Algunos aspectos actualizados sobre la polineuropatía diabética / Some up-to-date aspects on the diabetic polyneuropathy

La diabetes mellitus es una enfermedad crónica que puede causar complicaciones multiorgánicas como la polineuropatía diabética, con el consecuente trastorno invalidante a quienes la padecen. Por tal motivo, se realizó una revisión bibliográfica exhaustiva con el objetivo de actualizar algunos aspectos importantes sobre esta afección, tales como concepto, factores de riesgo, mecanismos patogénicos, clasificación, diagnóstico y tratamiento, entre otros. Se concluye que esta enfermedad se asocia con varios factores de riesgo, su diagnóstico es fundamentalmente clínico y como tratamiento se considera el control glucémico, el cuidado de los pies y el uso de fármacos.

The diabetes mellitus is a chronic disease that can cause multiorganic complications as the diabetic polyneuropathy, with the consequent invalidant disorder to whom suffer from it. For such a reason, an exhaustive literature review was carried out with the objective of upgrading some important aspects on this affection, such as concept, risk factors, pathogenic mechanisms, classification, diagnosis and treatment, among others. It was concluded that this disease is associated with several risk factors, its diagnosis is fundamentally clinical and the glycemic control, the care of feet and the use of medicines are considered as treatment.

Fatores associados ao maior risco de ulceração nos pés de indivíduos com diabetes mellitus / Factors associated with the greatest risk of ulceration on the feet of individuals with diabetes mellitus

Objetivo: Diante da alta prevalência do Diabetes Mellitus, o estudo se propõe a identificar os fatores associados ao maior risco de desenvolver úlceras nos membros inferiores. Métodos: O trabalho foi exploratório-descritivo, transversal e com abordagem quantitativa. A amostra foi composta por pacientes com Diabetes acima de 18 anos de um serviço de saúde particular e um público. A coleta de dados ocorreu através de anamnese, exame físico e procura em prontuário. A análise estatística foi realizada pelo Programa SPSS 20.0. Resultados: Obteve-se 102 participantes no estudo, destes, 67,6% apresentaram critérios diagnósticos para Polineuropatia Simétrica Distal. Os fatores associados ao risco de ulceração foram: o envelhecimento, a maior duração da Diabetes, hipertensão, doença arterial periférica e a presença de sintomas típicos da Polineuropatia. Conclusão: É necessário investir na prevenção de úlceras em indivíduos com Diabetes através de educação em saúde e acompanhamento por profissionais da saúde (AU)

Objective: Given the high prevalence of Diabetes Mellitus, the study aims to identify the factors associated with a higher risk of developing ulcers in the lower limbs. Methods: The work was exploratory-descriptive, transversal and with a quantitative approach. The sample consisted of patients with Diabetes over 18 years of age from a private and a public health service. Data collection occurred through anamnesis, physical examination and search in medical records. Statistical analysis was perform using the SPSS 20.0 program. Results: 102 study participants were obtained, of wich 67,6% had diagnostic criteria for Distal Symmetric Polyneuropathy. Factors associated with the risk of ulceration were: aging, longer duration of diabetes, hypertension, peripheral arterial disease and the presence of typical symptoms of polyneuropathy. Conclusion: It is necessary to invest in the prevention of ulcers in individuals with Diabetes, through health education and monitoring by health professionals.Keywords: Diabetes Mellitus, Diabetic neuropathies, Polyneuropathies, Foot ulcer, Diabetic foot (AU)

An experimental study of tangzhouling on morphological changes of nissl bodies in the dorsal root ganglion of DM rats / Un estudio experimental de tangzhouling sobre los cambios morfológicos de los cuerpos de nissl en el ganglio de la raíz dorsal de ratas DM

SUMMARY: This study aims to investigate the effect of Tangzhouling on the morphological changes of Nissl bodies in the dorsal root ganglion of DM Rats. In this study, 69 rats were randomly divided into a control group (n = 10) and a model group (n = 59). The rats in the model group were randomly divided into a diabetic group (n = 11), a vitamin C group (n = 12), a low dose Tangzhouling group (n = 12), a medium dose Tangzhouling group (n = 12) and a high dose Tangzhouling group (n = 12). The dose of Tangzhouling in the low dose group was 5 times that of the adult dose, being 0.44g/kg/d. The dose of Tangzhouling in the medium dose group was 10 times that of the adult dose, being 0.88g/kg/d. The dose of Tangzhouling in the high dose group was 20 times that of the adult dose, being 1.75g/kg/d. All doses above are crude drug dosages. Rats in the vitamin C group were given 10 times the dose of an adult, being, 0.05 g/ kg/d. The diabetic group and the control group were given the same amount of distilled water. Drug delivery time is 16 weeks. The dorsal root ganglion was placed in a freezing tube at the end of the experiment. The morphological changes of Nissl bodies in the dorsal root ganglion were detected by HE and Nissl staining. The study results showed that vitamin C had no significant effect on the quantity, size and nucleolus. Tangzhouling can improvee the morphology, quantity and nucleolus of Nissl bodies to a certain extent, and the high dose is better than the lower dose. Tangzhouling capsules can improve the nerve function of DM rats through Nissl bodies.

