Manejo racional de las neuropatías diabéticas: consenso multidisciplinario de expertos / Rational management of the diabetic neuropathies: a multidisciplinary expert group consensus

Resumen: La diabetes mellitus, un padecimiento crónico y progresivo, ocupó el tercer lugar en defunciones durante el período comprendido de enero a junio de 2021 en México. Su complicación crónica más frecuente es la neuropatía diabética que tiene un impacto importante en el sistema nervioso. En la Ciudad de México se reunió un grupo multidisciplinario de expertos para establecer un algoritmo de tratamiento que considere los aspectos sintomáticos y etiopatogénicos de la neuropatía diabética. Se utilizó un método Delphi en tiempo real con dos rondas de preguntas interactivas. La implementación del algoritmo propuesto permitirá abordar de manera integral al paciente diabético con neuropatía dolorosa y no dolorosa, tanto en el terreno de los síntomas como en la etiopatogenia. Este abordaje brinda la oportunidad de mejorar la calidad de vida y lograr la reinserción a la vida familiar y laboral. El panel de expertos recomienda al ácido tióctico como tratamiento etiopatogénico de primera línea en la neuropatía diabética.

Abstract: Diabetes mellitus, a chronic and progressive condition, was the third most common cause of death in Mexico between January and June 2021. Its most frequent chronic complication is diabetic neuropathy, which has a major impact on the nervous system. A multidisciplinary group of experts met in Mexico City to establish a treatment algorithm considering the symptomatic and etiopathogenic aspects of diabetic neuropathy. A real-time Delphi method with two rounds of interative questions was used. The implementation of the proposed algorithm will allow a comprehensive approach to the diabetic patient with painful and non-painful neuropathy, both in terms of symptoms and etiopathogenesis. This approach provides the opportunity to improve quality of life and achieve reintegration into family and work life. The expert panel recommends thioctic acid as the first line etiopathogenic treatment for diabetic neuropathy.

Early diagnosis of diabetic neuropathy and prophylaxis of diabetic foot / Diagnóstico precoce da neuropatia diabética e profilaxia do pé diabético

Introduction: the diabetic foot is one of the most serious complications of diabetes mellitus. About 50% of non-traumatic amputations occur in these patients. In addition, it is an important public health problem and constitutes a chronic and complex metabolic disorder that is characterized by impaired metabolism of glucose and other complications in essential organs for the maintenance of life. Objective: to evaluate the sensitivity and specificity of diabetic neuropathy using the Michigan self-assessment and physical examination in type 1 and type 2 diabetics. Methods: this is a cross-sectional study. The "Michigan Neuropathy Screening Instruments" classification was used to assess the degree of peripheral neuropathy, in which participants answered the questionnaire and were evaluated for the presence of foot lesions. All participants were stratified by the risk of developing foot ulcers according to the IWGDF protocol. Results: the sample had 200 participants. Regarding the IWGDF classification, 23 patients were classified as moderate risk (11.50%) and 61 as high risk for developing foot ulcers (30.50%). Using a cutoff of 2.5 on the physical examination score to diagnose neuropathy, a sensitivity of 97.62% and a specificity of 47.41% were obtained. Using a score greater than or equal to 6 in the self-assessment for the diagnosis of neuropathy, a sensitivity of 50.00% and a specificity of 94.83% were found. Conclusion: the association of the Michigan physical examination (high sensitivity) with self-assessment (high specificity) increases the accuracy for the diagnosis of diabetic neuropathy

Introdução: o pé diabético é uma das complicações mais sérias do diabetes mellitus. Cerca de 50% das amputações não traumáticas ocorrem nesses pacientes. Além disso, é um importante problema de saúde pública por ser um distúrbio metabólico crônico e complexo que se caracteriza pelo comprometimento do metabolismo da glicose associada a outras complicações em órgãos essenciais para manutenção vital. Objetivo: avaliar a sensibilidade e especificidade para neuropatia diabética da autoavaliação e do exame físico de Michigan nos diabéticos tipo 1 e tipo 2. Método: trata-se de um estudo transversal. Foi utilizada a classificação "Michigan Neuropathy Screening Instruments" para avaliação do grau de neuropatia periférica, em que os participantes responderam ao questionário e foram avaliados quanto a presença de lesões nos pés. Todos os participantes foram estratificados quanto ao risco de desenvolver úlcera nos pés de acordo com o protocolo do IWGDF. Resultados: a amostra contou com 200 participantes. Quanto à classificação do IWGDF, 23 pacientes foram classificados como risco moderado (11,50%) e 61 como alto risco para o desenvolvimento de úlceras nos pés (30,50%). Utilizando-se um corte de 2,5 na pontuação do exame físico para diagnosticar a neuropatia, foi obtida uma sensibilidade de 97,62% e uma especificidade de 47,41%. Utilizando-se uma pontuação maior ou igual a 6 na autoavaliação para o diagnóstico de neuropatia, foi obtida uma sensibilidade de 50,00% e uma especificidade de 94,83%. Conclusão: a associação do exame físico de Michigan (alta sensibilidade) com a autoavaliação (alta especificidade) tem melhor acurácia para o diagnóstico de neuropatia diabética.

