Peripheral sensory nerve dysfunction in children and adolescents with type 1 diabetes mellitus

No clear evidence of neuropathy among patients with high risk for the development of prediabetes/diabetes-a pilot study

Introduction

Autonomic and sensory neuropathy have been observed in both prediabetes and manifest diabetes mellitus. However, there is a lack of available data regarding whether patients at a moderate or high risk of developing diabetes, yet without a current diagnosis of prediabetes or diabetes, exhibit an increased prevalence of neuropathy.

Methods

FINDRISC (Finnish Diabetes Risk Score) was used to classify individuals at risk (≥12 points, n = 44; control <12 points, n = 28). HbA1c levels >5.6% served as exclusion criteria, and patients with known medical conditions predisposing to neuropathy were also excluded. Cardiac autonomic function (Ewing tests) and peripheral sensory neuropathy (Neurometer and Q-sense) were assessed by standardized protocols, and their potential association with increased FINDRISC points was analyzed using a regression model.

Results

Mean age was 46.7 ± 14.3 years in the control and 55.7 ± 14.1 years in the increased risk group. Male/female ratio did not differ. Individuals with increased risk of diabetes were more obese (BMI: 29.9 ± 12.5 kg/m2 vs. 25.9 ± 8.9 kg/m2). Additionally, hypertension was more frequent among them (68.2% vs. 17.9%), and their lipid parameters were also less favorable. Parasympathetic neuropathy was present in both groups (56.8% vs. 32.1%, respectively). Sympathetic neuropathy was not found. Sensory nerve dysfunction was of low prevalence in the high-risk group and did not occur in healthy controls. In multiple logistic regression analysis, HbA1c exhibited an independent association with parasympathetic neuropathy (OR: 5.9; 95% CI: 1.08-32.68; p < 0.041).

Discussion

An increased risk of developing prediabetes/diabetes does not appear to have a strong correlation with an increased likelihood of developing autonomic or sensory neuropathy. However, the etiology behind the occurrence of parasympathetic autonomic neuropathy in healthy individuals remains unknown.

A Review of Recent Pharmacological Advances in the Management of Diabetes-Associated Peripheral Neuropathy

Diabetic peripheral neuropathy is a common complication of longstanding diabetes mellitus. These neuropathies can present in various forms, and with the increasing prevalence of diabetes mellitus, a subsequent increase in peripheral neuropathy cases has been noted. Peripheral neuropathy has a significant societal and economic burden, with patients requiring concomitant medication and often experiencing a decline in their quality of life. There is currently a wide variety of pharmacological interventions, including serotonin norepinephrine reuptake inhibitors, gapentanoids, sodium channel blockers, and tricyclic antidepressants. These medications will be discussed, as well as their respective efficacies. Recent advances in the treatment of diabetes mellitus with incretin system-modulating drugs, specifically glucagon-like peptide-1 agonists, have been promising, and their potential implication in the treatment of peripheral diabetic neuropathy is discussed in this review.

Redefining distal symmetrical polyneuropathy features in type 1 diabetes: a systematic review

Diabetic neuropathy is among the most frequent complications of both type 1 (T1DM) and type 2 diabetes (T2DM) and commonly manifests as a distal symmetrical polyneuropathy (DSPN). Despite evidence that T1DM- and T2DM-related DSPN are separate entities, most of our knowledge on diabetic DSPN derives from studies focused on type 2 diabetes. This systematic review provides an overview of current evidence on DSPN in T1DM, including its epidemiological, pathophysiological and clinical features, along with principal diagnostic tests findings. This review included 182 clinical and preclinical studies. The results indicate that DSPN is a less frequent complication in T1DM compared with T2DM and that distinctive pathophysiological mechanisms underlie T1DM-related DSPN development, with hyperglycemia as a major determinant. T1DM-related DSPN more frequently manifests with non-painful than painful symptoms, with lower neuropathic pain prevalence compared with T2DM-associated DSPN. The overt clinical picture seems characterized by a higher prevalence of large fiber-related clinical signs (e.g., ankle reflexes reduction and vibration hypoesthesia) and to a lesser extent small fiber damage (e.g., thermal or pinprick hypoesthesia). These findings as a whole suggest that large fibers impairment plays a dominant role in the clinical picture of symptomatic T1DM-related DSPN. Nevertheless, small fiber diagnostic testing shows high diagnostic accuracy in detecting early nerve damage and may be an appropriate diagnostic tool for disease monitoring and screening.

