Diagnosis and Management of Diabetic Peripheral Neuropathy / 임상당뇨병

Diabetic peripheral neuropathy (DPN) is one of the most common complications of diabetes and is diagnosed as the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes. The prevalence of DPN was reported at 33.5% of type 2 diabetes patients by the Korean diabetes neuropathy study group. Early diagnosis is recommended to prevent diabetic foot ulcers, amputation, or disability. A questionnaire asking about symptoms and neurologic examination of feet is commonly used as a screening tool. However, complete diagnostic tests for DPN are not well established because of incomplete understanding of the pathogenetic mechanisms leading to the nerve injury, the various clinical manifestations, and the unclear natural history. Therefore, DPN has not been paid sufficient attention by clinicians. The roles of glycemic control and management of cardiovascular risk factors in the prevention and treatment of neuropathic complications are well known. Pathogenetically oriented or symptomatic agents are other options, though such treatments do not always produce a satisfactory outcome. Therefore, DPN remains a challenge for physicians to screen, diagnose, and treat. There have been recent advances in understanding the mechanisms underlying DPN and in the development of new diagnostic modalities and treatments. In this review, diagnosis and management of DPN will be discussed.

Multifocal Motor Neuropathy: Complementary Role of Ultrasound

Multifocal motor neuropathy (MMN) is an uncommon, asymmetric motor neuropathy. As MMN is a treatable disorder, its differentiation from lower motor neuron disease is important. Evidence of conduction block (CB) or positive IgM anti-GM1 is considered one of important markers for the diagnosis. However, some patients with atypical MMN have no detectable CB or anti-GM1 antibody. We experienced a case of MMN with focal nerve enlargement on ultrasound. Ultrasound can be a valuable tool in supporting the diagnosis of MMN.

The effectiveness of Beraprost sodium in elderly patients with diabetic peripheral neuropathy and its influence on serum nitric oxide and endothelin-1 levels / 中华老年医学杂志

Objective To evaluate the effectiveness of Beraprost sodium and its impact on vascular endothelial dysfunction in elderly patients with diabetic peripheral neuropathy (DPN).Methods A total of 86 elderly patients (age≥60 years) with DPN were recruited and randomly assigned into a control group (n=43) and a treatment group (n=43).Both groups received regular treatments including drug treatment such as glucose-lowering,lip-lowering,anti-platelet and neurotropic medications,and non-drug treatment measures such as smoking cessation and foot massage.In addition,the treatment group was given 40 μg oral Beraprost sodium three times a day for 90 days.Data on vibrating perception threshold (VPT),transcutaneous oxygen (tcpO2),ankle-brachial index (ABI),liver and kidney function,hemoglobin A1c (HbA1c),serum nitric oxide (NO) and endothelin-1 (ET-1) were collected before and after treatment.Results No adverse reaction was observed during the experiment.After 90-day treatment,both the control group and the treatment group showed decreased VPT values (F =23.06,195.13,both P ＜0.01),increased tcpO2 values (F =304.65,594.33,both P＜0.01),increased ABI (F=119.24,336.60,both P＜0.01),increased serum NOlevels (F =375.48,741.20,both P＜0.01),and decreased serum ET-1 levels (F=49.07,211.24,both P＜0.01).Compared with the control group,the value of VPT (F=25.16,P＜0.01)and the level of ET-1(F=61.83,P＜0.01) were significantly lower,while the level of NO and the values of tcpO2 and ABI were significantly higher (F =24.06,62.82,21.46,all P ＜ 0.01) in the treatment group.Conclusions Oral beraprost sodium can be effectively and safely used in DNP patients,and it can also alleviate endothelial dysfunction.