Papel de la neuropatía diabética en la aparición y desarrollo del síndrome del pie diabético / Role of Diabetic Neuropathy in the Onset and Development of Diabetic Foot Syndrome

Introducción: La neuropatía diabética es la complicación más frecuente de la diabetes mellitus y una de sus posibles consecuencias es el síndrome del pie diabético. Los médicos del primer nivel de atención deben conocer el comportamiento clínico de la neuropatía diabética y, sobre todo, como influye en la aparición y desarrollo del síndrome del pie diabético. Objetivo: Describir el papel de la neuropatía diabética en la aparición y desarrollo del síndrome del pie diabético. Métodos: Para la obtención de la información se utilizaron como motores de búsqueda de información científica los correspondientes a Scielo, Pubmed, y Google Académico. Se usaron como palabras clave: diabetes mellitus; neuropatía diabética; pie diabético; síndrome de pie diabético; úlcera de pie diabético; ataque de pie diabético. Se evaluaron diferentes trabajos de revisión, investigación y páginas web, y se excluyeron los artículos que tuvieran más de 10 años de publicados, en idiomas diferentes al español, portugués e inglés y que no se refirieran al tema de estudio a través del título. Esto permitió la cita de 45 referencias bibliográficas. Conclusiones: La neuropatía diabética constituye el principal factor de riesgo en la aparición y desarrollo del síndrome del pie diabético, sobre todo cuando se asocia a artropatía (defectos podálicos), enfermedad vascular periférica y/o sepsis. El control de la glucemia, la detección temprana del pie de riesgo y el cuidado preventivo de los miembros inferiores, repercutirá favorablemente en la salud y bienestar del paciente(AU)

Introduction: Diabetic neuropathy is the most frequent complication of diabetes mellitus and one of its possible consequences is diabetic foot syndrome. First level of care physicians should know the clinical behavior of diabetic neuropathy and, above all, how it influences the appearance and development of diabetic foot syndrome. Objective: To describe the role of diabetic neuropathy in the appearance and development of diabetic foot syndrome. Methods: To obtain the information, SciELO, PubMed and Google Scholar were used as search engines for scientific information. The keywords used were: diabetes mellitus; diabetic neuropathy; diabetic foot; diabetic foot syndrome; diabetic foot ulcer; diabetic foot attack. Different review papers, research papers and web pages were evaluated and articles that were more than 10 years old and published in languages other than Spanish, Portuguese and English and that did not refer to the subject of the study through the title were excluded. This allowed the citation of 45 bibliographic references. Conclusions: Diabetic neuropathy constitutes the main risk factor in the appearance and development of diabetic foot syndrome, especially when associated with arthropathy (foot defects), peripheral vascular disease and/or sepsis. Glycemic control, early detection of the foot at risk and preventive care of the lower limbs will have a favorable impact on the patient's health and well-being(AU)

To evaluate peripheral neuropathy of ulnar sensory nerve through nerve conduction studies in Type 2 diabetic patients

Background: Secretory defects or defects in action of insulin precipitate a condition of chronic hyperglycemia known as diabetes mellitus, a metabolic disorder progressive in nature with long asymptomatic stage. Diabetic neuropathy is the most life threatening complication. Aims and Objectives: Early detection of peripheral neuropathy helps to take remedial measures in controlling the progression of the disease. Materials and Methods: Forty clinically detectable peripheral neuropathy Type 2 diabetic patients and 40 age-matched control subjects were selected for the study and nerve conduction test of ulnar sensory nerve was done and distal latency (DL), sensory nerve action potential (SNAP), and sensory nerve conduction velocity (SNCV) were recorded using RMS-EMG-EP-MAK II machine to predict the extent and type of neuropathy in diabetics. Results: Significant difference (P < 0.05) of DL, SNCV, and SNAP of ulnar sensory nerve was found in clinically detectable peripheral neuropathy group as compared to controls. Predominantly, axonal type (loss of amplitude) of neuropathy was present in study group. Conclusion: Electrophysiological variables of ulnar sensory nerve were affected in most of the subjects suggesting axonal loss and demyelinating changes in the nerve.

Role of NLRP3 inflammasome in diabetic neuropathy and prevention and treatment with traditional Chinese medicine / 中国中药杂志

As one of the most frequent complications of diabetes, diabetic neuropathy often involves peripheral and central nervous systems. Neuroinflammation is the key pathogenic factor of secondary nerve injury in diabetes. NOD-like receptor pyrin domain-containing 3(NLRP3) inflammasome is a group of subcellular multiprotein complexes, including NLRP3, apoptosis associated speck-like protein(ASC), and pro-cysteinyl aspartate specific proteinase 1(pro-caspase-1). NLRP3 inflammasome is an inducer of innate immune responses. Its activation stimulates the inflammatory cascade reaction, promotes the release of inflammatory mediators, triggers cell death and uncontrolled autophagy, activates glial cells, facilitates peripheral immune cell infiltration, and initiates amyoid β(Aβ)-tau cascade reactions. As a result, it contributes to the central nerve, somatic nerve, autonomic nerve, and retinal nerve cell damage secondary to diabetes. Therefore, due to its key role in the neuroinflammation responses of the body, NLRP3 inflammasome may provide new targets for the treatment of diabetic neuropathy. With multi-target and low-toxicity advantages, traditional Chinese medicine plays a vital role in the treatment of diabetic neuropathy. Accumulating evidence has shown that traditional Chinese medicine exerts curative effects on diabetic neuropathy possibly through regulating NLRP3 inflammasome. Although the role of NLRP3 inflammasome in diabetes and related complications has been investigated in the literature, systematical studies on drugs and mechanism analysis for secondary neuropathy are still lacking. In this article, the role of NLRP3 inflammasome in diabetic neuropathy was explored, and the research progress on traditional Chinese medicine in the treatment of diabetic neuropathy through NLRP3 inflammasome was reviewed.