RESUMEN: Este estudio tuvo como objetivo investigar el efecto de Tangzhouling en los cambios morfológicos de los cuerpos de Nissl en el ganglio de la raíz dorsal de las ratas DM. En este estudio, 69 ratas se dividieron aleatoriamente en un grupo control (n = 10) y un grupo modelo (n = 59). Las ratas del grupo modelo se dividieron aleatoriamente en un grupo diabéticos (n = 11), un grupo vitamina C (n = 12), un grupo de dosis baja de Tangzhouling (n = 12), un grupo de dosis media de Tangzhouling (n = 12) y un grupo de dosis alta de Tangzhouling (n = 12). La dosis de Tangzhouling en el grupo de dosis baja fue 5 veces mayor que la dosis del adulto, siendo 0,44 g/kg/d. La dosis de Tangzhouling en el grupo de dosis media fue 10 veces mayor que la dosis del adulto, siendo 0,88 g/kg/d. La dosis de Tangzhouling en el grupo de dosis alta fue 20 veces mayor que la dosis del adulto, siendo 1,75 g/kg/d. Todas las dosis anteriores son dosis de fármaco crudo. Se les administró 10 veces la dosis de un adulto a las ratas del grupo vitamina C, siendo 0,05 g/kg/d. El grupo de diabéticos y el grupo de control recibieron la misma cantidad de agua destilada. El tiempo de entrega del fármaco fue de 16 semanas. El ganglio de la raíz dorsal se colocó en un tubo de congelación al final del experimento. Los cambios morfológicos de los cuerpos de Nissl en el ganglio de la raíz dorsal se detectaron mediante tinción de HE y Nissl. Los resultados del estudio mostraron que la vitamina C no tuvo un efecto significativo sobre la cantidad, el tamaño y el nucléolo. Tangzhouling puede mejorar la morfología, la cantidad y el nucléolo de los cuerpos de Nissl hasta cierto punto, y es mejor la dosis alta que la dosis baja. Las cápsulas de Tangzhouling pueden mejorar la función nerviosa de las ratas DM a través de los cuerpos de Nissl.

Fatores associados ao maior risco de ulceração nos pés de indivíduos com diabetes mellitus / Factors associated with the greatest risk of ulceration on the feet of individuals with diabetes mellitus

RESUMO: Objetivo: Diante da alta prevalência do Diabetes Mellitus, o estudo se propõe a identificar os fatores associados ao maior risco de desenvolver úlceras nos membros inferiores. Métodos: O trabalho foi exploratório-descritivo, transversal e com abordagem quantitativa. A amostra foi composta por pacientes com Diabetes acima de 18 anos de um serviço de saúde particular e um público. A coleta de dados ocorreu através de anamnese, exame físico e procura em prontuário. A análise estatística foi realizada pelo Programa SPSS 20.0. Resultados: Obteve-se 102 participantes no estudo, destes, 67,6% apresentaram critérios diagnósticos para Polineuropatia Simétrica Distal. Os fatores associados ao risco de ulceração foram: o envelhecimento, a maior duração da Diabetes, hipertensão, doença arterial periférica e a presença de sintomas típicos da Polineuropatia. Conclusão: É necessário investir na prevenção de úlceras em indivíduos com Diabetes através de educação em saúde e acompanhamento por profissionais da saúde. (AU)

ABSTRACT: Objective: Given the high prevalence of Diabetes Mellitus, the study aims to identify the factors associated with a higher risk of developing ulcers in the lower limbs. Methods: The work was exploratory-descriptive, transversal and with a quantitative approach. The sample consisted of patients with Diabetes over 18 years of age from a private and a public health service. Data collection occurred through anamnesis, physical examination and search in medical records. Statistical analysis was perform using the SPSS 20.0 program. Results: 102 study participants were obtained, of wich 67,6% had diagnostic criteria for Distal Symmetric Polyneuropathy. Factors associated with the risk of ulceration were: aging, longer duration of diabetes, hypertension, peripheral arterial disease and the presence of typical symptoms of polyneuropathy. Conclusion: It is necessary to invest in the prevention of ulcers in individuals with Diabetes, through health education and monitoring by health professionals. (AU)

Tetrahydropalmatine alleviated diabetic neuropathic pain by inhibiting activation of microglia via p38 MAPK signaling pathway / 中国中药杂志

