The assessment of clinical distal symmetric polyneuropathy in type 1 diabetes: a comparison of methodologies from the Pittsburgh Epidemiology of Diabetes Complications Cohort.

Distal symmetrical polyneuropathy (DSP) is the most common type of diabetic neuropathy, but often difficult to diagnose reliably. We evaluated the cross-sectional association between three point-of-care devices, Vibratron II, NC-stat(®), and Neurometer(®), and two clinical protocols, MNSI and monofilament, in identifying those with DSP, and/or amputation/ulcer/neuropathic pain (AUP), the two outcomes of major concern. This report presents data from 195 type 1 diabetic participants of the Epidemiology of Diabetes Complications (EDC) Study attending the 18-year examination (2004-2006). Participants with physician-diagnosed DSP, AUP or who were abnormal on the NC-stat, and the Vibratron II, MNSI, and monofilament were older (p<0.05) and had a longer duration of diabetes (p < 0.05). There was no difference by sex for DSP, AUP, or any testing modality, with the exception of NCstat (motor). The Vibratron II and MNSI showed the highest sensitivity for DSP (>87%) and AUP (>80%), whereas the monofilament had the highest specificity (98% DSP, 94% AUP) and positive predictive value (89% DSP, 47% AUP), but lowest sensitivity (20% DSP, 30% AUP). The MNSI also had the highest negative predictive value (83%) and Youden's Index (37%) and currently presents the single best combination of sensitivity and specificity of DSP in type 1 diabetes.

Risk factor associations with clinical distal symmetrical polyneuropathy and various neuropathy screening instruments and protocols in type 1 diabetes.

OBJECTIVE: To determine whether DSP and neuropathy-assessment instruments used by non-physicians have similar risk factors. RESEARCH DESIGN AND METHODS: analyses were cross-sectional (n=176). RESULTS: risk factors were similar for DSP and screening devices. CONCLUSIONS: these data support the clinical utility of neuropathy screening devices used by non-physician personnel.

Does diabetes-related distress explain the presence of depressive symptoms and/or poor self-care in individuals with Type 1 diabetes?

AIMS: To examine the relationship between depressive symptomatology, diabetes-related distress and aspects of diabetes self-care in a cohort of individuals with Type 1 diabetes. METHODS: Individuals with Type 1 diabetes taking part in the Pittsburgh Epidemiology of Diabetes Complications Study completed the Beck Depression Inventory (BDI), the Center for Epidemiologic Studies Depression (CES-D) Scale and the Problem Areas in Diabetes (PAID) scale. Self-care was measured by physical activity in the past week and over the previous year, frequency of blood glucose/urine testing, smoking status and alcohol intake. RESULTS: Clinically significant levels of depressive symptomatology (i.e. scores >or= 16) were reported by 14% of the study population on the BDI and by 18% on the CES-D. There were strong correlations between depressive symptoms and diabetes-related distress (PAID scores) and physical activity. Multivariate analyses indicated that depression was independently associated with diabetes-related distress scores and with physical activity, but not with frequency of blood glucose testing. CONCLUSIONS: These findings have implications for clinical practice and treatment of both psychological morbidity and diabetes. There may be significant effects of depression on aspects of diabetes self-care. Further prospective studies are required to confirm these findings.

Hypertension as a risk factor for diabetic neuropathy: a prospective study.

The pathogeneses of diabetic neuropathy is still unclear. This study prospectively investigated the risk factors for distal symmetrical polyneuropathy (DSP) in a cohort of childhood-onset IDDM patients. Subjects from the Epidemiology of Diabetes Complications (EDC) Study were clinically examined at baseline and then biennially. DSP was diagnosed by a combination of clinical criteria, symptoms and signs (Diabetes Control and Complications Trial [DCCT] exam), and quantitative sensory threshold (QST). Among the 463 (70.4%) subjects who were free of DSP at baseline, 453 (97.8%) participated in at least one biennial reexamination during the first 6 years of follow-up and were included in the current analysis. A total of 68 (15.0%) subjects developed DSP in 6 years, giving a cumulative probability of 0.29. The Cox proportional hazards model shows that longer IDDM duration, hypertension, poor glycemic control, height, and smoking were all independent predictors of the incidence of DSP (all P < 0.0001, except for smoking for which P = 0.03). Hypertension showed the greatest impact on the development of DSP for individuals with either short or long IDDM duration. This study confirms some risk factors for DSP found in cross-sectional studies and suggests a strong relationship between hypertension and DSP. The results indicate that in addition to good glycemic control, avoidance of smoking and good blood pressure control may be helpful in preventing or delaying the onset of DSP in IDDM patients.

Deep vein thrombosis: prevention in stroke patients during rehabilitation.

Deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE) is a major source of mortality and morbidity in stroke patients. This study was designed to determine the effectiveness of different prophylactic treatments in the prevention of DVT after a stroke in patients undergoing rehabilitation. An additional objective was the identification of risk factors for DVT in stroke in patients during rehabilitation. Three hundred and sixty patients, over a 3-year period, were randomly assigned to one of four groups: adjusted dose heparin, intermittent pneumatic compression (IPC), functional electrical stimulation (FES), or control. There was no significant difference in the development of DVT by treatment group. Patients with DVT on admission (prevalent, n = 61) were compared with the study patients (n = 360). Time interval (from stroke to admission) and lactic dehydrogenase (LDH) concentration were significant risk factors, as well as predictors, for development of DVT (p < .000). These results suggest that the longer a patient remains without DVT prophylaxis after a stroke, the greater the risk of developing DVT and this supports early prophylaxis before rehabilitation.

Accuracy and reliability of the Caltrac accelerometer for estimating energy expenditure.

The Caltrac accelerometer is designed to assess energy expenditure during normal activity. The aims of the present study were (a) to determine the interinstrument and intersession reliability of the Caltrac and (b) to validate these instruments with measures of oxygen uptake (VO2) and determine whether Caltracs accurately reflect differences in energy expenditure due to sex, body weight, and speed. Caltracs were found to have very good interinstrument and intersession reliability and to accurately reflect differences in expenditure due to sex, weight, and speed. However, Caltracs consistently over-estimated energy expenditure by an average of 9-13%. The absolute percent error (percent error without consideration of the sign) of the Caltrac was greater, averaging 23%. The correlations between Caltrac and VO2 averaged 0.68-0.74. Thus, the Caltracs seem well suited for studies of activity level of groups, but may be less useful in estimating an individual's activity.

The assessment of historical physical activity and its relation to adult bone parameters.

The aim of the present research was to determine the association between historical physical activity and baseline bone measurements in a group of 223 postmenopausal women participating in a clinical trial in Pittsburgh, Pennsylvania, from 1981 to 1986 by evaluating the effect of moderate physical activity on bone loss. Historical physical activity was assessed by a survey which divided the life span into four time periods (14-21, 22-34, 35-50, and 50+ years) and inquired about participation in leisure time physical activities for each period. From the responses, kilocalories of energy expenditure were calculated. Cortical bone density and area were measured in the radius with a computerized tomography scanner. The historical physical activity survey was administered a second time two to three months after the initial test to a 10% random sample of the women in order to determine the test-retest reliability of the instrument. Since the measurements of historical physical activity proved to be reliable, estimates of kilocalories determined for the entire population of women were correlated with bone area and density. A significant relation was found to exist between historical physical activity and dimensions of adult bone, particularly bone area. This association remained significant after adjustment for potential confounding variables and seemed to be strongest in the earlier age periods. To the authors' knowledge, this is the first report of a significant association between historical physical activity and bone.

A two year randomized exercise trial in older women: effects on HDL-cholesterol.

Most of the research on the level of high density lipoprotein cholesterol (HDL-C) and physical activity (PA) has been cross-sectional and thus self-selection of the exercisers may occur. In the current research, 229 white postmenopausal women, mean age 57.7 years, were randomized into either a walking or a control group. Of these 229 women, 204 women had blood samples available for lipid determinations. PA was measured subjectively by the Paffenbarger Survey and objectively with activity monitors. At baseline, there were no differences in PA, total HDL-C (HDL-TC), HDL-2C or HDL-3C between the two randomized groups. After two years, the PA of the walking group was significantly higher than the PA of the control group. This increase in PA was not accompanied by changes in any of the lipids or lipoproteins. Examination of the lipid changes in the walking group by compliance status and actual activity changes revealed little difference between groups. These results suggest that it is possible to increase physical activity in older women. However, the long-term effects of the increased activity on HDL-C were not apparent despite an observed strong cross-sectional relationship between PA and HDL-C.

A randomized exercise trial in older women: increased activity over two years and the factors associated with compliance.

The health effects of increased physical activity in the prevention or treatment of any disease can only be meaningfully assessed if compliance to the exercise regimen is maintained. The current research examined compliance in a clinical trial investigating the effect of walking on bone loss in 229 postmenopausal women, randomized into either a walking or a control group. Although at baseline there was no difference in physical activity between the two groups, after a period of 2 yr, the walking group reported significantly greater physical activity as measured by reported mean blocks walked daily and objective activity monitor day readings. Closer examination of the walking group revealed that compliers (average 7+ miles walked/wk over the 2 yr), when compared to non-compliers, tended at baseline to be more active, lighter weight, and non-smokers. However, the variable that best differentiated between the two compliance groups was the frequency of reported illness over the 2-yr period, with compliers claiming significantly less illness.