A nonobstructive condition: Medial arterial calcification / 中南大学学报(医学版)

Vascular calcification, including intimal and medial calcification, is closely associated with a significant increase in cardiovascular diseases. Although increased understandings were achieved, people still know much more about intimal calcification than medial calcification because the latter doesn't obstruct the arterial lumen, commonly considered as a non-significant finding. We clarified the pathologic characteristic of medial calcification, its difference from intimal calcification, principally focused on its clinical relevance, such as diagnosis, nosogenesis, and hemodynamics. We underline the importance of identifying and distinguishing medial calcification, understanding its effect to local/systematic arterial compliance, and relationship to diabetic neuropathy. Recent studies emphasize do not ignore its predictive role in cardiovascular mortality. It is of great clinical significance to summarize the mechanisms of occurrence, lesion characteristics, diagnostic methods, pathogenic mechanisms, hemodynamic changes, and the distinction as well as association of intimal calcification with intimal calcification.

Correlación entre pie diabético y retinopatía diabética en pacientes del hospital provincial de Zaire, Angola

Introducción: La diabetes mellitus produce complicaciones, dentro de las cuales se describen la neuropatía diabética y la angiopatía diabética, que en presencia de estas puede llegarse a un cuadro de pie diabético sin dejar de mencionar la pérdida visual por retinopatía diabética. Objetivo: Determinar la correlación existente entre la aparición de pie diabético y la presencia o no de la retinopatía diabética en pacientes del Hospital Provincial "María Eugenia Neto", Zaire, República de Angola, en el período comprendido entre septiembre de 2020 a septiembre de 2022. Método: Se realizó un estudio descriptivo en 181 pacientes de la consulta de pie diabético del hospital antes dicho, donde se describieron variables, tales como: edad, sexo, enfermedades crónicas asociadas, presencia o no de retinopatía diabética, úlceras en miembros inferiores, amputación en miembros inferiores y años con diabetes. Se realizaron pruebas de correlación bivariable, se analizó el coeficiente de correlación de Pearson. Resultados: El promedio de edad fue de 59,3 años, predominó el grupo etario de más de 70 años (28,2 %) y el sexo femenino (57,5 %). Presentaron amputaciones previas un 41,8 % y úlceras un 40,1 %. Sin tratamiento estable el 65,19 %, correlación estadísticamente fuerte y significativa entre pie diabético y la retinopatía diabética. Conclusiones: Se evidencia una fuerte y significativa relación existente entre los pacientes portadores de pie diabético, los cuales pueden padecer determinado grado de retinopatía diabética, más frecuentes en el sexo femenino después de la sexta década de la vida, con los cuales presentan mayor tiempo de evolución de su enfermedad.

Introduction: Diabetes mellitus leads to many associated complications, including diabetic neuropathy and diabetic angiopathy, both with a high incidence in the onset diabetic foot and including also the diabetic retinopathy disease cause of blindness. Objective: Determine if there is any correlation between the onset diabetes foot and whether or not diabetic retinopathy present in patients treated at the Hospital Provincial, María Eugenia Neto, Zaire, Republic of Angola, from September 2020 to September 2020. Method: A descriptive study was carried out in 181 patients treated in the diabetic foot department of the aforementioned hospital; variables described were as follow: age, sex, associated chronic diseases, presence or absence of diabetic retinopathy, lower limb ulcers, limb amputation and years with diabetes. Bivariate correlation tests were performed, and the Pearson´s correlation coefficient was analyzed. Results: The average age was 59.3 years, the age group over 70 years (28.2%) and the female sex (57.5%) predominated. The 41.8% of patients presented previous amputations and 40.1% had ulcers. The 65.19% of patients had irregular treatment patterns, statistically strong and significant correlation between diabetic foot and diabetic retinopathy. Conclusions: There is evidence of a strong and significant relationship between patients with diabetic foot, who may suffer from a certain degree of diabetic retinopathy, more frequent in females after their sixth decade of life that cause a longer evolution of his disease.

Introdução: O diabetes mellitus produz complicações, dentre as quais são descritas a neuropatia diabética e a angiopatia diabética, que na presença destas podem levar ao quadro de pé diabético, sem falar na perda visual pela retinopatia diabética. Objectivo: Determinar a correlação existente entre o aparecimento de pé diabético e a presença ou ausência de retinopatia diabética em doentes do Hospital Provincial "María Eugenia Neto", Zaire, República de Angola, no período de setembro de 2020 a setembro de 2022. Método: Estudo descritivo realizado em 181 pacientes do ambulatório de pé diabético do referido hospital, onde foram descritas variáveis como: idade, sexo, doenças crônicas associadas, presença ou ausência de retinopatia diabética, úlceras de membros inferiores, amputação de membros inferiores e anos com diabetes. Foram realizados testes de correlação bivariada e analisado o coeficiente de correlação de Pearson. Resultados: A média de idade foi de 59,3 anos, predominando a faixa etária acima de 70 anos (28,2%) e o sexo feminino (57,5%). 41,8% tinham amputações anteriores e 40,1% tinham úlceras. Sem tratamento estável 65,19%, correlação estatisticamente forte e significativa entre pé diabético e retinopatia diabética. Conclusões: Existe evidência de uma relação forte e significativa entre os doentes com pé diabético, que podem sofrer de um certo grau de retinopatia diabética, mais frequente no sexo feminino a partir da sexta década de vida, com os quais apresentam maior evolução da sua doença.