Neuropathic pain is one of the common complications of diabetes. Tetrahydropalmatine(THP) is a main active component of Corydalis Rhizoma with excellent anti-inflammatory and pain-alleviating properties. This study aims to investigate the therapeutic effect of THP on diabetic neuropathic pain(DNP) and the underlying mechanism. High-fat and high-sugar diet(4 weeks) and streptozotocin(STZ, 35 mg·kg~(-1), single intraperitoneal injection) were employed to induce type-2 DNP in rats. Moreover, lipopolysaccharide(LPS) was used to induce the activation of BV2 microglia in vitro to establish an inflammatory cellular model. Fasting blood glucose(FBG) was measured by a blood glucose meter. Mechanical withdrawal threshold(MWT) was assessed with von Frey filaments, and thermal withdrawal latency(TWL) with hot plate apparatus. The protein expression levels of OX42, inducible nitric oxide synthase(iNOS), CD206, p38, and p-p38 were determined by Western blot, the fluorescence expression levels of OX42 and p-p38 in the dorsal horn of the rat spinal cord by immunofluorescence, the mRNA content of p38 and OX42 in rat spinal cord tissue by qRT-PCR, and levels of nitric oxide(NO), interleukin-1β(IL-1β), interleukin-6(IL-6), tumor necrosis factor-α(TNF-α), interleukin-10(IL-10), and serum fasting insulin(FINS) by enzyme-linked immunosorbent assay(ELISA). RESULTS:: showed that the mo-del group demonstrated significant decrease in MWT and TWL, with pain symptoms. THP significantly improved the MWT and TWL of DNP rats, inhibited the activation of microglia and p38 MAPK signaling pathway in rat spinal cord, and ameliorated its inflammatory response. Meanwhile, THP promoted the change of LPS-induced BV2 microglia from the pro-inflammatory M1 phenotype to the anti-inflammatory M2 phenotype, suppressed the activation of the p38 MAPK signaling pathway, decreased the expression levels of inflammatory factors NO, IL-1β, IL-6, and TNF-α, and increased the expression level of anti-inflammatory factor IL-10. The findings suggested that THP can significantly ameliorate the pain symptoms of DNP rats possibly by inhibiting the inflammatory response caused by M1 polarization of microglia via the p38 MAPK pathway.

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.

Maior frequência de neuropatia periférica diabética associada ao hiperparatireoidismo secundário / Higher prevalence of diabetic peripheral neuropathy associated with secondary hyperparathyroidism

INTRODUÇÃO: A neuropatia periférica diabética (ND) é comum na nefropatia diabética (NFD) e não há informações se o hiperparatireoidismo secundário (HPS) aumenta seus sintomas. O objetivo foi determinar ND por sinais em pacientes com HPS. MATERIAL E MÉTODOS: É um estudo caso-controle. O Grupo Controle (GC) é composto por doentes com NFD e valores de paratormônio (PTH)<60pg / ml. O Grupo de Hiperparatireoidismo (GH) engloba pacientes com NFD e PTH≥60pg/ml e critérios bioquímicos de HPS. As variáveis foram, entre outras, a presença de sinais de ND e foram comparados com o teste t de Student e o qui-quadrado. RESULTADOS: Foram 60 participantes em cada grupo, sendo 35 (58,3%) homens no GC vs 33 (55,0%) em GH (p = 0,713). A idade do GC foi de 67±11,0 anos, vs 72±11 anos GH (p=0,009). A taxa de filtração glomerular (TFG) no GC foi 53,82±25,13 vs GH 35,34±18,43ml/min/1,73m2 (p <0,001). O PTH no GC foi de 38,02±15,32 pg/ml, em GH 119,07±84,33 pg/ml (p <0,001). A ND, devido aos sintomas no GC, foi de 28,3% e 36,6% no GH (p=0,330). A neuropatia por sinais no GC foi de 38,3% e no GH 83,3% (p<0,001). O odds ratio de GH para neuropatia presente devido a sinais foi de 8,044 (IC 95% 3,42­8,92). CONCLUSÃO: Constatou-se uma maior presença de sinais de NPD em pacientes com HPS em nosso centro.

BACKGROUND: Diabetic peripheral neuropathy (DN) is common in diabetic nephropathy (DNP), and there is no information if secondary hyperparathyroidism (SHP) increases its symptoms. The purpose was to determine DN by signs in patients with SHP. METHODS: It is a case-control study. Control patients (CG) with DN and parathyroid hormone (PTH) values<60pg/ml. The Hyperparathyroidism group (HG), patients with DNP and PTH≥60pg/ml and HPS biochemical criteria. The variables were, among others, the presence of DN signs, and were compared with Student's t and chi-square. RESULTS: There were 60 participants in each group, 35(58.3%) men in CG vs.33(55.0%) in GH (p=0.713). The age of the CG was 67±11.0 years, vs 72±11years HG (p=0.009). The glomerular filtration rate (GFR) in the CG was 53.82±25.13 vs in HG 35.34±18.43ml/min/1.73m2(p<0.001). The PTH in the CG were 38.02±15.32pg/ml and in GH 119.07±84.33pg/ml(p<0.001). The DN due to symptoms in CG was 28.3% and in GH 36.6%(p=0.330). Neuropathy due to signs in the CG was 38.3% and in GH 83.3% (p<0.001). The HG odds ratio to present neuropathy due to signs was 8.044 (95% CI 3.42­18.92). CONCLUSION: There was a statistical association between HPS and signs of DN in patients with DNP in our canter.

