake, reduces clinic visits, and identifies painful distal symmetrical polyneuropathy and the at-risk foot. Combined large- and small-nerve-fibre assessment using non-invasive, quantitative and quick point-of-care devices may be an effective model for the early diagnosis of distal symmetrical polyneuropathy

    Corneal confocal microscopy for diagnosis of diabetic peripheral neuropathy: an analysis of patients with diabetes screened as part of the South Manchester Diabetic Retinopathy Screening Service

    Get PDF
    Background and Aims: Quantitative assessment of small nerve fibre damage is key to the early diagnosis of diabetic peripheral neuropathy (DPN) and assessment of its progression. Corneal confocal microscopy (CCM) is a non-invasive, in-vivo diagnostic technique that provides an accurate surrogate biomarker for small fibre neuropathy. Its diagnostic efficacy has been previously validated in several studies. This thesis uses CCM images obtained, for the first time, in a large cohort of patients whose CCM examinations were undertaken during retinopathy screening in primary care. The following were the primary aims of the study: 1. To determine the prevalence of diabetic peripheral neuropathy, as defined by CCM parameters in a cohort of people with diabetes 2.To assess whether abnormalities in corneal nerve fibre morphology are present during the first two years following diabetes diagnosis. 3. To assess whether abnormalities in corneal nerve morphology are present prior to any retinopathy, defined as grade 1 or more. 4. To assess whether abnormalities in corneal nerve morphology are present prior to clinical evidence of diabetic neuropathy, as defined by diabetic neuropathic symptom (DNS) scoring of 1 or more The hypotheses for these main aims were that firstly, the prevalence of diabetic peripheral neuropathy, defined using CCM parameters would be lower in this population in comparison to previous CCM studies using patients under the hospital eye service to determine prevalence of DPN. There will be evidence of abnormalities in corneal nerve fibre morphology in some, but not all, patients with diabetic disease duration of less than or equal to 2 years, patients with retinopathy and maculopathy grade 0 and patients with a DNS score of 0. Methods: In this retrospective, primary care, cross-sectional study, 427 patients with diabetes (18 T1DM, 407 T2DM, 2 unknown) and 40 healthy controls underwent quantification of corneal nerve parameters using both automated and semi-automated analysis software. Clinical levels of neuropathy were assessed via diabetic neuropathy symptom score (DNS). Diabetic Retinopathy (DR) was graded using the Early Treatment Diabetic Retinopathy Study (ETDRS) grading scale. Results: Patients with diabetes demonstrated significant differences in all nerve parameters in comparison to healthy control subjects (p0.05). There was no significant difference in any CCM parameters between white and black patients with diabetes (p>0.05). Automated software showed poor agreement with semi-automated results, with a general underestimation for CNFD, CNFL and CNBD. Conclusion: In patients attending primary care screening, CCM in a sensitive biomarker for DPN. Semi-automated CCM quantification reliably detected corneal nerve abnormalities soon after diagnosis of diabetes. Changes in corneal nerve morphology were present prior to any neuropathy symptoms or retinopathy. CCM measured using automatic software requires development to improve agreement with semi-automated analysis

    Foot complications in patients with diabetes

    Get PDF

    The evaluation of tactile dysfunction in the hand in type 1 diabetes: a novel method based on haptics