A study of taste alterations in type 2 diabetes mellitus patients with a good glycemic control

Background: The increasing prevalence of type 2 diabetes mellitus (T2DM) and its complications pose a challenge to healthcare systems today, with a paucity of research examining the impact of T2DM on gustatory functions, especially in India. Aim and Objective: The objective of this study was to assess gustatory function in T2DM patients with good glycemic control and a disease duration ?5 years and compare it with the findings in normal individuals. Materials and Methods: This was a cross-sectional study with a sample size of 40, including patients and controls, aged 25–50 years. The Institute’s Ethics Committee clearance was taken, and written informed consent was obtained from the subjects. The evaluation of gustatory function was done using the triple drop test. Different concentrations of tastants were presented to the subjects. Scoring was done on the identification of increasing concentrations from “5” to “1.” Results: Taste scores for sweet, salty, sour, and bitter tastants were lesser in diabetic patients. This was statistically significant (P < 0.05). Conclusion: Taste impairment seems to affect diabetic patients relative to healthy controls. This could be an indication of central diabetic neuropathy. Hypogeusia in type 2 diabetic patients may influence the choice of nutrients such as an increased preference for sweet-tasting or salty foods, thus imposing health risks and affecting the quality of life.

Transient receptor potential vanilloid 1 (TRPV1) receptor stimulation by topical capsaicin for the functional assessment of diabetic neuropathy leading to diabetic foot disease

Objectives: As neuropathy predominates vasculopathy, predicting functional deterioration of autonomic neurovascular dysfunction is essential to reduce diabetic foot ulcers. The present study has evaluated the possibility of stimulating the TRPV1 receptors of the small fibres using topical capsaicin to assess diabetic neuropathy in the dorsum of the foot functionally. Materials and Methods: A prospective cross-sectional study was carried out on ten healthy volunteers and 20 diabetic patients after receiving ethical approval. The subjects underwent vascular Doppler analysis after giving written agreement followed by monofilament testing. Then, topical capsaicin was applied to measure the local autonomic neurovascular reaction. With the use of an infrared-based digital instrument that was specially created, the vasodilation and proportional increase in temperature brought on by the application of capsaicin were quantified. Results: The percentage change in the local temperature in the control group varied from 0.478 to 3.315 compared to the diabetic group, which varied from 1.862 to ?3.932. There is a statistically significant difference in the mean of the two groups (P = 0.006) at a 95% confidence interval. Conclusion: This study suggests that TRPV1 receptor stimulation using capsaicin and resultant vasodilation monitored by the increase in local temperature can be used as a quantitative predictor of the early small fibre neuropathy in Distal Symmetric Polyneuropathy before the patient ends up with diabetic foot ulcer.

Prevalence of Pain Conditions in Type 2 Diabetes Mellitus patient: A Cross Sectional Study

Background: Type-2 Diabetes mellitus (T2DM) is a metabolic disease characterized by hyperglycemia and may causes long term organs dysfunctions like retinopathy, nephropathy, neuropathy, cardiovascular and autonomic dysfunction. Musculoskeletal and nervous system can also be affected by T2DM resulting pain, dysfunctions and disabilities. Objectives: This study is to find the prevalence of different pain conditions in patients with T2DM.Material & Methods:The study was conducted in public and private hospitals of four cities (Brahmanbaria, Dhaka, Gazipur and Faridpur) of Bangladesh from 1st April to 31st September, 2021. The patients of type II diabetes mellitus with both gender and age above 40 were included, and patients with other active systemic disease of bones and soft tissues were excluded. A self-structured questionnaire was developed. The questionnaire was distributed among 500 patients, out of whom 450 patients responded. The non-probability convenient sampling technique was used for data collection. The data was analyzed by SPSS and percentages were calculated to estimate the musculoskeletal complications in patients with T2DM.Results:The result showed high prevalence of pain conditions in T2DM patients. Older age groups of 61-65 (24%) years suffering from T2DM for more than 3 years having higher bloodsugar level 17-19 mmol/L with positive family history of DM were affected mostly. The prevalence of musculoskeletal pain condition in T2DM was 71.11%, while the low back pain was (42.88%), frozen shoulder was 31.33%, diabetic neuropathy was (26.89%) were the most common musculoskeletal problems, followed by knee pain (17.33%). Conclusions:It is concluded that the prevalence of different pain conditions are high among patients of T2DM and low back pain, shoulder pain, peripheral neuropathy and knee pain are common. These are mostly manageable conservatively.

Comparative study of soleus H-reflex in normal humans and in patients with neuropathies

Background: The H-reflex derived its name from Hoffman. Hoffmann reflex is an electrically induced reflex analogous to the mechanically induced spinal stretch reflex. This measurement can be used to assess the response of the nervous system to various neurological conditions, musculoskeletal injuries, and application of therapeutic modalities, pain, exercise training, and performance of motor tasks. This simple and reproducible physiological response was studied to evaluate conduction along the course of the whole “final common pathway” from the moto neuron to the terminal axon as well as to gain some information regarding the function of large diameter group la afferent fibers supplying the muscle spindle. Aims and Objectives: The aim of the study was to compare the H-reflex latency between the normal person and in neuropathic patients. The study aimed to see whether there is any difference in H-reflex latency in the right leg of normal person and in neuropathic patients. The study aimed to see whether there is any difference in H-reflex latency in the left leg of normal person and in neuropathic patients. Materials and Methods: The study was conducted among 25 normal subjects and 25 neuropathic patients between 20 and 70 years of age from Nootan Medical College and Research Centre, Visnagar. The normal subjects were evaluated clinically to find their normal condition. The neuropathic patients which are included in study are of diabetic neuropathy, plexopathy, radiculopathy, vitamin deficiency, and Guillain Barre Syndrome. The patients who had bilateral neuropathy were included in the study. The study was conducted using mainly stimulator circuit, stimulating and recording electrodes, preamplifier, and oscilloscope. The software used for this experiment was RMS EMG EPMK II, one of the latest software with facilities for nerve conduction velocity, electromyography, F-wave, and H-reflex recording. Results: Out of the 50 participants, 25 participants who were suffering with any kind of neuropathy evaluated for their H-reflex latency in both leg. Patients with neuropathy showed higher latency in the right leg compared to the 25 participants in the control group in the right leg demonstrated significantly higher latency in the group with neuropathy. The 25 participants who were suffering with any kind of neuropathy evaluated for their H-reflex latency left leg compared to the 25 participants in the control group left leg demonstrated significantly higher latency in the group with neuropathy. Conclusion: The results show that there is an increase in the H-reflex latency in neuropathy patients as compared to normal subjects but it can be not used as a specific test for diagnosis of neuropathies, because the H-reflex latency may also change in normal subjects as the age of the persons is increases or the height of the persons increases but H-reflex latency can be used for the diagnosis of the proximal nerve root injuries as it mainly investigates the proximal nerve reflex arc.