Diabetic neuropathy in children and youth: New and emerging risk factors

Pediatric neuropathy attributed to metabolic dysfunction is a well-known complication in children and youth with type 1 diabetes. Moreover, the rise of obesity and in particular of type 2 diabetes may cause an uptick in pediatric neuropathy incidence. However, despite the anticipated increase in neuropathy incidence, pathogenic insights and strategies to prevent or manage neuropathy in the setting of diabetes and obesity in children and youth remain unknown. Data from adult studies and available youth cohort studies are providing an initial understanding of potential diagnostic, management, and preventative measures in early life. This review discusses the current state of knowledge emanating from these efforts, with particular emphasis on the prevalence, clinical presentation, diagnostic approaches and considerations, and risk factors of neuropathy in type 1 and type 2 diabetes in children and youth. Also highlighted are current management strategies and recommendations for neuropathy in children and youth with diabetes. This knowledge, along with continued and sustained emphasis on identifying and eliminating modifiable risk factors, completing randomized controlled trials to assess effectiveness of strategies like weight loss and exercise, and enhancing awareness to support early detection and prevention, are pertinent to addressing the rising incidence of neuropathy associated with diabetes and obesity in children and youth.

Peripheral and Autonomic Neuropathy Status of Young Patients With Type 1 Diabetes Mellitus at the Time of Transition From Pediatric Care to Adult-Oriented Diabetes Care

INTRODUCTION

The prevalence of neuropathic lesions in young patients with type 1 diabetes mellitus (T1DM) at the time of transition from pediatric care to adult-oriented diabetes care is poorly studied. A comparative study with healthy volunteers to assess the possible neuropathic condition of this special population and to identify the potential early screening needs has not been performed yet. The results may provide important feedback to pediatric diabetes care and a remarkable baseline reference point for further follow up in adult diabetes care.

PATIENTS AND METHODS

Twenty-nine young patients with T1DM [age: 22.4 ± 2.9 years; HbA1c: 8.5 ± 2.1%, diabetes duration: 12.2 ± 5.8 years; (mean ± SD)] and 30 healthy volunteers (age: 21.5 ± 1.6 years; HbA1c: 5.3 ± 0.3%) were involved in the study. Autonomic function was assessed by standard cardiovascular reflex tests. Complex peripheral neuropathic testing was performed by Neurometer^®, Neuropad^®-test, Tiptherm^®, Monofilament^®, and Rydel-Seiffer tuning fork tests.

RESULTS

T1DM patients had significantly higher diastolic blood pressure than controls (80 ± 9 vs. 74 ± 8 mmHg, p < 0.01), but there was no significant difference in systolic blood pressure (127 ± 26 vs. 121 ± 13 mmHg). Cardiovascular reflex tests had not revealed any significant differences between the T1DM patients and controls. No significant differences with Neurometer^®, Neuropad^®-test, and Monofilament^® were detected between the two groups. The vibrational sensing on the radius on both sides was significantly impaired in the T1DM group compared to the controls with Rydel-Seiffer tuning fork test (right: 7.5 ± 1.0 vs. 7.9 ± 0.3; left: 7.5 ± 0.9 vs. 7.9 ± 0.3, p < 0.05). The Tiptherm^®-test also identified a significant impairment in T1DM patients (11 sensing failures vs. 1, p < 0.001). In addition, the neuropathic complaints were significantly more frequently present in the T1DM patient group than in the controls (9 vs. 0, p < 0.01).

CONCLUSION

In this young T1DM population, cardiovascular autonomic neuropathy and cardiac morphological alterations could not be found. However, Rydel-Seiffer tuning fork and Tiptherm^®-tests revealed peripheral sensory neurological impairments in young T1DM patients at the time of their transition to adult diabetes care.

