Differences between risk factors for falling in homebound diabetics and non-diabetics

The purpose of this study was to identify the differences in fall risk factors between diabetic and non-diabetic homebound adults in a population identified at high risk for falls. The sample compared 210 non-diabetic homebound adults to 74 diabetic homebound adults. Five research hypotheses supported this study. It was hypothesized that, 1) incidence and severity of somatosensory changes in the feet of diabetics surpassed that of non-diabetics; 2) incidence of lower leg and foot pain in diabetics surpassed that of non-diabetics; 3) deficits in sensory integration would be greater in diabetics than non-diabetics; 4) balance deficits were more evident in diabetics and non-diabetics; and 5) fear of falling was more prominent in diabetics than in non-diabetics. An one-way ANOVA showed a significant difference in sensation between groups, with diabetics reporting less sensation than non-diabetics in all age categories. A small effect size limited external validity. No other significant differences emerged for the other fall risk factors. Gender and age category failed to influence differences between diagnostic groups

A study on prevalence of peripheral neuropathy in patients with newly diagnosed diabetes mellitus and impaired glucose tolerance

The aim of the present study was to find the prevalence of peripheral neuropathy in patients with newly diagnosed diabetes mellitus and in impaired glucose tolerance. • Forty patients were selected in each of the three groups randomly from among patients attending the department of diabtology. The presence of neuropathy was assessed with the help of nerve conduction studies as well as symptoms and signs for the same. The patients were also assessed regarding the various risk factors that might be associated with the disease. • The prevalence of diabetic neuropathy was found to be 42.5% among newly diagnosed diabetics and 20% among patients with impaired glucose tolerance. • The risk factors found to be associated with neuropathy among new diabetics were BMI, blood pressure (both systolic and diastolic), postprandial blood sugar levels as well as HbA1c. • The risk factors associated with the neuropathy of impaired glucose tolerance were age, BMI, systolic blood pressure, fasting and postprandial blood sugar values as well as HbA1c values. • This study calls for early screening of newly diagnosed and impaired glucose tolerance patients for the presence of peripheral neuropathy

A Study of QTd as an indicator of Cardiac Autonomic Neuropathy in Type 2 Diabetes Mellitus

INTRODUCTION: Cardiac Autonomic Neuropathy (CAN) is often overlooked both in diagnosis and treatment simply because there is no widely accepted single approach to its diagnosis. Currently, Cardiovascular autonomic reflex tests (CART) are the gold standard for diagnosing CAN in persons with DM .It include four tests: (i) heart rate variation to deep breathing (ii) heart rate variation to Valsalva, (iii.) heart rate response to standing (30:15), and (iv) orthostatic hypotension. But these tests are cumbersome and not easy to perform in every patient. Therefore, there is a need of simple, non-invasive bed side test to detect early autonomic involvement in diabetes. AIMS AND OBJECTIVES: 1. To determine QTc maximum, QTc mean, QTc minimum QTc dispersion in Type2 diabetic patients. 2. Comparison of QTc maximum, QTc minimum, QTc dispersion, QTc mean in both study group and control group. 3. To study the significance of QTd as an indicator of CAN in Type 2 Diabetes mellitus. MATERIALS&METHOD: The study was conducted among patients from General Medicine wards of Government Rajaji Hospital, Madurai during the period of February 2016 to July 2016. The study included 100 cases of diabetes and 100 age and sex matched controls. Subjects believed to fulfill all eligibility criteria, and none of the exclusion criteria were included in the study. METHODOLOGY: A previously designed proforma was used to collect the demographic data, history and clinical details of the patients. A battery of five autonomic function tests are done in all cases to assess CAN. A score of 0-2 is assigned to each test. Based on the score obtained from the test, patients are divided in to three groups-severe, early and no CAN. A 12 lead ECG is taken after 10 minutes rest in all patients at 50 mm/second speed. RR interval, heart rate, QTc interval, QTc maximum, QTc minimum and QTc dispersion are calculated from the ECG. Comparisons of heart rate, QTc mean, QTc max, QTc min, QTc dispersion are made in various groups and controls and significance assessed by Students t test. Relation between age, sex, and autonomic neuropathy are assessed by Pearson correlation test. RESULTS: The average age for study group was 54 years. Among the 100 patients studied 55 were males and 45 females. Among the cases studied 62 had CAN .Of these 62, 44 had Grade 2(severe) CAN, 18 had Grade1(early) CAN .Mean heart rate was found to be high in diabetic patients compared to controls .Among the cases the heart rate was higher in those with severe CAN . QT mean ,QT minimum, QT maximum, QT dispersion was significantly more in patients with CAN than those without CAN and controls. Among those with CAN these were found to be significantly more in patients with Grade 2 CAN than those with Grade 1 CAN. CONCLUSION: Diabetics with CAN had significantly higher QTc mean, QTc maximum ,QTc minimum, QTc dispersion values compared to diabetics without CAN and controls