    Get PDF
    Aims We present an innovative method based on haptics for the evaluation of the sense of touch in the hand, in people affected by type 1 diabetes. Methods Forty individuals affected by diabetes and 20 healthy controls took part in the study; the diabetes group was further divided into two subgroups based on vibration sensitivity in the lower limb. By means of a novel haptic device, tactile sensitivity in the fingertip was measured as the ability of the participants to discriminate slip motion speed. Results Tactile sensitivity was significantly lower in individuals affected by diabetes as compared to controls. Depending on the subgroup, the difference from the controls was equal to 0.11 (95% CI from 0.029 to 0.186) and to 0.267 (95% CI from 0.198 to 0.336). Within the diabetes group, tactile sensitivity correlated with vibration sensitivity in the upper (p = 0.001) and lower limb (p = 0.003). A significant relationship between nerve conduction parameters and tactile sensitivity was found (p = 0.03). Finally, we combined the different predictors (clinical, vibratory and electroneurography data) by using cluster analysis; tactile sensitivity was found to be significantly different between different clusters (p = 0.004). Conclusions Early signs of tactile dysfunction in the hand were found in individuals affected by diabetes, even in absence of diabetic neuropathy. The protocol presented in this study is a promising tool for the assessment of tactile dysfunction in the hand in people affected by type 1 diabetes

    Diabetes mellitus type 2; The incretin effect and interaction with the autonomic nervous system