Diabetic neuropathy in children and adolescents with type 1 diabetes mellitus: Diagnosis, pathogenesis, and associated genetic markers

Diabetic neuropathy (DN) is a common long-term complication of type 1 (T1D) and type 2 (T2D) diabetes mellitus, with significant morbidity and mortality. DN is defined as impaired function of the autonomic and/or peripheral nervous system, often subclinical, particularly in children and adolescents with T1D. Nerve conduction studies (NCS) and skin biopsies are considered gold-standard methods in the assessment of DN. Multiple environmental and genetic factors are involved in the pathogenesis of DN. Specifically, the role of metabolic control and glycemic variability is of paramount importance. A number of recently identified genes, including the AKR1B1, VEGF, MTHFR, APOE, and ACE genes, contribute significantly in the pathogenesis of DN. These genes may serve as biomarkers to predict future DN development or treatment response. In addition, they may serve as the basis for the development of new medications or gene therapy. In this review, the diagnostic evaluation, pathogenesis, and associated genetic markers of DN in children and adolescents with T1D are presented and discussed.

Development of a youth-report measure of DPN symptoms: Conceptualization and content validation

Aims

To develop a content valid youth-report measure of diabetic peripheral neuropathy (DPN) symptoms.

Methods

Semi-structured interviews with 5 clinicians and 15 youth aged 8–17 with diabetes were conducted to elicit and clarify youth’s DPN experiences. A systematic review of existing adult-report DPN symptom measures was conducted to identify item concepts representative of each experience. The concepts were transformed into items that were iteratively revised based on cognitive interviews (n = 13 youth aged 8–17) and readability analyses.

Results

Clinician and youth interviews supported a tripartite conceptual framework of youth DPN symptoms: paresthesia, pain, and anesthesia. Forty-eight youth-report items were generated to represent DPN symptoms identified through the semi-structured interviews and a systematic review of 13 symptom questionnaires for adults. Of these, 23 were eliminated and 3 were revised based on cognitive interviews conducted with youth. The remaining 25 items were on average, written at a 3rd grade reading level.

Conclusions

This study is the first to generate a content valid self-report measure of youth’s lived experiences with DPN that uses developmentally appropriate terminology. With further psychometric testing, the measure could be used to advance research on pediatric DPN and enhance clinicians’ capacity to identify the condition in childhood.

Is there a connection between postprandial hyperglycemia and IGT related sensory nerve dysfunction?

BACKGROUND AND AIMS

To assess the risk factors for sensory nerve dysfunction in subjects with isolated impaired glucose tolerance (IGT).

METHODS AND RESULTS

Seventy-two people with isolated IGT (WHO 1999 criteria) and 39 gender and age-matched healthy volunteers underwent detailed clinical and neurological assessment including quantitative sensory testing using the Neurometer device (current perception threshold measurement on four limbs at three different frequencies). Sensory nerve dysfunction was defined as at least two abnormalities on any frequencies on the upper or lower limbs. Sensory nerve dysfunction was more prevalent among subjects with IGT compared to controls (58.3 vs. 10.3%, OR: 11.23, 95%CI: 3.57-35.35). This association was not influenced by BMI, systolic and diastolic blood pressure, heart rate and autonomic neuropathy (multiple adjusted OR: 13.87, 95%CI: 3.18-60.58), but further adjustment for glycaemic measures abolished the association (OR: 1.58, 95%CI: 0.07-35.68). Assessing the components of glycaemic measures separately, the association between sensory nerve dysfunction and IGT was not affected by HbA1c (OR: 13.94, 95%CI: 1.84-105.5). It was, however, substantially attenuated by fasting plasma glucose (OR: 6.75, 95%CI: 1.33-34.27) while the significance was lost after adjustment for 120 min postload glucose level (OR: 3.76, 95%CI: 0.26-54.10). In the pooled population assessed, independent determinants of sensory nerve dysfunction were older age, 120 min glucose, higher height and cardiovascular autonomic neuropathy at near significance.

CONCLUSIONS

Sensory nerve dysfunction amongst subjects with IGT was not explained by cardiovascular covariates, only by glycaemic measures. In addition to 120 min glucose, cardiovascular autonomic neuropathy at borderline significance, age, and height were the independent determinants of sensory nerve dysfunction.