Auditory brainstem response in type 2 diabetes mellitus patients

Background: Diabetes is a chronic metabolic disorder and its complications pose a significant healthcare burden. Basic pathophysiology of diabetic complications is angiopathy leading to neuropathy. Angiopathy of small vessels of cochlea and neuropathy of cochlear nerve may lead to hearing impairment. Aim and Objectives: The present study was taken up with an objective to evaluate the changes in the auditory brainstem evoked potentials in type 2 diabetic patients leading to hearing loss compared to healthy controls. Materials and Methods: A total of 40 subjects in the age group of 40–60 were enrolled into the study and were categorized into 2 groups of 20 each. In the Group 1, age- and sex-matched healthy controls were included and in the Group 2 subjects with type 2 diabetes of more than 5 years duration were included in the study. Any hearing impairment caused by a known disease, drug or injury either traumatic, iatrogenic or noise induced were excluded from the study. They were subjected to auditory brainstem response test Brainstem evoked response audiometry. Absolute latency of wave I-V and interpeak latencies (IPL) I-III, III-V, and I-V was recorded. The data obtained were evaluated using VassarStats. Results: There was no significant difference in the wave latency of wave I and II between the groups; however, the latencies of waves III, IV, and V was higher in the diabetic group compared to controls on both right and left ear stimulation and it was statistically significant. With respect to the IPL comparison, it was observed that IPL I-III, III-V, and I-V were significantly increased in diabetics with both right and left ear stimulation were statistically significant on comparison with the controls. Conclusion: The delayed transmission of the auditory pathway at the level of brainstem and midbrain observed in the study advocates the presence of central neuropathy in patients with type 2 diabetes mellitus.

Study on electrophysiological changes of peripheral nerves in type 2 diabetes mellitus

Background: Peripheral neuropathy is a common and disabling complication due to diabetes mellitus. In such neuropathy, the function of sensory neurons, motor neurons, and autonomic functions are affected. The involvement of sensory function predominates in majority of cases. The neuropathy when develops is not reversible and also can not be stopped with any modality of treatment. Aim and Objectives: The objective is to evaluate diabetic neuropathy using the electrodiagnostic studies which are considered as a valuable tool. These studies are sensitive, specific, reproducible, and easily standardized. Material and Methods: Forty patients were subjected to electrodiagnostic study to evaluate the status of peripheral nerves in type- 2 diabetic patients. The different conduction velocities (motor nerve conduction velocity [MNCV], sensory nerve conduction velocity [SNCV]), distal latency (DL), nerve action potential (sensory nerve action potential [SNAP], and combined muscle action potential [CMAP]) are studied. All the cases were divided into two groups based on normal and abnormal diabetic neuropathy score. Sex, body mass index matched thirty numbers of healthy adults of both sexes were included in the control group. Nerve conduction study (NCS) of all the three groups were compared. Result: Neuropathy mostly peripheral was observed in 15 (37.5%) cases. The age of majority of cases was from 50–60 (45%) with mean age of 52.42 ± 7.39, having predominance of male (66.67%) in cases with symptoms of neuropathy. Fourteen (93.33%) cases out of the above cases had abnormal NCS. Abnormal NCS was also found in cases without clinical neuropathy, i.e. 14 (56%). The mean values of CMAP, SNAP, MNCV, and SNCV with prolonged DL are observed which was statistically significant. The conduction defect was observed more in lower limbs than in upper limbs. In the category of the motor nerve (common peroneal) is the most affected whereas the most affected sensory nerve was Sural nerve. Conclusion: Affection of nerves with neuropathies due to diabetes was in Sensory nerve than motor nerve. Early screening for neuropathy in clinical practice with NCSs can help in early diagnosis and their management.

Metabolomics in Diabetic Neuropathy / 中国医学科学院学报

Diabetic neuropathy is a common diabetic complication.The application of metabolomics in the research on diabetic neuropathy is beneficial for us to understand the pathophysiological processes and overall metabolic disturbance of the nervous system under the condition of hyperglycemia,decipher the pathogenesis of diabetic neuropathy,and mine the potential biomarkers for clinical diagnosis and treatment.Long-term hyperglycemia may lead to disorders in multiple pathways,such as tricarboxylic acid circle,amino acid metabolism,and lipid metabolism.These metabolic changes are closely associated with the injuries of the peripheral and central nervous system.In the paper,we reviewed the metabolomics-based studies about diabetic neuropathy in the last five years.