Clinical Observation of Wrist-ankle Acupuncture plus Bloodletting Cupping for Diabetic Peripheral Neuropathies / 上海针灸杂志

Objective To observe the clinical efficacy of wrist-ankle acupuncture plus bloodletting cupping in treating diabetic peripheral neuropathies (DPN). Method A total of 120 patients were randomized into two groups by using the random number table. Sixty cases in the treatment group were intervened by wrist-ankle acupuncture plus bloodletting cupping; sixty cases in the control group were treated with Mecobalamin tablets. The clinical efficacies were evaluated and electroneurogram was tested after 28-day treatment. Result The total effective rate was 95.0% in the treatment group versus 88.3% in the control group. The clinical efficacy of the treatment group was significantly superior to that of the control group (P<0.05). The treatment group was significantly better than the control group in comparing the major symptoms and signs including numbness, pain, and weakness in limbs (P<0.05); there were no significant between-group differences in comparing symptoms including cold limbs, short of breath and unwilling to speak, lassitude, and thirsty with desire to drink (P>0.05). The treatment group had better effect than the control group in comparing the motor conduction velocity of superficial peroneal nerve and sensory conduction velocity of common peroneal nerve (P<0.05). Conclusion Wrist-ankle acupuncture plus bloodletting cupping is effective in treating DPN, and it benefits the recovery of motor and sensory function of the impaired peripheral nerves.

Neurogenic Pain Disorder in the Foot and Ankle: Peripheral Neuropathy / 대한정형외과학회잡지

Most common peripheral neuropathy around foot and ankle is diabetic neuropathy, but there are another cause of peripheral neuropathy, such as rheumatoid arthritis, metabolic disease, genetic disease, toxic material, and so on. The main symptom of peripheral neuropathy is pain. The disturbance of sensory and balancing, weakness of muscle, deformity of foot and neuropathic arthropathy are also the symptoms of the peripheral neuropathy. History taking is most important to identify the cause of peripheral neuropathy. Neurological exam have to include the pin prick test, vibration test, 10 g-monofilamant test and ankle reflex test. Simple radiography is essential to observe the deformities or neuropathic arthropathy at foot and ankle. The presence of peripheral neuropathy, involvement and severity can be identified from nerve conduction study. The study of occlusive arteritis is essential for diabetic neuropathy. The medical treatment of associated disease is important but the pain of peripheral neuropathy should be controlled simultaneously. Medicine include the antidepressants, anticonvulsants, opioids and topical agents. The surgical treatment of peripheral neuropathy include lengthening of Achilles tendon, correction of deformity, the total contact cast and arthrodesis. Surgical decompression of specific nerve might helpful in pain control of peripheral neuropathy.

Polineuropatía asociada a infección por VIH. Revisión del tema ypresentación de un caso / Polyneuropathy associated to VIH infection. Review of the topic and case report

La infección por el virus de inmunodeficiencia humana (VIH) constituye un problema de salud pública. Laafectación neurológica en los pacientes infectados por el VIH es frecuente, involucrando tanto al sistema nerviosocentral como al periférico, y en algunos casos puede ser la primera manifestación de la infección. Entrelas afecciones neurológicas, las neuropatías periféricas pueden observarse en el 100% de las autopsias. Lasmismas pueden adoptar diferentes formas, que por lo general dependen de la fase de la enfermedad en la quese encuentre el paciente. Las neuropatías autoinmunes como el síndrome de Guillain-Barré y la polineuropatíadesmielinizante inflamatoria crónica (CIDP) aparecen en los estadios iniciales de la infección, cuando el conteode CD4 está ligeramente disminuido. La CIDP tiene criterios clínicos y electrofisiológicos bien definidos quela diferencian de otras formas de neuropatías periféricas, responde bien al tratamiento inmunomodulador,pero su diagnóstico puede ser difícil de realizar debido a su forma insidiosa de comienzo. Se realiza una breverevisión de las neuropatías periféricas que pueden asociarse a la infección por VIH y se presenta un caso deasociación de esta infección con CIDP.

Infection by Human Immune deficiency (VIH) is a public health problem. Neurological affection in those patients is frequent, it involve central and peripheral nervous system. In some cases neurological involvement is the first sign of the infection. Peripheral neuropathies are the most common of neurological illness associated to VIH infection; it could be observed in 100 % of autopsy. Autoimmune neuropathies like Guillain Barré and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) appear at initial phase of infection, when CD4 count is slight diminish. CIDP has defined clinic and electrophysiological criteria to differentiate it from other types of neuropathies, CIDP has a good response to immunomodulation treatment, it has an insidious start, which could difficult the diagnostic. We show a brief revision of peripheral neuropathic associated to VIH infection; we show a case with VIH infection and CIDP.