Dor devido à polineuropatia simétrica distal em diabetes mellitus / Dolor por polineuropatía simétrica distal en la diabetes mellitus / Distal Symmetric Polyneuropathy Pain in Diabetes Mellitus

Objective: To evaluate neuropathic pain (NP), its intensity, and complications in people with type 2 diabetes mellitus (T2DM) in a city of eastern São Paulo. Method: Cross-sectional study conducted with 96 individuals with T2DM served by primary health units in São João da Boa Vista-SP. The following instruments were used to screen NP: Michigan Neuropathy Screening Instrument, Leeds Assessment of Neuropathic Symptoms and Signs, Douleur Neuropathique 4, and Brief Pain Inventory. The data were analyzed using descriptive and inferential statistics, with a 5 % significance level. Results: Of the 96 people with T2DM for longer than five years, 22.9 % had pain. NP was related to high levels of fasting blood glucose (mean = 214 ± 65.58 mg/dl; p = 0.0002), glycated hemoglobin (mean = 8.8 ± 0.11 %; p < 0.001), absence of a balanced diet (p = 0.0066), obesity (p = 0.023), and high blood pressure (p < 0.001). Conclusion: Higher values ​​of glycated hemoglobin rates increased three times the chance of NP. The screening and management of painful diabetic neuropathy is a challenge but adopting a screening protocol supports the secondary prevention of this manifestation.

Objetivo: evaluar el dolor neuropático (DN), su intensidad y sus complicaciones en personas con diabetes mellitus tipo 2 (DM2) en una ciudad del este de São Paulo. Método: estudio transversal realizado con 96 individuos con DM2 atendidos en unidades básicas de salud en São João da Boa Vista-SP. Se utilizaron los siguientes instrumentos para rastrear el DN: el instrumento para la detección de la neuropatía de Michigan, la evaluación de signos y síntomas neuropáticos de Leeds, el cuestionario Douleur Neuropathique 4 y el inventario breve del dolor. Los datos se analizaron mediante estadística descriptiva e inferencial, con un nivel de significancia del 5 %. Resultados: de las 96 personas con DM2 durante más de cinco años, el 22,9 % tenía dolor. El DN se relacionó con niveles altos de glucosa en sangre en ayunas (media = 214 ± 65,58 mg/dl; p = 0,0002), la hemoglobina glucosilada (media = 8,8 ± 0,11 %; p < 0,001), la ausencia de una dieta (p = 0,0066), la obesidad (p = 0,023) y la hipertensión arterial (p < 0,001). Conclusión: los altos valores en las tasas de hemoglobina glucosilada aumentaron tres veces la probabilidad de DN. La detección y el tratamiento de la neuropatía diabética dolorosa es un desafío, pero la adopción de un protocolo de detección contribuye a la prevención secundaria de esta manifestación.

Objetivo: avaliar a dor neuropática (DN), sua intensidade e suas complicações em pessoas com diabetes mellitus tipo 2 (DM2) numa cidade do leste de São Paulo, Brasil. Método: estudo transversal realizado com 96 indivíduos com DM2 atendidos em unidades básicas de saúde em São João da Boa Vista, São Paulo. Foram utilizados os seguintes instrumentos para rastrear a DN: o instrumento para detectar a neuropatia de Michigan, a avaliação de sinais e sintomas neuropáticos de Leeds, o questionário de Douleur Neuropathique 4 e a escala breve da dor. Os dados foram analisados por meio de estatística descritiva e inferencial, com um nível de significância de 5 %. Resultados: das 96 pessoas com DM2 durante mais de cinco anos, 22,9 % sentiam dor. A DN esteve relacionada com níveis altos de glicose em sangue em jejum (média = 214 ± 65,58 mg/dl; p = 0,0002), hemoglobina glicosilada (média = 8,8 ± 0,11 %; p < 0,001), ausência de dieta (p = 0,0066), obesidade (p = 0,023) e hipertensão arterial (p < 0,001). Conclusões: os altos valores nas taxas de hemoglobina glicosilada aumentaram três vezes a probabilidade de DN. A detecção e o tratamento da neuropatia diabética dolorosa são um desafio, mas a adoção de um protocolo de detecção contribui para a prevenção secundária dessa manifestação.