Clinical characteristics and risk factors of diabetic peripheral neuropathy of type 1 diabetes mellitus patients

BACKGROUND

Small nerve fibers are more easily injured than large ones for diabetic peripheral neuropathy (DPN). The study investigated the characteristics and related risk factors of DPN of T1DM patients using nerve conduction velocity and CPT values, which provided evidences for its early diagnosis.

METHODS

70 T1DM patients and 48 healthy volunteers were included. All subjects accepted nerve conduction velocity and CPT examinations for four limbs. Detailed clinical indicators were recorded. CPT values were compared between TIDM group and control group. The risk factors affecting DPN were further explored.

RESULTS

Compared with the control group, CPT values under three frequencies were decreased in T1DM group. The abnormality rate of sural nerves was higher than that of median nerves (P<0.001). Median nerve dysfunction mainly presented as hypoesthesia under 250Hz and 5Hz current stimulus. And sural nerve dysfunction mainly presented as hyperesthesia under three frequencies. Compared with left median nerve, abnormal rate of right median nerve was higher under 2000Hz current stimulus (P=0.035). However, abnormal rate of left sural nerve was higher than that of right side under 250Hz and 5Hz current stimulus (P=0.001, <0.001). Duration, NDS scores and CPT values of right median nerve under 2000Hz current stimulus were independent risk factors of abnormal nerve conduction velocity.

CONCLUSIONS

The study proved that DPN of T1DM are mainly lower limb-injured., amyelinated and thin myelinated nerve fiber-involved. CPT can be combined with traditional nerve conduction velocity examination, which will help the diagnosis of DPN of T1DM earlier and more comprehensively.

Assessment of Peripheral Neuropathy Using Measurement of the Current Perception Threshold with the Neurometer® in patients with type 1 diabetes mellitus

OBJECTIVE

The aim of this study is to evaluate the role of current perception threshold (CPT) measurement in peripheral neuropathy in type 1 diabetic patients by using the Neurometer(®), a nerve measuring instrument.

METHODS

52 patients with type 1 diabetes mellitus with a disease duration of less than five years and normal neuropathy symptom score (NSS), neuropathy disability score (NDS) and sensory nerve conduction velocity (SCV), and 40 healthy controls were enrolled in this study. Measurement of CPT using the Neurometer(®) at 2000, 250 and 5 Hz assesses function in the bilateral median nerve and sural nerve in all studied cases. We also evaluated the glycated hemoglobin, microalbuminuria, urinary albumin/creatinine ratio and other metabolism indexes of all patients.

RESULTS

The CPT of the bilateral median nerve and sural nerve was significantly lower in diabetic patients (P<0.01). Moreover, the number of median nerve injuries in the diabetic group (left side 8/52, right side 8/52) is significantly different from the number of its ipsilateral sural nerve injuries (left side 28/52, right side 22/52) (left side P<0.01, right side P<0.01). By comparing those with DPN and those without DPN in the diabetic group, DPN groups had significantly higher glycated hemoglobin (t=2.518, P<0.05). Using binary logistic regression, high glycated hemoglobin was identified to be an independent risk factor of DPN incidence (OR (95% CI): 1.317 (1.013 -1.712), P<0.05).

CONCLUSION

These data suggest that CPT is useful in early detection of peripheral neuropathy in patients with type 1 diabetes mellitus. Patients with diabetic peripheral neuropathy, the lower limb nerve is more vulnerable than the upper limb nerve. In addition, patients with DPN had higher glycated hemoglobin which is an independent risk factor of DPN.

Reproducibility of vibration perception threshold values in children and adolescents with type 1 diabetes mellitus and associated factors

AIMS

To define the reproducibility of vibration perception thresholds (VPTs) and the possible associated factors, as an early index of peripheral diabetic neuropathy (PDN) in type 1 diabetes mellitus (T1DM) children and adolescents.