Profile of Electrocardiograph in Type 2 Diabetes Patients and Its Correlation to Cardiac Dysautonomia

INTRODUCTION: Diabetes mellitus is a multi-metabolic disorder that shares the common phenotype of hyperglycemia. Globally, Diabetes Mellitus is a major threat to human health. The number of people with Diabetes has increased alarmingly since 1985 and the rate of new cases is escalating. In 1985, an estimated 30 million people worldwide had diabetes; by 2003, it was estimated that approximately 194 million people had diabetes, and this figure is expected to rise to almost 350 million by 2025. Type 2 Diabetes is a major health problem in India. The WHO has highlighted that India currently holds the top spot for most no. of people with diabetes and would continue to hold the top position in future also. The estimated burden in India would be around 79.4 million by the year 2030. Autonomic dysfunction in diabetes is common. Abnormal cardiovascular test suggesting cardiovascular autonomic neuropathy is present in 16-40% of diabetic population. Patients with diabetic cardiac autonomic neuropathy are more prone for sudden cardiac death probably due to silent myocardial ischemia or infarction or due to primary malignant ventricular arrhythmias. The ECG, which reflects the electrical activity of heart, is liable to show abnormalities in diabetics more often than in non-diabetics by virtue of the more attendant factors that are more commonly seen in diabetics. In this context the factors that modify impulse generation, conduction, nervous control of heart, vascular supply of the myocardium, state of myocardium, all required to be considered individually. There is a higher prevalence of RBBB and AV block in diabetics that cannot accounted by the increased incidence of ischemic heart disease alone. Higher incidence of these blocks is seen independent of ischemic heart disease. Autonomic dysfunction is often asymptomatic. Hence diagnosing asymptomatic cardiac autonomic dysfunction, a precursor of symptomatic cardiac autonomic neuropathy will help in a long way in taking sufficient precaution to delay (or) arrest its progression by various measures. Recent observations noted that corrected QT interval (QTc) in surface ECG seems prolonged in diabetics with autonomic neuropathy and postulations are made that it may be one of the cause of sudden death or a compounding factor for the predisposition of malignant ventricular arrhythmias. This highlights the importance of simple noninvasive investigation like ECG in diagnosing asymptomatic cardiac autonomic dysfunction. This study is performed to study the various ECG abnormalities in type 2 Diabetic patients to estimate the prevalence of cardiac dysautonomia in type 2 Diabetic patients by various ECG markers and to compare with the age and sex matched controls. AIMS OF THIS STUDY: 1. To study the various ECG abnormalities in Type 2 Diabetes mellitus patients as compared to controls. 2. To study the prevalence of cardiac dysautonomia in type 2 diabetes mellitus patients by various ECG markers. MATERIALS AND METHODS: MATERIALS: Study Population: 1. Study group- 50 patients with type 2 diabetes mellitus. 2. Control group- 50 age and sex matched controls. Place of Study: Out patients department, Department of Medicine, Department of Diabetology, Stanley Medical College, Chennai-1. Period of Study: Feb 2008 to September 2009. METHODS: All the study population and controls were subjected for thorough physical examination. Blood samples were drawn and subjected to estimation of causal blood glucose and renal function tests. INCLUSION CRITERIA: Type 2 diabetes patients except the ones with the following exclusion criteria: EXCLUSION CRITERIA: 1. Age > 60 years, 2. Documented CAD/ischemic heart disease, 3. Documented valvular heart disease/congenital heart disease, 4. Hypertension, 5. Uremia, 6. Drugs-any drug which alters the sinus node impulse generation and AV conduction, 7. Features of hypo and hyperthyroidism, 8. Fever and features suggestive of infections, 9. Chronic obstructive pulmonary disease and other chronic lung disorders, 10. Parkinsonism and other movement disorders, 11. Dyselectrolytemia. RESULTS: 1. The mean resting heart rate of study (diabetics) group (84.2±12.86bpm) is significantly higher (p<0.05) than that of control group (75.2±10.65). 2. The R-R interval of study group (725.4±121.49msec) is significantly lower (p<0.05) than that of controls (815.4±114.41msec). 3. The PR interval of study group (162.4±11.67msec) is significantly (p<0.05) higher than that of control group (138.2±16.99msec). 4. The QRS duration is prolonged in study group (68.4±11.67msec) as compared to that of controls (65±8.69msec). But it is not statistically significant. (p>0.05). 5. The QRS axis of study group is more towards left (26.4±30.54 degrees) as compared to that of controls (67.6±27.82 degrees) which is statistically significant(p<0.05). 6. The QTc interval in study group (405.16±40.38 msec) is significantly prolonged (p<0.05) than the controls (365.38±25.3 msec). 7. The ECG changes of ischemia and infarction is significantly higher in the study group (26%&10% respectively) when compared to the control group (12%&6%). 8. Prevalence of asymptomatic heart disease in the study group (27.78%) is higher when compared to the control group (11.11%). 9. The prevalence of intraventricular conduction blocks in diabetics (8%) is higher than that of controls (2%). 10. 28% of study group have abnormal HRBD suggesting early parasympathetic dysfunction. 11. 6% of the study group show significant postural drop of SBP (>30 mm Hg) on standing which probably indicates sympathetic nervous system dysfunction. 12. There is a positive correlation between QTc prolongation and significant postural fall in SBP (>30 mm Hg). All the three patients had significant QTc prolongation. CONCLUSIONS: The following ECG manifestations were present in type 2 Diabetic patients compared to non-diabetic population. 1. High resting heart rate, 2. Prolongation of PR interval, 3. Increased prevalence of ischemia and infarction, 4. Increased incidence of asymptomatic IHD, 5. Left ward QRS axis, 6. No significant difference in QRS duration. Following manifestations suggestive of cardiac dysautonomia in type 2 Diabetics Were: 1. Abnormal HRBD≤10bpm, 2. Prolonged QTc interval (QTc>460 msec) in 8%, 3. Significant postural drop in SBP (>30 mm Hg) in 6%, 4. There is a positive linear correlation between QTc prolongation (QTc>460 msec) and postural drop on SBP (>30 mm Hg). Thus, the evaluation of various cardiovascular reflexes in type 2 diabetics gives an easy and feasible bedside technique to determine the presence of cardiac dysautonomia