Eficácia das palmilhas customizadas na melhora da distribuição da pressão plantar em pacientes com neuropatia diabética: Protocolo de um ensaio clínico randomizado e controlado / Efficacy of customized insoles in the improvement of plantar pressure in patients with diabetic neuropathy: Protocol of a randomized and controlled clinical trial

OBJETIVO: Avaliar a influência das palmilhas customizadas na pressão plantar de diabéticos com neuropatia em comparação ao grupo sham. MÉTODOS: O método do estudo, devidamente registrado no Registro Brasileiro de Ensaios Clínicos ­ REBEC (Clinical Trial Brazilian Register) (http://www.ensaiosclinicos.gov.br/) RBR-5NQK4K, incluiu um ensaio clínico randomizado, controlado, prospectivo, duplo-cego, com uma amostra de 46 voluntários que serão randomizados aleatoriamente numa razão de 1: 1 para serem direcionados aos grupos intervenção e controle. O grupo intervenção receberá palmilhas customizadas, com barra retrocapital e placa de etil vinil acetato (EVA) no mesmo formato da barra retrocapital, com a finalidade de reduzir a pressão no antepé. No grupo controle, as palmilhas planas serão confeccionadas sem nenhum objetivo terapêutico. Este projeto foi conduzido de acordo com o padrão de protocolo para ensaios clínicos randomizados (SPIRIT). Junto com a avaliação clínica, serão coletados dados demográficos da amostra para identificar e confirmar a presença de neuropatia periférica, em seguida, será avaliada a podobarografia e, por fim, os pacientes responderão ao questionário FAAM para avaliação da funcionalidade do pé. O desfecho primário será a análise dos pontos de pressão em KiloPascal (kPa) no pé dos pacientes com neuropatia diabética por meio da podobarografia nos pacientes do grupo intervenção e controle. O desfecho secundário será a funcionalidade do pé nas atividades de vida diária através do questionário FAAM (Foot and Ankle Ability Measure), considerando os voluntários na avaliação inicial, 3º e 6º meses. CONSIDERAÇÕES FINAIS: os futuros resultados deste estudo nos mostrarão principalmente se há ou não uma alteração estrutural na análise da pressão plantar decorrente do uso contínuo da palmilha, além de avaliar se o uso da palmilha terapêutica é eficaz na funcionalidade do pé nos mesmos portadores quando comparado à palmilha sham.

| OBJECTIVE: To evaluate the influence of customized insoles in the plantar pressure of diabetes patients with neuropathy in comparison to the sham group. METHODS: The work method, duly registered at the Registro Brasileiro de Ensaios Clínicos ­ REBEC (Clinical Trial Brazilian Register) (http://www.ensaiosclinicos.gov.br/) RBR-5NQK4K, includes a randomized, controlled, prospective, doubleblinded clinical trial, with a sample of 46 volunteers that will be randomly randomized in a 1: 1 ratio to be referred to intervention and control groups. The intervention group will receive customized insoles, with a retrocapital bar and an ethyl vinyl acetate plaque (EVA) in the same shape as the retrocapital bar, in order to reduce the pressure on the forefoot. In the control group, flat insoles will be prepared without any therapeutic objective. This project was developed according to the standard protocol for randomized clinical trials (SPIRIT). Along with the clinical evaluation, demographic data of the sample will be collected to identify and confirm the presence of peripheral neuropathy, next, the pedobarographic will be evaluated, and finally, the patients will answer the FAAM questionnaire to assess foot functionality. The primary outcome will be analyzing pressure points in KiloPascal (kPa) in the patients' feet through pedobarographic of the patients in the intervention and control groups. The secondary outcome will be the foot functionality in activities of daily living through the FAAM (Foot and Ankle Ability Measure), considering the volunteers in the initial evaluation, third and sixth months. FINAL CONSIDERATIONS: Mainly, results of this study will show whether there is a structural alteration in the analysis of the plantar pressure due to the continuous use of insoles and present the evaluation of whether the use of therapeutic insoles improves the foot functionality of the same users when compared to sham insoles.

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.

Efficacy of exercise on balance, fear of falling, and risk of falls in patients with diabetic peripheral neuropathy: a systematic review and meta-analysis

ABSTRACT Diabetic peripheral neuropathy (DPN) is the most common complication of diabetes mellitus. Our objective was to evaluate the efficacy of exercise interventions in DPN patients from randomized controlled trials. The primary outcomes were the risk of falls, fear of falling, balance and quality of life. Two reviewers independently selected studies from Embase, Medline, LILACS, CENTRAL, and PEDro. They assessed the risk of bias and extracted data from the trials. The relative risk (RR) and the differences between means (MD) were calculated with a 95% confidence interval (CI) and used as the effect size. We used a random-effects model to pool results across studies, and the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate the certainty of evidence. Eight trials were included. No clear effect was observed in the risk of falls (RR: 0.93, 95% CI: 0.41 to 2.09, 79 participants, 1 trial, low-certainty evidence). Regarding fear of falling, using the Falls Efficacy Scale, a small difference in favor of the intervention was observed (MD: −2.42, 95%, CI: −4.7 to −0.15, 3 trials, 185 participants, low-certainty evidence). The meta-analysis of balance using the unipedal stance test showed a small difference in favor of the intervention. One study evaluated quality of life, and in the mental score there was a MD in favor of the intervention. In DPN patients, a combination of gait, balance, and functional training improved balance, the fear of falling, quality of life in the mental score, but not the risk of falls.