    Get PDF
    Bakgrunn: Inkretineffekten er kroppens evne til økt insulinsekresjon når glukose inntas peroralt sammenliknet med administrert intravenøst, utløst av spesifikke hormoner fra tarmen. En redusert inkretineffekt leder til forhøyet blodsukker etter måltid, og er et tidlig fenomen ved diabetes type 2, også påvist i forstadier til diabetes, såkalt prediabetes, og ved fedme. En bevart inkretineffekt ser delvis ut til å være avhengig av et intakt autonomt nervesystem. Autonom nevropati har vært betraktet som en sen komplikasjon til diabetes mellitus, men det er økende evidens for at nevropati også kan oppstå tidlig i forløpet. Kjennskap til disse faktorene ledet oss til en hypotese om at tidlig autonom nevropati kan bidra til den reduserte inkretineffekten ved diabetes type 2. Mål: Vårt primære mål var å undersøke om det var assosiasjon mellom inkretineffekt og grad av autonom nevropati. Sekundære mål var å se på inkretineffekten relatert til grad av hyperglykemi og varighet av diabetes, og sammenlikne en ny test som innebærer ballongdilatasjon i rektum, som mål for tarmens sensitivitet og videre signaloverføring, med mer etablerte tester for nevropati. Et siste sekundærmål var å undersøke gjennomførbarheten av en norsk versjon av spørreskjemaet, «Composite Autonomic Symptom Score» (COMPASS) 31, som kan påvise mulige symptomer fra autonom dysfunksjon, og vi testet om dette var assosiert med øvrige nerveundersøkelser. Metode: Tre grupper ble inkludert; en gruppe med diabetes type 2 varighet >10 år, en gruppe med nyoppdaget type 2 diabetes siste året, uten behov for medikamentell behandling, og en kontrollgruppe matchet for alder, kjønn og kroppsmasseindeks. Inkretineffekten ble kalkulert fra c-peptid (areal under kurven) ved oral glukosebelastning sammenliknet med intravenøs isoglykemisk glukose infusjon. Gastrointestinal glukose-håndtering (GIGD) ble kalkulert fra glukose gitt oralt sammenliknet med glukose tilført intravenøst. Tester for nevropati inkluderte kardiovaskulære reflekstester, hjertefrekvensvariabilitet, svettefunksjon, nerveledningshastighet i nervus suralis og monofilament test. Som mål på gastrointestinal visceral nervefunksjon utførte vi rektal ballongdilatasjon med registrering av trykk for første følelse av dilatasjon og ubehagelig følelse av dilatasjon. Evokerte hjernepotensial ble målt som respons på ballongdilatasjon ved gjentatte stimuli av nevnte trykk. Spørreskjemaet COMPASS 31 ble besvart digitalt. Resultat: Deltakerne med diabetes trengte høyere trykk for å oppnå første følelse av ballongdilatasjon i rektum, uavhengig av diabetesvarighet. Økt behov for trykk korrelerte med nedsatt GIGD, men ikke med inkretineffekt. Økt behov for trykk korrelerte også med nedsatt følelse på monofilament test. GIGD og inkretineffekt korrelerte signifikant med både grad av hyperglykemi og diabetesvarighet. Det ble funnet få tilfeller av nevropati totalt sett, og få forskjeller mellom gruppene. Det var en tendens til at lenger latenstid og mindre amplituder på evokerte hjernepotensial var assosiert med lavere hjertefrekvensvariabilitet og kardiovaskulære reflekstester, sural nerveledning og monofilament test, men ikke statistisk signifikant etter korreksjon for multippel testing. Høyere score på COMPASS 31 ble funnet hos dem med langvarig diabetes og hos kvinner, med best sensitivitet og negativ prediktiv verdi for score <10. Konklusjon: Vi fant rektal hyposensitivitet både ved langvarig og tidlig type 2 diabetes og dette var assosiert med redusert GIGD, men ikke med redusert inkretineffekt. Dette kan tyde på at adekvat nervefunksjon i tarmen er viktig for andre faktorer enn inkretineffekten i håndteringen av glukose. Redusert GIGD og inkretineffekt er assosiert med økende hyperglykemi og varighet av diabetes, som viser et kontinuum i tarmens glukosehåndtering fra normo- til hyperglykemi. Vi fant klinisk plausible tegn på at sentral nerveledning er assosiert med perifer nervefunksjon, men resultatene må tolkes med forsiktighet, gitt multippel testing. Rektal ballongdilatasjon med måling av sensitivitet og evokerte hjernepotensial synes å være en lovende metode for undersøkelse av nervefunksjon i tarmen, også når øvrige autonome tester er normale. Til sist finner vi spørreskjemaet COMPASS 31 lovende til bruk både i forskning, men også i den kliniske hverdag, hvor autonome symptomer ofte er neglisjert. I en liknende populasjon som vår vil en score på 10 poeng eller mindre nærmest utelukke kardiovaskulær autonom nevropati.Background: The incretin effect refers to the amplified insulin response when glucose is administered orally compared to intravenously. A reduced incretin effect is found at early stages of type 2 diabetes, even in prediabetes and obesity, but the mechanisms behind are unknown. Evidence suggests that part of the effect of incretin hormones are mediated through vagal nerve transmission. Diabetic autonomic neuropathy is considered a late complication of diabetes mellitus, but there is an increasing awareness that neuropathy can exist in both prediabetes and early stages of diabetes. This led us to the hypothesis that the incretin effect could be affected by early autonomic neuropathy because of a reduced transmission of signals. Aims: Our main objective was to explore whether a reduced incretin effect could be associated with autonomic neuropathy. Secondarily, we aimed to explore the incretin effect in relation to degree of dysglycemia and the duration of diabetes. Other secondary objectives were to explore a novel test of gut visceral sensitivity and central transmission of peripheral signals, and to compare it with established tests for diabetic neuropathy, including assessment of symptoms using the Composite Autonomic Symptom Score (COMPASS) 31. Methods: This was case-control study including three groups of participants: People with type 2 diabetes for >10 years (longstanding), people with newly discovered type 2 diabetes within the last year, without the need for antidiabetic medication (early), and a group of matched controls in age, sex, and body mass index. An oral glucose tolerance test followed by an intravenous isoglycemic glucose infusion were performed to calculate the incretin effect (from c-peptide area under the curve). Gastrointestinal-mediated glucose disposal (GIGD) was calculated as an estimate of the body’s ability to cope with the challenge of a carbohydrate ingestion. Neuropathy tests included cardiovascular reflex tests, heart rate variability, sudomotor function, sural nerve, and the monofilament test. Rapid rectal balloon distention measuring visceral sensitivity and evoked potentials was performed as a proxy for gut autonomic nerve function. The COMPASS 31 questionnaire was distributed and answered online. Results: Both groups of diabetes were hyposensitive to first sensation performing rapid rectal balloon distention. Also, those with reduced sensation performing the monofilament test showed hyposensitivity. A correlation was found between rectal hyposensitivity at the first sensation and reduced GIGD, but not with the incretin effect. Both GIGD and the incretin effect were found to correlate with degree of dysglycaemia and duration of diabetes, and were comparable to previous studies. Overall, few cases of confirmed neuropathy were detected, and there were few differences between groups regarding established neuropathy tests. Longer evoked potential latencies and smaller amplitudes plausibly correlated with lower heart rate variability and cardiovascular reflex test score, reduced parameters in the sural nerve test and monofilament sensation, but not statistically significant considering multiple testing. Higher scores in COMPASS 31 were correlated with longstanding diabetes and female sex. We found an acceptable negative predictive value for cardiovascular autonomic neuropathy at a 10-point cut-off . Conclusions: Rectal hyposensitivity may be an early manifestation of type 2 diabetes, and associated with GIGD, but not with the incretin effect. GIGD and the incretin effect are associated with degree of dysglycemia and duration of diabetes, indicating a continuum in the diminished effect. Central neuronal signal processing appears to be affected in parallel with peripheral neuronal function, but the results must be interpreted with caution. In general, we found that investigating evoked potentials following rapid rectal balloon distention may be a useful research tool for evaluating gut autonomic neuropathy, also when other autonomic neuropathy tests are normal. The Norwegian version of COMPASS 31 was easy to use and for assessing autonomic neuropathy in diabetes, and we suggest a cut off at ten points for screening purposes. Symptoms of autonomic neuropathy seems to be more frequent in people with longstanding diabetes and in women.Doktorgradsavhandlin

