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Ziegler D, Winter K, Strom A, Zhivov A, Allgeier S, Papanas N, Ziegler I, Brüggemann J, Ringel B, Peschel S, Köhler B, Stachs O, Guthoff RF, Roden M. Spatial analysis improves the detection of early corneal nerve fiber loss in patients with recently diagnosed type 2 diabetes. PLoS One 2017; 12:e0173832. [PMID: 28296936 PMCID: PMC5352008 DOI: 10.1371/journal.pone.0173832] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 02/27/2017] [Indexed: 12/15/2022] Open
Abstract
Corneal confocal microscopy (CCM) has revealed reduced corneal nerve fiber (CNF) length and density (CNFL, CNFD) in patients with diabetes, but the spatial pattern of CNF loss has not been studied. We aimed to determine whether spatial analysis of the distribution of corneal nerve branching points (CNBPs) may contribute to improving the detection of early CNF loss. We hypothesized that early CNF decline follows a clustered rather than random distribution pattern of CNBPs. CCM, nerve conduction studies (NCS), and quantitative sensory testing (QST) were performed in a cross-sectional study including 86 patients recently diagnosed with type 2 diabetes and 47 control subjects. In addition to CNFL, CNFD, and branch density (CNBD), CNBPs were analyzed using spatial point pattern analysis (SPPA) including 10 indices and functional statistics. Compared to controls, patients with diabetes showed lower CNBP density and higher nearest neighbor distances, and all SPPA parameters indicated increased clustering of CNBPs (all P<0.05). SPPA parameters were abnormally increased >97.5th percentile of controls in up to 23.5% of patients. When combining an individual SPPA parameter with CNFL, ≥1 of 2 indices were >99th or <1st percentile of controls in 28.6% of patients compared to 2.1% of controls, while for the conventional CNFL/CNFD/CNBD combination the corresponding rates were 16.3% vs 2.1%. SPPA parameters correlated with CNFL and several NCS and QST indices in the controls (all P<0.001), whereas in patients with diabetes these correlations were markedly weaker or lost. In conclusion, SPPA reveals increased clustering of early CNF loss and substantially improves its detection when combined with a conventional CCM measure in patients with recently diagnosed type 2 diabetes.
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Affiliation(s)
- Dan Ziegler
- Institute for Clinical Diabetology, German Diabetes Center at Heinrich Heine University, Leibniz Center for Diabetes Research, Düsseldorf, Germany
- Department of Endocrinology and Diabetology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
- * E-mail:
| | - Karsten Winter
- Institute of Anatomy, University of Leipzig, Leipzig, Germany
| | - Alexander Strom
- Institute for Clinical Diabetology, German Diabetes Center at Heinrich Heine University, Leibniz Center for Diabetes Research, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Andrey Zhivov
- Department of Ophthalmology, University of Rostock, Rostock, Germany
| | - Stephan Allgeier
- Institute for Applied Computer Science, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | - Nikolaos Papanas
- Institute for Clinical Diabetology, German Diabetes Center at Heinrich Heine University, Leibniz Center for Diabetes Research, Düsseldorf, Germany
| | - Iris Ziegler
- Institute for Clinical Diabetology, German Diabetes Center at Heinrich Heine University, Leibniz Center for Diabetes Research, Düsseldorf, Germany
| | - Jutta Brüggemann
- Institute for Clinical Diabetology, German Diabetes Center at Heinrich Heine University, Leibniz Center for Diabetes Research, Düsseldorf, Germany
| | - Bernd Ringel
- Institute for Clinical Diabetology, German Diabetes Center at Heinrich Heine University, Leibniz Center for Diabetes Research, Düsseldorf, Germany
| | - Sabine Peschel
- Department of Ophthalmology, University of Rostock, Rostock, Germany
| | - Bernd Köhler
- Institute for Applied Computer Science, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | - Oliver Stachs
- Department of Ophthalmology, University of Rostock, Rostock, Germany
| | - Rudolf F. Guthoff
- Department of Ophthalmology, University of Rostock, Rostock, Germany
| | - Michael Roden
- Institute for Clinical Diabetology, German Diabetes Center at Heinrich Heine University, Leibniz Center for Diabetes Research, Düsseldorf, Germany
- Department of Endocrinology and Diabetology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
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Papanas N, Ziegler D. New vistas in the diagnosis of diabetic polyneuropathy. Endocrine 2014; 47:690-8. [PMID: 24839196 DOI: 10.1007/s12020-014-0285-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 05/02/2014] [Indexed: 01/01/2023]
Abstract
New modalities are now available to improve the diagnosis of diabetic polyneuropathy (DPN). The present review discusses the progress achieved in this area. First, the minimal diagnostic criteria have been better clarified. Moreover, there are now new bedside tests available, such as the indicator test Neuropad, NeuroQuick, Ipswich Touch Test (IpTT), Vibratip, NC-stat(®)/DPNCheck™ for automated nerve conduction study (NCS), tactile circumferential discriminator, steel ball-bearing, and SUDOSCAN(®), while more sophisticated modalities include skin biopsy and corneal confocal microscopy (CCM). Some tests can be used as screening tools, including primary care setting (Neuropad, IpTT, Vibratip, automated NCS), while others are more suitable for research, including evaluation of DPN in prospective studies (CCM, skin biopsy). Importantly, there is some evidence of earlier DPN diagnosis with the aid of some tests (Neuropad, skin biopsy, CCM). Further advantages provided by different tests are educational value and self-examination. Thus far, the potential of these tests has not been fully utilised. In particular, they have not been validated against standardised clinical examination scores in terms of predicting foot ulcers and amputations. Hence, it now remains to investigate the potential benefits from the widespread use of these tests for earlier and easier diagnosis of DPN in the everyday clinic.
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Affiliation(s)
- Nikolaos Papanas
- Institute for Clinical Diabetology, German Diabetes Center at Heinrich Heine University, Leibniz Center for Diabetes Research, Auf'm Hennekamp 65, 40225, Düsseldorf, Germany
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Abstract
Corneal confocal microscopy (CCM) is a noninvasive method for the study of human cornea in vivo. It has increasingly been used to assess the morphology of the sub-basal corneal nerve plexus. CCM has good reproducibility and may contribute to the early diagnosis of diabetic polyneuropathy. It may also be useful to document favorable changes in nerve fiber structure early after therapeutic intervention. Corneal nerve pathology is more pronounced in patients with diabetic polyneuropathy and is associated with its clinical severity. The sensitivity and specificity of CCM for the diagnosis of polyneuropathy is moderate to high. CCM now merits further use in large longitudinal studies to provide more information on the natural history of diabetic neuropathy and effects of treatment. Moreover, there is a need for a larger normative database. Finally, technical progress is expected to enable visualization of larger corneal areas and improve nerve fiber quantification, increasing diagnostic accuracy.
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Affiliation(s)
- N Papanas
- Institute for Clinical Diabetology, German Diabetes Center at the Heinrich Heine University, Auf'm Hennekamp 65, 40225, Düsseldorf, Germany
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