METHODS

A single examiner studied 118 T1DM subjects (aged 13.5±3.4 years) and 79 controls (aged 12.0±3.07 years). Glycaemic control was assessed with HbA1c levels. VPT was measured twice on upper and lower limbs, using a Biothesiometer. Concordance between the two VPT measurements was evaluated using the Cohen's Weighted Kappa statistic (Kappa=0.41-0.60→moderate concordance, Kappa=0.61-0.80→substantial concordance).

RESULTS

T1DM children had significantly higher VPTs than controls at all sites (p=0.001), but with lower Kappa values (0.64-0.70). VPT values increased in parallel with HbA1c (a.<8%, b. 8-9.5%, c.>9.5%) and T1DM duration (a.<5 years, b.5.1-10, c.>10 years). However, Kappa values were lower in the groups with the poorest control (HbA1c>9.5%) (Kappa=0.54-0.76) or the longest T1DM duration (>10 years) (Kappa=0.49-0.71). Although VPTs increased with stature and male gender, no effect on VPT reproducibility was observed. However, obesity was associated with lower VPT values and poorer concordance.

CONCLUSIONS

These findings suggest that the reproducibility of VPTs is lower in the high-risk patients for early subclinical PDN development, who need a regular follow-up.

Pudendal and median nerve sensory perception threshold: a comparison between normative studies

BACKGROUND

For the evaluation of sensory innervation, normative data are necessary as a comparison.

AIMS

To compare our current perception thresholds (CPTs) with normative data from other research.

METHODS

Healthy volunteers were assessed for 2000, 250, and 5 Hz CPTs of the median and pudendal nerve and data were compared with other studies.

RESULTS

Normative data in the studied group n = 41 (male: 21; female: 20) for the median nerve, 2 kHz, 250 Hz, and 5 Hz were respectively: 241.85 ± 67.72 (140-444); 106.27 ± 39.12 (45-229); 82.05 ± 43.40 (13-271). Pudendal nerve CPTs 250 Hz were: 126.44 ± 69.46 (6-333). For men 2 kHz: 349.95 ± 125.76 (100-588); 5 Hz: 132.67 ± 51.81 (59-249) and women 2 kHz:226.20 ± 119.65 (64-528); 5 Hz: 92.45 ± 44.66 (35-215). For the median nerve no statistical differences for gender were shown. For the pudendal nerve, only 250 Hz showed no difference for gender (t-test: 0.516). Comparison of our data with CPTs of other normative data showed no agreement for the pudendal nerve. For the median nerve only 2 kHz showed agreement in three studies and for 5 Hz with one study.

CONCLUSION

Comparing normative data of multiple studies shows a variety of results and poor agreement. Therefore, referring to normative data of other studies should be handled with caution.

Type 1 diabetes and cardiovascular disease

The presence of cardiovascular disease (CVD) in Type 1 diabetes largely impairs life expectancy. Hyperglycemia leading to an increase in oxidative stress is considered to be the key pathophysiological factor of both micro- and macrovascular complications. In Type 1 diabetes, the presence of coronary calcifications is also related to coronary artery disease. Cardiac autonomic neuropathy, which significantly impairs myocardial function and blood flow, also enhances cardiac abnormalities. Also hypoglycemic episodes are considered to adversely influence cardiac performance. Intensive insulin therapy has been demonstrated to reduce the occurrence and progression of both micro- and macrovascular complications. This has been evidenced by the Diabetes Control and Complications Trial (DCCT) / Epidemiology of Diabetes Interventions and Complications (EDIC) study. The concept of a metabolic memory emerged based on the results of the study, which established that intensified insulin therapy is the standard of treatment of Type 1 diabetes. Future therapies may also include glucagon-like peptide (GLP)-based treatment therapies. Pilot studies with GLP-1-analogues have been shown to reduce insulin requirements.

Reproducibility of current perception threshold with the Neurometer(®) vs the Stimpod NMS450 peripheral nerve stimulator in healthy volunteers: an observational study

PURPOSE

Current methods of assessing nerve blocks, such as loss of perception to cold sensation, are subjective at best. Transcutaneous nerve stimulation is an alternative method that has previously been used to measure the current perception threshold (CPT) in individuals with neuropathic conditions, and various devices to measure CPT are commercially available. Nevertheless, the device must provide reproducible results to be used as an objective tool for assessing nerve blocks.