Chemotherapy-induced Peripheral Neuropathy and Depression in Cancer Patients

PURPOSE: The purpose of this study was to assess chemotherapy induced peripheral neuropathy (CIPN) and to examine the relationship between CIPN and depression. METHODS: A purposive sample of 105 patients treated with chemotherapy were recruited in the cross-sectional survey design. Data were collected using self-report questionnaires. The instruments used were the Chemotherapy Induced Peripheral Neuropathy Assessment Tool (CIPNAT) and Hospital Anxiety Depression Scale (HADS). RESULTS: The most frequent suffering symptom of CIPN was 'tingling feeling in the hand and foot'. Of the motor symptoms, 'muscle weakness' was the most frequent symptom and 'muscle or joint aches' was the strongest suffering symptom of CIPN. The mean score for suffering of CIPN was 4.1. The mean score was 1.04 for depression and the prevalence was 48.5%. CIPN was significantly positively correlated with depression (r=.38, p<.001). The result of simple regression analysis revealed that CIPN was predictive of depression (R2=.136, p<.001). CONCLUSION: Based on the findings of this study, nursing intervention programs focusing on CIPN management and alleviating depression are recommended.

Reliability and Validity of the Korean Version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire to Assess Chemotherapy-induced Peripheral Neuropathy

PURPOSE: This study was performed to assess the reliability and validity of the Korean version of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - Chemotherapy-induced peripheral neuropathy 20 items (EORTC QLQ-CIPN20) in patients receiving neurotoxic chemotherapy. METHODS: A convenience sample of 249 Korean cancer patients, previously or currently, being treated with peripheral neurotoxic chemotherapeutic agents were asked to fill in the questionnaire. Collected data were analyzed using SPSS 21.0 and AMOS 21.0. Construct validity, known-group validity, concurrent validity, and internal consistency reliability of the Korean version of the QLQ-CIPN20 were evaluated. RESULTS: Factor analysis confirmed 3 dimensions of CIPN: sensory, motor, and autonomic. The factor loadings of the 20 items on the 3 subscales ranged from .38 to .85. The 3 subscale-model was validated by confirmatory factor analysis (GFI=.90, AGFI=.86, RMSR=.05, NFI=.87, and CFI=.94), and concurrent validity was demonstrated with the EORTC QLQ-C30. Furthermore, the QLQ-CIPN20 established known-group validity. The Cronbach's alpha coefficients for internal consistency of the subscales ranged from .73 to .89. CONCLUSION: The Korean version of the EORTC QLQ-CIPN20 showed satisfactory construct, concurrent, and known-group validity, as well as internal reliability.

Current perception threshold and reaction time in the assessment of sensory peripheral nerve fibers through sinusoidal electrical stimulation at different frequencies

INTRODUCTION: The Perception Sensory Threshold (ST) for sinusoidal current stimuli at 5, 250, and 2,000 Hz is commonly used in the assessment of peripheral nerve fibers (C, Aδ, and Aβ, respectively). However, the neuroselectivity of these frequencies is far from consensus. In addition, Reaction Time (RT) measurements suggest that 2,000 Hz stimuli excite Aβ-fibers, 250 Hz Aβ- or Aδ-fibers, as well as 5 Hz Aβ-, Aδ- or C-fibers. Therefore, we suppose that the sinusoidal current neuroselectivity may be better observed if ST and RT parameters are jointly evaluated. In addition, we have investigated whether there are other sets of frequencies that could be used. METHODS: Thus this work investigates ST and RT for stimuli with frequency ranging from 1 to 3,000 Hz, on 28 healthy subjects aged from 19 to 44 years old (27.1±5.49). ST and RT dissimilarity among different frequencies was evaluated applying bi-dimensional Fisher Quadratic Discriminant. RESULTS: The lowest classification error (3.6%) was obtained for 1, 250, and 3,000 Hz. Error for 5, 250, and 2,000Hz was 16.7%. Stimulation frequency at 1 Hz evoked more sensations related to C-fibers (53% of reports) than to Aβ-fibers (36%). However, this behavior did not repeat itself at 5 Hz (only 21% of perceptions were related to C-fibers against 64% to Aβ-fibers). Sensations related to Aβ-fibers prevailed for the highest frequencies presented to the subjects (2,000 Hz - 82% and 3,000 Hz - 93%). Mean RT values showed a decreasing trend with frequency. CONCLUSION: These results suggest that frequencies 1, 250, and 3,000 Hz are more neuroselective than 5, 250, and 2,000 Hz for the evaluation of peripheral sensitive fibers. Furthermore, they show RT usefulness.