Cutaneous vascular haemodynamics in diabetes mellitus.

In this thesis the laser Doppler flowmeter and other microvascular methods were used to investigate the skin microcirculation in non-diabetic and diabetic subjects in order to gain a greater understanding of the normal microcirculation and to define abnormalities relevant to the diabetic state. The principle findings were- 1. The normal skin microvascular response to thermal and mechanical injury is a substantial increase in blood flow. In diabetic subjects with and without complications this hyperaemic response was reduced and degree of impairment was found to be greatest in those with the severest complications. 2. In diabetic patients, the diameter of foot skin capillaries was reduced and the basement membrane width was found to increase progressively with increasing severity of complications. These structural changes may partly explain the reduced hyperaemic responses and their relationship with severity of complications. These structural and functional abnormalities may be implicated in the pathogenesis and impaired healing of diabetic foot lesions. 3. In normal subjects, blood flow in the toe pulp fell by 80% when the foot was lowered 50 cm below the heart. Toe blood flow in neuropathic diabetic subjects was three fold higher than in normal subjects, and on lowering the foot this difference was even greater; dependent flow was seven fold higher and the fall in blood flow was only 50%. These findings are compatible with reduced central sympathetic tone and/or peripheral sympathetic nerve failure. 4. In young non-neuropathic diabetic subjects, the more severe stress of sitting still for 50 minutes with the foot 1 meter below heart level, also revealed an increase in toe pulp blood flow. This was associated with elevated capillary pressure, failure in the expected rise in plasma osmotic pressure, and increased foot swelling. These results provide evidence of capillary hypertension and impairment of oedema preventing mechanisms in the dependent foot of diabetic subjects. These abnormalities may be important in initiating structural and functional damage to the skin microcirculation

Comparison of vascular and neurological parameters between diabetic subjects without diabetic foot ulceration or amputation and those with either foot ulceration or a lower extremity amputation : a pilot study