To explore the characteristics of nerve injury in patients with diabetic peripheral neuropathy and the predictive value of current perception threshold combined with nerve conduction velocity / 中国医师进修杂志

Objective:To analyze the characteristics of nerve injury in patients with diabetic peripheral neuropathy (DPN) and explore the diagnostic value of current perception threshold (CPT) and nerve conduction velocity (NCV) for DPN.Methods:One hundred and thirty-six DPN patients admitted to Beijing Puren Hospital from June 2017 to December 2019 were selected, and 130 diabetic non-DPN patients admitted during the same period were used as controls. All the subjects were tested by CPT and NCV. Among them, the detection of NCV included sensory nerve conduction velocity (SCV) and motor nerve conduction velocity (MCV). Statistical analysis was performed on the relevant indicators of the two groups of subjects.Results:The CPT values of the upper limb median nerve and ulnar nerve at 2 000 Hz, 250 Hz, and 5 Hz, the superficial peroneal nerves at 250 Hz, and 5 Hz, and the CPT values of the sural nerve at 2 000 Hz and 250 Hz were higher than those of non-DPN patients, DPN injury mainly occurred in myelinated nerve fibers in the lower extremities [60.29%(82/136)], and the difference were statistically significant ( P<0.05). The SCV and MCV of the median nerve, ulnar nerve, and common peroneal nerve in the DPN group were lower than those in the non-DPN group, the SCV abnormal rate was higher than the MCV: 55.88%(76/136) vs. 37.50%(51/136); 58.82%(80/136) vs. 41.18% (56/136); 67.65%(92/136) vs. 50.00%(68/136), and the differences were statistically significant ( P<0.05). The area under the predictive value curve (AUC) of CPT for DPN was 0.815 (95% CI 0.735 ~ 0.895). The AUC of NCV for DPN was 0.875 (95% CI 0.813 ~ 0.944). The AUC of CPT and NCV for DPN was 0.923 (95% CI 0.876 ~ 0.970). Conclusions:DPT patients have abnormal CPT and NCV, and nerve damage occurs mostly in myelinated nerve fibers and SCV. Diagnosing DPN by combining CPT and NCV is helpful to improve the detection rate of DPN.

Estudio de factores de riesgo para el desarrollo de pie diabético: Campaña 1N / A study of risk factors in the development of diabetic foot: 1N Campaign

Introducción: el examen del pie es fundamental en pacientes con diabetes mellitus (DM). La correcta evaluación del pie en el paciente que concurre a control diabetológico es clave para establecer factores de riesgo para el desarrollo de úlceras, detectar lesiones, tomar medidas preventivas, realizar una derivación temprana y educar en cuidados del pie. Objetivos: en este estudio se examinaron los pies de personas con DM durante la Campaña de Concientización y Prevención del Pie Diabético el 1º de noviembre de 2019 con el fin de evaluar la presencia de síntomas y signos relacionados con neuropatía, enfermedad vascular periférica, y prevalencia de los mismos, y conocer el riesgo. Materiales y métodos: se analizaron 165 pacientes en cuatro centros: Sanatorio Güemes (Servicio de Diabetes y Endocrinología), PREDIGMA (Centro de Medicina Preventiva, Posadas, Misiones), Hospital Central de San Isidro, Nexo Centro Médico (Ciudad de Junín) y Hospital Municipal de General Viamonte (Provincia de Buenos Aires). Resultados: se encontró que el 43,6% presentaba algún síntoma en miembros inferiores y hasta el 57% alteración en las pruebas de tamizaje de neuropatía diabética o enfermedad arterial periférica, con mayor prevalencia a mayor tiempo de evolución de la DM. Los signos más frecuentemente hallados en el examen físico fueron: piel seca (71,5%), distrofia ungueal (60,6%) o alteración de la almohadilla plantar (52,1%). Las comorbilidades más frecuentes fueron: hipertensión (74,5%) y dislipemia (73,3%). La mediana de hemoglobina glicosilada fue de 7,40% (6,70-8,10), mayor en personas con antecedentes de retinopatía (7,8%; p<0,01) y en pacientes que refirieron tener calambres (7,85 a 7,30; p=0,03) o ardor (8,0 vs 7,3; p<0,01). El porcentaje de pacientes con pie de alto riesgo por antecedentes, inspección o tamizaje de neuropatía o enfermedad vascular representó desde el 40% en aquellos con DM de menos de cinco años de evolución hasta el 86% en quienes tenían más de 20 años. Conclusiones: el elevado porcentaje de pacientes con pie de riesgo identificado en este estudio sugiere que, además del correcto examen físico, se requiere la toma de conductas por parte del médico tratante, como la indicación de plantillas o calzado adecuado, así como una fluida derivación al técnico en ortesis, traumatólogo o fisiatra.

Introduction: foot examination is essential in patients with diabetes mellitus (DM). The correct evaluation of the foot in the patient who attends diabetes control is key to establish risk factors for the development of ulcers, detect injuries, take preventive measures, make an early referral and educate in foot care. Objectives: in this study, the feet of people with DM were examined during the Diabetic Foot Awareness and Prevention Campaign on November 1, 2019 in order to assess the presence of symptoms and signs related to neuropathy, peripheral vascular disease, prevalence of the same and know the risk. Materials and methods: 165 patients were analyzed in four centers: Sanatorio Güemes (Diabetes and Endocrinology Service), PREDIGMA (Preventive Medicine Center, Posadas, Misiones), Central Hospital of San Isidro, Nexo Medical Center (Junín City) and Hospital Municipal of General Viamonte (Province of Buenos Aires). Results: it was found that 43.6% had some symptoms in the lower limbs and up to 57% had an alteration in the screening tests for diabetic neuropathy or peripheral arterial disease, with a higher prevalence the longer the evolution of DM. The most frequent signs found in the physical examination were: dry skin (71.5%), nail dystrophy (60.6%) or alteration of the foot pad (52.1%). The lost frequent comorbidities were: hypertension (74.5%) and dyslipidemia (73.3%). The median glycated hemoglobin was 7.40% (6.70-8.10), higher in people with a history of retinopathy (7.8%; p <0.01) and in patients who reported having cramps (7, 85 to 7.30; p = 0.03) or burning (8.0 vs 7.3; p <0.01). The percentage of patients with high-risk foot due to antecedents, inspection or screening for neuropathy or vascular disease represented from 40% in those with DM of less than five years of evolution to 86% in those who were older than 20 years. Conclusions: this high percentage of patients with foot at risk identified in this study suggests that, in addition to the correct physical examination, the attending physician requires the taking of behaviors, such as the indication of appropriate footwear or insoles, as well as a fluid referral to the orthotic technician, orthopedic surgeon, or physiatrist.