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.

Comparação da dor e qualidade de vida entre indivíduos com e sem neuropatia diabética / Comparison of pain and quality of life between individuals with and without diabetic neuropathy / Comparación del dolor y la calidad de vida entre individuos con y sin neuropatía diabética

Objetivo: comparar a dor e a qualidade de vida de indivíduos com e sem neuropatia diabética. Método: estudo transversal realizado com 251 participantes com diabetes mellitus tipo 2. Utilizou-se a escala Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) para avaliar neuropatia diabética, características da dor, perda de sensibilidade protetora (PSP) e avaliar a qualidade de vida pelo Short-Form 6 Dimensions-Brasil/SF-6D. Realizou-se análise estatística descritiva. Resultados: 16,3% apresentaram neuropatia, 97,6% queixaram-se de dor, sendo a maioria crônica e nos pés ou panturrilhas. 51,2% dos neuropáticos tiveram PSP no teste do monofilamento (p=0,001). Os descritores de dor mais referidos pelos neuropáticos: queimação (p=0,004), formigamento (p=0,002) e alfinetada e/ou agulhada (p=0,003) e os domínios de qualidade de vida afetados foram: dor, saúde mental e vitalidade. Conclusão: aqueles com neuropatia têm maior intensidade de dor, acordam à noite e apresentam alteração na sensibilidade dos pés, que pode ser rastreada na atenção primária.

Objective: to compare pain and quality of life in individuals with and without diabetic neuropathy. Method: a cross-sectional study with 251 participants with type 2 diabetes mellitus. The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scale was used to assess diabetic neuropathy, pain characteristics, loss of protective sensitivity (LPS) and to assess the quality of life by Short-Form 6 Dimensions-Brasil/SF-6D. Descriptive statistical analysis was performed. Results: among the participants, 16.3% had neuropathy, 97.6% complained of pain, most of them chronic and in the feet or calves. Also, 51.2% of neuropathic patients had LPS in the monofilament test (p=0.001). The pain descriptors most frequently reported by neuropathic patients were: burning (p=0.004), tingling (p=0.002), and pinprick and/or needling (p=0.003). The affected quality of life domains were: pain, mental health, and vitality. Conclusion: those with neuropathy have greater pain intensity, wake up at night, and have altered foot sensitivity, which can be tracked in primary care.

Objetivo: comparar el dolor y la calidad de vida en individuos con y sin neuropatía diabética. Método: estudio transversal con 251 participantes con diabetes mellitus tipo 2. Se utilizó la escala Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) para evaluar la neuropatía diabética, las características del dolor, la pérdida de sensibilidad protectora (PSP) y para evaluar la calidad de vida por Short-Form 6 Dimensiones-Brasil/SF-6D. Se realizó análisis estadístico descriptivo. Resultados: el 16,3% presentaba neuropatía, el 97,6% se quejaba de dolor, la mayoría crónico y en pies o pantorrillas. El 51,2% de los pacientes neuropáticos tenían PSP en la prueba de monofilamento (p = 0,001). Los descriptores de dolor informados con mayor frecuencia por los pacientes neuropáticos fueron: ardor (p = 0,004), hormigueo (p = 0,002) y pinchazo y/o punción (p = 0,003) y los dominios de calidad de vida afectada fueron: dolor, salud mental y vitalidad. Conclusión: las personas con neuropatía tienen mayor intensidad de dolor, se despiertan por la noche y tienen alteración de la sensibilidad de los pies, lo que se puede rastrear en atención primaria.