METHODS

We recruited ten healthy volunteers to examine CPT reproducibility using the Neurometer(®) and the Stimpod NMS450 peripheral nerve stimulator. Each subject's CPT was determined for the median (second digit) and ulnar (fifth digit) nerve sensory distributions on both hands - with the Neurometer at 5 Hz, 250 Hz, and 2000 Hz and with the Stimpod at pulse widths of 0.1 msec, 0.3 msec, 0.5 msec, and 1.0 msec, both at 5 Hz and 2 Hz. Intraclass correlation coefficients (ICC) were also calculated to assess reproducibility; acceptable ICCs were defined as ≥ 0.4.

RESULTS

The ICC values for the Stimpod ranged from 0.425-0.79, depending on pulse width, digit, and stimulation; ICCs for the Neurometer were 0.615 and 0.735 at 250 and 2,000 Hz, respectively. These values were considered acceptable; however, the Neurometer performed less efficiently at 5 Hz (ICCs for the second and fifth digits were 0.292 and 0.318, respectively).

CONCLUSION

Overall, the Stimpod device displayed good to excellent reproducibility in measuring CPT in healthy volunteers. The Neurometer displayed poor reproducibility at low frequency (5 Hz). These results suggest that peripheral nerve stimulators may be potential devices for measuring CPT to assess nerve blocks.

Changes of the different neuropeptide-containing nerve fibers and immunocells in the diabetic rat's alimentary tract

Peripheral neuropathy is a common complication of diabetes mellitus, where neuropeptides and immunocells might play important roles in the pathogenesis of the disease. In this article we have quantified the different neuropeptide-containing nerve fibers and immunocells in the streptozotocin-induced diabetic rat's alimentary tract (tongue, duodenum, colon) using immunohistochemical and immunocytochemical methods. The immunoreactive (IR) nerve fibers were found in all layers of the alimentary tract and their distribution pattern was similar in both control and diabetic groups. Mast cell-nerve fiber contacts were rarely found in the controls. However, after 4 weeks duration of diabetes the number of IR nerve fibers and the immunocompetent cells increased significantly (P < 0.05), and the number of mast cell-nerve fiber contacts was even more significantly increased (P < 0.001). The distance between nerve fibers and immunocells was about 1 mum or even less. Some of the mast cells were degranulated in the vicinity of nerve fibers. No immunocompetent cells were IR for any antisera in the control. However, after the streptozotocin treatment, a large number of the immunocompetent cells showed immunoreactivity for SP and NPY. Counting all immunocompetent cells in whole sections showed that 12.3% of them were IR for SP and 25.4% were IR for NPY. Increased number of SP-containing nerve fibers and immunocells in diabetes mellitus might be the reason for painful neuropathy and might amplify the inflammatory reaction in an axon reflex manner; the released histamine and leukotrienes, cytokines, and chemokines might cause inflammations and lesions of the mucosa.

Prevalence of diabetes complications in adolescents with type 2 compared with type 1 diabetes

OBJECTIVE

To compare the prevalence of diabetes complications and their risk factors in youth with type 1 versus type 2 diabetes.

RESEARCH DESIGN AND METHODS

We performed a comparative clinic-based study of 1,433 patients with type 1 diabetes and 68 patients with type 2 diabetes aged <18 years from New South Wales, Australia. Retinopathy was assessed by seven-field stereoscopic retinal photography; albumin excretion rate from three consecutive, timed, overnight urine collections; peripheral neuropathy by thermal and vibration threshold; and autonomic neuropathy by pupillometry. HbA(1c) (A1C) and lipids were measured in all patients and C-peptide in patients with type 2 diabetes.