    Quantitative Tactile Examination Using Shape Memory Alloy Actuators for the Early Detection of Diabetic Neuropathy

    Get PDF
    Diabetic neuropathy (DPN) is asymptomatic in its early phases but can cause serious complications as it progresses. Most DPN tests are cumbersome and produce only qualitative assessments, and simpler approaches that yield quantitative results are needed. Techniques that allow patients to perform examinations themselves would be especially valuable. In this study, we focused on quantifying the decline in tactile sensation associated with DPN and developed a measurement device that used a thin shape memory alloy (SMA) wire as the actuator. An ON/OFF pulse current caused the wire to shrink and expand. This vibration was amplified by a round-headed pin, allowing even DPN patients with reduced tactile sensitivity to detect the stimuli generated when lightly touching the pin with their fingertips. The tactile stimuli were ranked into 30 levels of intensity. A key advantage of the device is that it can be used by patients themselves, returning quantified results within minutes. Although developed for DPN, the method can be applied to the detection of peripheral neuropathy in general

    Diabetic Foot Infections: Current Diagnosis and Treatment

    Get PDF
    Diabetes mellitus (DM) is a global epidemic, and diabetic foot ulcer (DFU) is one of its most serious and costly complications. DFUs result from a complex interaction of a number of risk factors. Once the protective layer of skin is broken, deep tissues are exposed to bacterial infection that progresses rapidly. Patients with DFUs frequently require amputations of the lower limbs and, in more than half the cases, infection is the preponderant factor. Given the challenges of treating these complex infections, this paper aims to provide a hospital-based framework for the diagnosis and treatment of diabetic foot infections (DFIs). We propose a treatment-oriented assessment of DFIs based on a cross-examination of the medical, foot, and wound history; a systemized and detailed physical examination; and the results of complementary diagnostic procedures. We stress the need for a clinical diagnosis of DFIs and the importance of microbiological evaluation for antibiotic therapy guidance. Regarding treatment, we propose a multidisciplinary approach prioritizing invasive infection drainage, necrosis debridement, and the prompt start of empirical antibiotic therapy, followed by complete and appropriate vascular reconstruction. For severe DFIs, we suggest that negative pressure wound therapy (NPWT) be included in the treatment pathway. We also provide rules for managing particular situations, such as osteomyelitis. It is our hope that this protocol will improve the hospital management of DFIs and, ultimately, the prognosis of DFI patients
    corecore