Prevención de la amputación en pacientes con pie diabético / Prevention of amputation in patients with diabetic foot / Prevenção da amputação em pacientes com pé diabético

Introducción: las intervenciones estratégicas para reducir las tasas de amputación y mejorar la sobrevida de los pacientes con Diabetes Mellitus parte de la prevención, es decir, de la educación del paciente sobre los factores de riesgo y el tratamiento multidisciplinario de las heridas. Objetivo: describir cuáles son las intervenciones efectivas para prevenir la amputación en pacientes con pie diabético. Metodología: revisión integrativa de la literatura. Se incluyeron artículos en español, inglés y portugués de cualquier nacionalidad y diseño metodológico, publicados entre los años 2015 a 2020, en bases de datos como: Clinicalkey, BVS biblioteca virtual en salud, Scopus, EBSCOHost, Pubmed y Cuiden. Se filtraron por título, resumen y texto completo; se clasificaron según nivel de evidencia y grado de recomendación. Finalmente, se efectuó la lectura crítica mediante las escalas de Amstar, Consort, Strobe, CASPe y Trend. Resultados: se seleccionaron 29 artículos y se organizaron las estrategias en tres temáticas, por niveles de prevención: 1) promoción, prevención y mitigación del daño; 2) identifcación, diagnóstico y tratamiento, y 3)rehabilitación. Conclusiones: la evaluación periódica del pie diabético es de vital importancia y debe ser realizada por el equipo interdisciplinario.

Introduction: strategic interventions intended to reduce the amputation rates and enhance the survival among patients with diabetes mellitus starts from the prevention based on educating the patients, identifies risk factors and multidisciplinary treatment of the wounds. Objective: To describe the effective interventions to prevent the amputation in patients with diabetic foot. Methodology: It is a comprehensive review of literature, including articles in Spanish, English and Portuguese coming from any country and conducted under any design that were published between 2015 and 2020 in the data bases: Clinicalkey, BVS biblioteca virtual en salud, Scopus, EBSCOHost, Pubmed y Cuiden. Selection was filtered based on abstract, title and full text. Articles were sorted according to evidence level and recommendation. Finally, a critical reading was carried out after the scales of Amstar, Consort, Strobe, CASPe y Trend. Results: At the end 29 article were selected and strategies were organized in to 3 topics according to the prevention level: Level one: promotion, prevention and mitigation of damage. Level two: identification, diagnosis and treatment, and level three: rehabilitation. Conclusions: Regular evaluation of diabetic foot is crucial and must be done by an interdisciplinary team

ntrodução: as intervenções estratégicas para reduzir as taxas de amputação e melhorar a sobrevida dos pacientes com Diabetes Mellitus partem de uma prevenção baseada na educação do paciente, que identifica fatores de risco e tratamento multidisciplinar das feridas. Objetivo: descrever quais as intervenções efetivas para prevenir a amputação em pacientes com pé diabético. Metodologia: revisão integrativa da literatura. Incluíram-se artigos em espanhol, inglês e português de qualquer nacionalidade e desenho metodológico, publicados entre 2015 e 2020, nas bases de dados: Clinicalkey, BVS biblioteca virtual em saúde, Scopus, EBSCOHost, Pubmed e Cuiden. Foram filtrados por título, resumo e texto completo; classificaram-se segundo nível de evidência e grau de recomendação. Por fim, foi feita a leitura crítica usando as escalas de Amstar, Consort, Strobe, CASPe E Trend. Resultados: foram selecionados 29 artigos finais e organizadas as estratégias em três temáticas por níveis de prevenção: Primeiro nível: Promoção, Prevenção e Mitigação de danos. Segundo nível: Identificação, diagnóstico e tratamento, e Terceiro nível: Reabilitação. Conclusões: a avaliação periódica do pé diabético é de vital importância e deve ser realizada pela equipe interdisciplinar

Recomendaciones de manejo del paciente con pie diabético. Curso de instrucción / Management recommendations for diabetic foot patients. Instructional course

El ataque de pie diabético es uno de los desenlaces más fatídicos para el paciente con diabetes, lo que demuestra la importancia del control en una enfermedad que avanza hasta presentar cambios macroscópicos importantes en el miembro inferior. Durante la progresión de la Diabetes, la enfermedad puede derivar en un aumento de la morbilidad e intervenciones invasivas y limitantes para el paciente, de ahí la importancia de la detección e intervención temprana y oportuna de la patología por parte del equipo médico. Estas recomendaciones van dirigida a médicos generales y especialistas en diversas ramas médicas, con el objetivo de enfatizar el cómo se debe realizar el abordaje integral del paciente con pie diabético. Abarcando la prevención, diagnóstico inicial, evaluación de la progresión de la patología, estratificación con las clasificaciones propuestas, y por último el tratamiento según el estadio en el que se encuentre el paciente. Esto con el fin de minimizar desenlaces, intervenciones y complicaciones derivadas de la progresión del pie diabetico. Hablamos de recomendaciones y no de guías debido a la ausencia en un gran número de oportunidades de evidencia científica debidamente estructurada (I y II). Tal vez lo más importante por recalcar en todas estas recomendaciones es recordarle al lector que en los casos de afectación de un pie diabético, siempre se debe tener en cuenta que el pie contralateral también ha estado sometido a la misma enfermedad durante el mismo tiempo y por lo tanto aunque no tenga síntomas se debe considerar igualmente enfermo y se debe examinar también.