Tropomyosin receptor kinase B-mediated signaling in integration of neuropathic pain and obesity in diabetic polyneuropathy / Sinalização mediada pelo receptor de tropomiosina quinase tipo B na integração de dor neuropática e obesidade na polineuropatia diabética

ABSTRACT Objective: To assess the quantitative serum levels of tropomyosin receptor kinase receptor B, and to estimate its association with serum concentration of brain-derived neurotrophic factor and obesity in patients with painful and painless forms of diabetic polyneuropathy. Methods: We examined 70 patients with diabetic polyneuropathy with confirming peripheral nerve dysfunction by electroneuromyography and measuring of serum levels tropomyosin receptor kinase receptor B and brain-derived neurotrophic factor by enzyme immunoassay. Diabetic polyneuropathy was diagnosed using the modified Toronto Consensus (2011) criteria, while neuropathic pain was assessed using an 11-point Numerical Pain Rating Scale. The patients were divided into two groups according to presence or absence of neuropathic pain. Control Group consisted of 14 healthy persons. Results: The serum levels of tropomyosin receptor kinase receptor B and brain-derived neurotrophic factor in patients with diabetic polyneuropathy are significantly higher than healthy controls (p=0.000). Hyperexpression of brain-derived neurotrophic factor in serum was associated with painful form of diabetic polyneuropathy (R=0.392, p=0.012) and obesity (R=0.412, p=0.001). On the contrary high concentration of tropomyosin receptor kinase receptor B in serum associated with painless diabetic polyneuropathy by Pain DETECT (R=-0.354, p=0.015), low body weight (R=-0.354, p=0.015) and severe demyelization of nerve fibers (R=-0.574, p=0.001), indicated "non-working" receptor detected in serum. Conclusion: Tropomyosin receptor kinase receptor B signaling is involved in the modulation of neuropathic pain and obesity in diabetic polyneuropathy.

RESUMO Objetivo: Avaliar os níveis séricos quantitativos do receptor da tropomiosina quinase B, e estimar sua associação com os níveis séricos do fator neurotrófico derivado do cérebro e a obesidade, em pacientes com formas dolorosas e indolores de polineuropatia. Métodos: Examinamos 70 pacientes com polineuropatia diabética, com disfunção de nervo periférico confirmada por eletroneuromiografia e medida de níveis séricos do receptor da tropomiosina quinase B e do fator neurotrófico derivado do cérebro, por imunoensaio enzimático. Polineuropatia diabética foi diagnosticada através dos critérios modificados do Consenso de Toronto (2011), e a dor neuropática foi avaliada pela escala Numerical Pain Rating com 11 pontos. Os pacientes foram divididos em dois grupos, conforme presença ou ausência de dor neuropática. O Grupo Controle tinha 14 indivíduos saudáveis. Resultados: Os níveis séricos do receptor da tropomiosina quinase B e do fator neurotrófico derivado do cérebro em pacientes com polineuropatia diabética são significativamente mais elevados do que controles saudáveis (p=0,000). Hiperexpresssão do fator neurotrófico derivado do cérebro no soro foi associada à forma dolorosa da polineuropatia diabética (R=0,392, p=0,012) e obesidade (R=0,412, p=0,001). Por outro lado, alta concentração sérica de receptor da tropomiosina quinase B, associada à polineuropatia diabética indolor por PainDETECT (R=-0,354, p=0,015), baixo peso corporal (R=-0,354, p=0,015) e grave desmielização de fibras nervosas (R=-0,574, p=0,001), indicaram receptor "não funcionante" detectado no soro. Conclusão: A sinalização do receptor da tropomiosina quinase B está envolvida na modulação da dor neuropática e obesidade na polineuropatia diabética.

Diabetes mellitus tipo 2 de inicio en paciente joven: implicancias en la población chilena / Young-onset type 2 diabetes mellitus: implications in the chilean population

La diabetes mellitus tipo 2 (DM2), habitualmente asociada a adultos en edad media y adulto mayor, ha presentado un aumento en su incidencia en pacientes menores de 40 años, lo que se conoce como DM2 de inicio en paciente joven. Varios estudios sugieren que este tipo de diabetes presenta no sólo un deterioro más rápido de las células beta-pancreáticas en comparación con la DM2 de inicio más tardío, sino que también un mayor riesgo de complicaciones que pacientes con DM Tipo1, lo que sugiere una variable independiente de los años de exposición a la enfermedad y por tanto, un fenotipo más agresivo. Por otra parte, hay evidencia que afirma que existen grupos poblacionales en mayor riesgo de desarrollar esta patología, particularmente ciertas etnias. En el presente trabajo se exponen los principales hallazgos de una reciente revisión del tema y se los compara con los datos nacionales disponibles. Dada la alta prevalencia de DM2 en la población chilena y la escasa cantidad de estudios epidemiológicos de calidad que permitan conocer nuestro panorama con mayor precisión, es que se destaca la importancia de estos últimos para poder tomar medidas de salud pública adecuadas.

Type 2 diabetes mellitus type 2 (T2DM), commonly associated with the middle to old aged adults group, has shown an increase in incidence in patients younger than 40 years old, which is known as young-onset type 2 diabetes mellitus. Several studies suggest that this type of diabetes not only exhibits a faster deterioration of the beta-pancreatic cells in comparison with type 1 diabetes mellitus patients, but also a greater risk of complications not regarding the time of exposure to the disease, therefore a more aggressive phenotype. Otherwise, there is evidence which asserts that some population groups are in mayor risk of developing this disease, especially certain ethnics. In this work it is exposed the main findings of a recent review of the subject and it is contrasted with available national data. Given the high prevalence of T2DM in the chilean population and the little amount of epidemiological high-quality studies that allows us to know our outlook with greater precision, it is highlighted the need for them in order to make adequate public health decisions.