Background: It is likely that lower limb ulceration, lower limb amputation, or their absence in diabetic subjects, indicate varying degrees of long-term diabetes and its complications, and that measures of atherosclerosis and neuropathy would reflect these differences. Objectives: To determine feasibility and, based on our results, make sample size estimates for future study: By comparing peripheral and central vasculature between diabetic subjects with lower extremity ulcers, diabetic subjects with lower extremity amputation and a group of diabetics without these complications — through evaluating toe blood pressure (TBP), toe-brachial index (TBI) and pulse wave velocity (PWV); also, by comparing peripheral and autonomic nervous system integrity between these groups — through sensory, nerve conduction, needle-examination and autonomic function assessment. Study design: A cross-sectional, descriptive and comparative pilot study. Setting: Pretoria Academic Hospital. Participants: Three groups of ten patients consecutively selected from diabetes and diabetic foot clinics — ten with chronic lower extremity ulcers, ten with healed lower extremity amputations and ten diabetic controls. Methods: Assessment of peripheral and autonomic neuropathy included evaluation of 5.07/10-g monofilament sensation, vibration perception (using a 128Hz tuning fork), nerve conduction and electromyography, cutaneous autonomic response and heart rate variability (expressed as an Expiration: Inspiration (E:I)-ratio). For evaluation of vascular status, we obtained the photo-plethysmographically-derived TBI and assessed carotid-femoral (CF) and carotid-radial (CR) PWV. Sample sizes for future studies were calculated through a nomogram for three-group comparisons, ANOVA, simulation and log-transformation of non-parametric data. Results: Absence of vibration perception in at least one leg, with significant p-values of 0.000 at toe-, and 0.027 at medial malleolus- level, occurred more frequently in the amputation, than in the control group. For the total bilateral monofilament count a statistically significant difference between groups was demonstrated (p-value 0.043). Peripheral neuropathy based on abnormality of at least one conduction attribute in at least two distinct nerves, the E:I-ratio, assessment of cutaneous autonomic responses and TBI, by worsening across groups, seemed to display a correlation with severity of lower limb complications, but without statistically significant results. For CF- and CR PWV, the lowest values were observed in the amputation group. Sample size calculations based on our TBP, TBI, vibration and monofilament results, lead to a proposed equal group size of between 34 and 103 for future three-group comparisons using these outcomes measures. Should PWV be included, the group size would have to be between 160 and 222. Conclusions: This study confirmed the usefulness of monofilament sensation and vibration perception assessment in identifying diabetic patients with differing degrees of lower extremity risk. Also, due to the large differences between groups, it demonstrated the effectiveness of these measures to display differences between groups, even in the event of very small sample sizes. The tendencies to worsen across the three groups, of the E:I -ratio, peripheral neuropathy based on nerve conduction, and the TBI, will have to be re-examined in a study with larger sample size. In order to demonstrate statistically significant CF- and CR PWV results, a larger sample size may also be required.Dissertation (MSc (Clinical Epidemiology))--University of Pretoria, 2007.Clinical Epidemiologyunrestricte

Liquid crystal thermography in neuropathic assessment of the diabetic foot.

Primary aetiologic factors of diabetic foot disease include peripheral neuropathy and peripheral vascular disease. Assessment of circulation, neuropathy, and foot pressure is employed routinely to determine the risk of foot ulceration in the patient with diabetes mellitus. Routine neuropathic evaluation includes assessment of sensory loss in the plantar skin of the foot using both the Semmes Weinstein monofilament and the biothesiometer. Progressive degeneration of sensory nerve pathways is thought to affect thermoreceptors and mechanoreceptors. However, thermological measurements of the foot to assess responses to thermal stimuli and cutaneous thermal discrimination threshold are relatively uncommon. Recent improvements in liquid crystal technology (LCT) including insensitivity to pressure, faster response times, lower cost and fast image acquisition offer potential for routine thermographic assessment of the diabetic foot. The present study was designed to evaluate if an association exists between abnormal plantar thermal images and sensory loss under conditions of normal loading. The system comprises a robust measurement platform, thermochromic liquid crystal polyester sheet (TLC), instrumentation and analysis software. In vitro calibration was performed to characterise three physical forms of TLC on the basis of linearity, hysteresis, pressure sensitivity and response time. An in vivo pilot evaluation study of the system was performed using three sub-groups (i) neuropathic diabetic (n=30), (ii) non neuropathic diabetic (n=30) and (iii) a healthy control group (n=30). The principal results of this study indicate raised plantar temperatures for the diabetic groups at baseline and post stress relative to the control group. Furthermore, poor recovery response to thermal stimulus in the neuropathic diabetic group suggests degeneration of thermoreceptors. Thus by assessing the thermal parameters at the same sites as that of sensory testing, the new LCT based approach appears capable of providing an alternative confirmation of clinical neuropathy and offers potential as an improved method compared to existing techniques