Diabetic foot is one of the most fatal outcomes for patients with diabetes; the importance of control in a disease that progresses until presenting important macroscopic changes in the lower limb is absolutely relevant. Along diabetes progression, the disease can lead to increased morbidity and invasive and limiting interventions for the patient, hence the importance of early and timely detection and intervention of the pathology by the medical team. These recommendations are addressed to general practitioners and specialized faculty in various medical branches, emphasizing how a comprehensive approach to the patient with diabetic foot should be carried out. Covering prevention, initial diagnosis, evaluation of the progression of the pathology, stratification with the proposed classifications, and finally the treatment according to the stage in which the patients are, is actually well described herein in order to minimize unsatisfactory outcomes, interventions and complications derived from the progression of diabetic foot. We are talking about recommendations and not guidelines due to the absence in a large number of opportunities of properly structured scientific evidence (I and II). Perhaps, the most important thing to emphasize in all these recommendations is to remind the reader that in cases of treating a diabetic foot, it should always be kept in mind that the contralateral foot is not healthy because it has also been subjected to the same disease, for the same period of time and stressed equally as well. Therefore, even if the contralateral foot does not have symptoms, it should be considered equally ill and should be examined and treated likewise.

Management recommendations for diabetic foot patients. Instructional course / Recomendaciones de manejo del paciente con pie diabético. Curso de instrucción

Diabetic foot is one of the most fatal outcomes for patients with diabetes; the importance of control in a disease that progresses until presenting important macroscopic changes in the lower limb is absolutely relevant. Along diabetes progression, the disease can lead to increased morbidity and invasive and limiting interventions for the patient, hence the importance of early and timely detection and intervention of the pathology by the medical team. These recommendations are addressed to general practitioners and specialized faculty in various medical branches, emphasizing how a comprehensive approach to the patient with diabetic foot should be carried out. Covering prevention, initial diagnosis, evaluation of the progression of the pathology, stratification with the proposed classifications, and finally the treatment according to the stage in which the patients are, is actually well described herein in order to minimize unsatisfactory outcomes, interventions and complications derived from the progression of diabetic foot. We are talking about recommendations and not guidelines due to the absence in a large number of opportunities of properly structured scientific evidence (I and II). Perhaps, the most important thing to emphasize in all these recommendations is to remind the reader that in cases of treating a diabetic foot, it should always be kept in mind that the contralateral foot is not healthy because it has also been subjected to the same disease, for the same period of time and stressed equally as well. Therefore, even if the contralateral foot does not have symptoms, it should be considered equally ill and should be examined and treated likewise.

El ataque de pie diabético es uno de los desenlaces más fatídicos para el paciente con diabetes, lo que demuestra la importancia del control en una enfermedad que avanza hasta presentar cambios macroscópicos importantes en el miembro inferior. Durante la progresión de la Diabetes, la enfermedad puede derivar en un aumento de la morbilidad e intervenciones invasivas y limitantes para el paciente, de ahí la importancia de la detección e intervención temprana y oportuna de la patología por parte del equipo médico. Estas recomendaciones van dirigida a médicos generales y especialistas en diversas ramas médicas, con el objetivo de enfatizar el cómo se debe realizar el abordaje integral del paciente con pie diabético. Abarcando la prevención, diagnóstico inicial, evaluación de la progresión de la patología, estratificación con las clasificaciones propuestas, y por último el tratamiento según el estadio en el que se encuentre el paciente. Esto con el fin de minimizar desenlaces, intervenciones y complicaciones derivadas de la progresión del pie diabetico. Hablamos de recomendaciones y no de guías debido a la ausencia en un gran número de oportunidades de evidencia científica debidamente estructurada (I y II). Tal vez lo más importante por recalcar en todas estas recomendaciones es recordarle al lector que en los casos de afectación de un pie diabético, siempre se debe tener en cuenta que el pie contralateral también ha estado sometido a la misma enfermedad durante el mismo tiempo y por lo tanto aunque no tenga síntomas se debe considerar igualmente enfermo y se debe examinar también.

Clinical study of neurological presentation of diabetes mellitus in a tertiary care hospital

Background: A wide range of commotions affecting the central and peripheral nervous systems, either directly or indirectly, may be observed in patients with diabetes mellitus. The spectrum of neurological complications among diabetes are quite varied.Methods: Authors conducted a Cross-sectional prospective observational study to study different neurological manifestations of diabetes mellitus. at NRI General Hospital, Chinakakani, Guntur District, Andhra Pradesh. The selected patients were studied in detail with history and physical examination. The investigations included Fasting Blood Sugar (FBS), Postprandial Blood Sugar (PPBS), Glycosylated Hemoglobin (HbA1C).Results: A total of 100 subjects were included in the final analysis. Majority of participants were aged between 46 to 65 years, and 55% of them were males. Only 13% of the participants had HBA1c value below 7.5 gm%. Out of 100 participants, 82% participants had diabetic peripheral neuropathy. A total of 6 subjects had cranial neuropathy, with 5% participants having 3rd nerve and one participant had 6th nerve. Involuntary movements (Chorea) was present in 4% of patients. Among the people with Seizures, 6% participants had Hyperglycemic, and 2% participants had Hypoglycemic seizures. Out of 100 participants, 7 participants had dysautonomia.Conclusions: Peripheral neuropathy was the most common neurological manifestation among the diabetic population. The other key neurological abnormalities include cranial nerve palsy, dysautonomia, seizures and Chorea. Clinicians need to be aware the entire spectrum of neurological abnormalities among patients with type 2 Diabetes.