Dragon-tiger fighting needling therapy in treatment of painful diabetic peripheral neuropathy: a randomized controlled trial / 中国针灸

OBJECTIVE@#To compare the clinical therapeutic effect on painful diabetic peripheral neuropathy (PDPN) between dragon-tiger fighting needling and pregabalin capsules.@*METHODS@#A total of 60 patients with PDPN were randomized into an observation group and a control group, 30 cases in each one. On the base of treatment with routine anti-hyperglycaemic measures and nutritional neurotherapy, the dragon-tiger fighting needling was exerted at Sanyinjiao (SP 6), Zusanli (ST 36), Yinlingquan (SP 9) and Xuehai (SP 10) in the observation group, once daily. Pregabalin capsules were prescribed for oral administration in the control group, 75 mg, twice a day. The treatment for 2 weeks was as one course and 2 courses of treatment were required in total. The score of visual analogue scale (VAS), the score of MOS item short form health survey (SF-36) and nerve conduction velocity before and after treatment were compared between the two groups. The clinical therapeutic effect was evaluated in the two groups.@*RESULTS@#After treatment, VAS score was reduced as compared with before treatment in the two groups (@*CONCLUSION@#The dragon-tiger fighting needling therapy relieves painful symptoms, improves the quality of life and increases nerve conduction velocity in the patients with diabetic peripheral neuropathy, and the therapeutic effect is better than oral administration of pregabalin capsules.

Acupuncture at / 中国针灸

OBJECTIVE@#To observe the effect of acupuncture at @*METHODS@#Sixty patients with type-2 diabetic peripheral neuropathy were randomly divided into an observation group and a control group, 30 cases in each one. Both groups were treated with basic treatment, and the observation group was additionally treated with acupuncture at Neiting (ST 44), Xiangu (ST 43), Dadu (SP 2), Taibai (SP 3), Zusanli (ST 36), etc. once every other day, 3 times a week for 4 weeks. The changes of TCM symptom score, Toronto clinical assessment (TCSS) score, visual analogue scale (VAS) score of pain and serum tumor necrosis factor α(TNF-α) level were observed before and after treatment in the two groups, and the clinical effects of the two groups were evaluated.@*RESULTS@#Compared before treatment, the TCM syndrome score and the TCSS score in the two groups were reduced after treatment (@*CONCLUSION@#Acupuncture at

Clinical comprehensive evaluation of Mudan Granules in treatment of diabetic peripheral neuropathy with Qi-deficiency and collateral stagnation syndrome / 中国中药杂志

This study explored the clinical comprehensive evaluation of Mudan Granules, aiming to promote the safe, effective and rational use of Mudan Granules, reflect its clinical value and provide a basis for medical decision-making. The safety, effectiveness, economy, innovation, suitability, accessibility, and characteristics of traditional Chinese medicine of Mudan Granules were combed, and the multi-criteria decision analysis(MCDA) model was used to carry out comprehensive evaluation on each dimension. In terms of safety, multiple sources of evidence showed that the adverse reactions of Mudan Granules mainly involved gastrointestinal system, with controllable safety risk rated as grade B. In terms of effectiveness, Mudan Granules can significantly alleviate the diabetic peripheral neuropathy(Qi-deficiency and collateral stagnation syndrome), limb and trunk numbness, pain and sensory abnormalities and other clinical symptoms, exhibiting positive curative effect rated as grade A. In terms of economy, Mudan Granules combined with Mecobalamin and other conventional western medicines is economical compared with the western medicine alone group, which is supported by sufficient evidence and clear results, rated as grade B. In terms of innovation, Mudan Granules is the only Chinese patent medicine with the indication of benefiting Qi for activating blood circulation and dredging collaterals in the Medicine Catalogue for National Basic Medical Insurance, Industrial Injury Insurance, and Maternity Insurance. It has important clinical innovation and is evaluated as grade A. In the aspect of suitability, Mudan Granules has good suitability in ADR treatment, drug characteristics and usage, and is rated as grade B. In terms of accessibility, Mudan Granules has the price level comparable to that of similar drugs, with good affordability. The resources of medicinal materials for the preparation of Mudan Granules are abundant and available, which is rated grade B. Moreover, Mudan Granules, as a hospital preparation with both functions of tonification and purgation, reflects the combination between syndrome differentiation and disease differentiation as well as the combination between overall and local characteristics, and has prominent Chinese medicine features. According to the above dimensions, we suggest to classify Mudan Granules as a class A preparation which can be directly included the policy results of basic clinical drug administration.