Chemotherapy-induced Peripheral Neuropathy and Quality of Life in Breast Cancer Patients

PURPOSE: This study was performed to identify the levels of paclitaxel-containing chemotherapy-induced peripheral neuropathy (CIPN) in relation to quality of life (QOL) in patients with breast cancer. METHODS: A total of 82 breast cancer patients with CIPN participated in this study. Data were collected through self-reported questionnaires containing three instruments by the European Organization for Research and Treatment of Cancer (EORTC), such as QLQ-C30 for health-related QOL, QLQ-BR23 for breast cancer-related QOL, and QLQ-CIPN20 for CIPN. Scores from all three instruments were transformed into 0 to 100 scale. Data were analyzed using SPSS/WIN20 with descriptive statistics and Pearson's correlations. RESULTS: The mean score for each subscale of health-related QOL was 46.14 for global health status, 62.43 for functional scale, and 31.29 for symptom scale. The mean score for each subscale of breast cancer-related QOL was 56.55 for the functional scale and 42.06 for the symptom scale. Also, the CIPN's mean score on the sensory scale was 30.42, 24.03 on the motor scale, and 22.70 on the autonomic scale. There were significant moderate correlations between QOLs and CIPN (r ranged from -.37 to .65). CONCLUSION: There is a need to develop interventions for breast cancer patients to enhance their quality of life and to alleviate chemotherapy-induced peripheral neuropathy.

The Effects of Foot Reflexology on Peripheral Neuropathy, Symptom Distress, Anxiety and Depression in Cancer Patients Treated with Oxaliplatin

PURPOSE: This study was done to clarify the effects of foot reflexology on peripheral neuropathy, symptom distress, anxiety and depression in cancer patients treated with oxaliplatin. METHODS: A quasi-experimental design was employed. Changes in the variables were evaluated to test the effects of foot reflexology. Participants were cancer patients treated with oxaliplatin (experimental group 14 and control group 17). Peripheral neuropathy, symptom distress, anxiety and depression were measured before and after reflexology. Data were collected from October, 2010 to April, 2011. chi2-test, Fisher's exact test, t-test, Wilcoxon signed rank test and the Mann-Whitney U test were used to analyze the data. RESULTS: The experimental group who received foot reflexology experienced less peripheral neuropathy and symptom distress than the control group. There was no difference in anxiety and depression between the experimental and control group. CONCLUSION: The foot reflexology program adopted in this study was found to be an effective method to reduce peripheral neuropathy and symptom distress. We recommend foot reflexology for patients with chemotherapy induced peripheral neuropathy.

Management of guillain-barré syndrome-an autoimmune disorder: A review.

Guillain-Barré syndrome is a disorder in which the body's immune system attacks part of the peripheral nervous system. The first symptoms of this disorder include varying degrees of weakness or tingling sensations in the legs. In many instances, the weakness and abnormal sensations spread to the arms and upper body. There is no known cure for Guillain-Barré syndrome, but therapies can lessen the severity of the illness and accelerate the recovery in most patients. There are also a number of ways to treat the complications of the disease. Currently, plasmapheresis and high-dose immunoglobulin therapy are used. Plasmapheresis seems to reduce the severity and duration of the Guillain-Barré episode. In high-dose immunoglobulin therapy, doctors give intravenous injections of the proteins that in small quantities, the immune system uses naturally to attack invading organism. The most critical part of the treatment for this syndrome consists of keeping the patient's body functioning during recovery of the nervous system. This can sometimes require placing the patient on a respirator, a heart monitor, or other machines that assist body function. The aim of present article is to provide in depth knowledge about Guillain-Barré syndrome which is no doubt, a rare autoimmune disorder. In this article the author has explained all the clinical aspects related to Guillain-Barré syndrome. This article presents a brief review of Guillain-Barré syndrome with an emphasis on its possible management and therapies.