RESULTS

In patients with type 1 versus type 2 diabetes, median (interquartile range) age was 15.7 years (13.9-17.0) and 15.3 years (13.6-16.4), respectively (P = 0.2), whereas median diabetes duration was 6.8 years (4.7-9.6) and 1.3 years (0.6-3.1), respectively (P < 0.0001). Retinopathy was significantly more common in patients with type 1 diabetes (20 vs. 4%, P = 0.04), while microalbuminuria and hypertension were significantly less common (6 and 16% in type 1 diabetes vs. 28 and 36% in type 2 diabetes). Rates of peripheral and autonomic neuropathy were similar (27 and 61% in type 1 diabetes vs. 21 and 57% in type 2 diabetes). In multivariate analyses, microalbuminuria was significantly associated with older age (odds ratio 1.3 [95% CI 1.2-1.5], P < 0.001) and systolic hypertension (3.63 [2.0-6.3], P < 0.001) in type 1 diabetes, while only higher A1C (1.7 [1.3-2.9], P = 0.002) was significant in patients with type 2 diabetes.

CONCLUSIONS

Youth with type 2 diabetes have significantly higher rates of microalbuminuria and hypertension than their peers with type 1 diabetes, despite shorter diabetes duration and lower A1C. The results of this study support recommendations for early complications screening and aggressive targeting of glycemic control in patients with type 2 diabetes.

Persistent Neuropathy and Hyperkeratosis from Distant Arsenic Exposure

The purpose of this case series is to assess long-term sequelae of arsenic exposure in a cohort acutely exposed to arsenic in drinking water from a well dug into a landfill containing arsenical pesticides. Ten of the 13 individuals (or next of kin) in the initial study agreed to participate in the follow-up study. Next of kin provided questionnaire data and released medical information on the three individuals who had died. The remaining seven cohort members were assessed by an interview, questionnaire, detailed physical examination and sensory nerve testing. Available medical records were obtained and reviewed. Sensory testing was performed using an automated electrodiagnostic sensory Nerve Conduction Threshold (sNCT) evaluation. Sensory complaints and electrodiagnostic findings consistent with polyneuropathy were found in a minority (3/7) of subjects 28 years after an acute toxic arsenic exposure. Two of the seven patients examined (1 of 3 with neuropathic findings) also had hyperkeratotic lesions consistent with arsenic toxicity and one of the patients had hyperpigmentation on their lower extremities possibly consistent with arsenic toxicity.

Nerve conduction in children suffering insulin dependent diabetes mellitus

OBJECTIVE

To determine the incidence of peripheral neuropathy in children suffering Insulin Dependent Diabetes Mellitus (IDDM) as well as to determine the relationship between other criteria of the disease and neuropathy.

METHODS

40 children (17 males, mean age 11.9 years) suffering IDDM and receiving insulin therapy involving two injections a day and 30 healthy children (17 males, mean age 11.7 years) were included in the study. They were inquired about their demographical characteristics as well as the presence of neurological symptoms. Their detailed neurological examinations were conducted. Their glycemic control values (Hb A1C) were recorded, and their nerve conduction studies were performed from right upper and lower extremities.

RESULTS

All nerve conduction values of children with IDDM were found to be significantly lower (p<0.0001) as compared to the control group. 60% of diabetic children (n=24) were found to suffer peripheral neuropathy. Statistically significant relationships were found between the glycemic control values and the peroneal, sural, tibial, ulnar and median nerve conduction velocities, and also between the duration of disease and the peroneal, sural, tibial and median nerve conduction velocities.

CONCLUSION

The peripheral neuropathy is rather a frequently observed complication in diabetic children. The duration of disease and impaired glycemic control play an important role in the development of neuropathy. The introduction of new methods designed to ensure better glycemic control will reduce the incidence of the complication.

Early diabetes-related complications in children and adolescents with type 1 diabetes. Implications for screening and intervention

Although children and adolescents with type 1 diabetes are faced with the threat of the acute complications of hypoglycemia and ketoacidosis on a day-to-day basis, in the long-term, the microvascular and macrovascular complications of the disease place them at greatest risk for serious morbidity and earlier than expected mortality. The families of children with diabetes should be provided with information about the complications of diabetes beginning at the time of diagnosis, and this information needs to be reinforced throughout the follow-up period. Appropriate surveillance for the earliest evidence of microvascular disease should begin at the onset of puberty and after 3 to 5 years of diabetes. Therapeutic interventions, particularly excellent metabolic control, may be exceedingly effective in preventing complication onset or significantly retarding the rate of progression.