HIV-associated neuromuscular weakness syndrome in Brazil: report of the two first cases

We describe two Brazilian patients with HIV-associated neuromuscular weakness syndrome (HANWS), a unique clinical toxic syndrome that was recently reported in developed countries. Both patients were women, used stavudine and had hyperlactatemia, one of them with lactic acidosis. Eletrophysiological studies were consistent with axonal neuropathy. After discontinuation of antiretroviral therapy the patients had significant improvement in neurologic manifestations, and normalization of lactate levels. To our knowledge, this is the first report of HANWS in developing countries. Growing use of antiretroviral therapy in this setting, particularly stavudine, make it likely that similar cases will be observed.

Os autores descrevem dois pacientes brasileiros com a síndrome da fraqueza neuromuscular associada ao HIV, uma síndrome tóxica, clínicamente particular, que foi recentemente relatada em países desenvolvidos. Ambas pacientes eram do sexo feminino, usavam estavudina e apresentaram hiperlactatemia, uma delas com acidose láctica. Os exames electrofisiológicos foram consistentes com neuropatia axonal. As pacientes melhoraram significativamente das alterações neurológicas, assim como normalizaram os níveis de lactato, após descontinuar o uso dos antiretrovirais. Até onde sabemos, este é o primeiro relato da síndrome de fraqueza neuromuscular associada ao HIV em países em desenvolvimento. Nesse contexto, o uso crescente de antiretrovirais, particularmente a estavudina, possibilitarão que casos similares sejam observados.

A pilot study on the effect of statins, fibrates and its combination in rat nerves

OBJECTIVE: To determine the histopathological effect of statins, fibrates and its combination in rat nervesMETHODOLOGY: This is a pilot experimental study. Four male albino rats were used in this study. Each rat was given therapeutic doses of simvastatin alone, gemfibrozil alone, gemfibrozil and simvastatin combination and placebo. On day 21, the sciatic nerve was harvested for histopathologic examinationRESULTS: Although not marked, the combination of simvastatin and gemfibrozil produced more axonal degeneration than did simvastatin alone or gemfibrozil alone. Axonal degeneration was documented on teased nerve fibers and epon cross sectionsCONCLUSION: The use of lipid lowering agents may induce peripheral neuropathy Recommendation: This pilot study serves as rationale to proceed with an experiment not only to document neuropathy but also correlate the possible association of the pathomechanism of myotoxicity and neurotoxicity of lipid lowering agents.

Relationship of plasma homocysteine and gene polymorphism of homocysteine metabolism related enzyme with diabetic peripheral neuropathy / 中华内分泌代谢杂志

Sixty cases of type 2 diabetes with diabetic peripheral neuropathy (DPN), 46 cases of type 2 diabetes without DPN and 50 healthy persons were recruited. Plasma homocysteine (Hcy), serum folic acid, vitamin B 12 levels and the mutations of Hcy metabolism related enzyme-methyhenetetrahydrofolate reductase (MTHFR) were assayed in individuals in this study. The results showed that high Hcy, low folic acid and vitamin B 12 levels are related with DPN in the patients with type 2 diabetes. The mutation of MTHFR C677T is associated with diabetes, but not with DPN.

The effects of cobamamide vs vitamin B12 in treating diabetic peripheral neuropathy(DPN) / 中国糖尿病杂志

92 type 2 diabetics with DPN were treated by cobamamide (n=46) vs vitamin B12 (n=46) for 4 weeks.Cobamamide improved the spontaneous pain, numbness of limbs, nerve reflection and nerve conduction velocities in higher rates as compared with vitamin B12 treatment, and did not cause obvious adverse reactions.