Diabetic neuropathy

Cost-effectiveness of prevention program for type 2 diabetes mellitus in high risk patients in the Republic of Srpska, Bosnia and Herzegovina

The Republic of Srpska (RS), as a part of the Western Balkans (WB) region, has a higher diabetes prevalence than the EU. This study aims to assess the cost-effectiveness of early treatment of high-risk patients with pre-diabetes and undiagnosed diabetes in our setting. We designed a Markov chain Monte Carlo (MCMC) model which reflects the current International Diabetes Federation (IDF) three-step plan for the prevention of T2DM in those at increased risk. The model captures the evolution of the disease in FINDRISC high-risk patients from normal glucose tolerance (NGT) to impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) and then to T2DM and its complications. We developed two MCMC models, in order to follow the progression of the disease in high-risk cases, ie, when early treatment is undertaken or when it is not undertaken. The health costs and quality adjusted life years (QALY) were discounted at an annual rate of 3%. The key model parameters were varied in one-way and probabilistic sensitivity analysis. Early treatment resulted in increased life expectancy, postponement of the onset of diabetes and increased QALY for all patients. The discounted incremental cost-effectiveness-ratios (ICER) in NGT, IFG, IGT, and T2DM patients were -289.9, 9724.03, -1478.59 and 4084.67 €. In high-risk IGT patients, ICER was the most favorable, being both a cost saving and QALY gaining, with the consistent results confirmed by the sensitivity analysis. The results recommend the acceptance of a new health policy of identifying IGT patients with the use of FINDRISC questionnaire and plasma glucose measurements; providing them with a lifestyle change program; and implementing intensive diabetes treatment, as their disease progresses. Our results are especially significant for the Western Balkan countries, since this was the first cost-effectiveness study of T2DM prevention in this region.

Rodent Models of Diabetic Neuropathy, Role of Calcium Homeostasis in Pain and KB-R7943 as a Potential Therapeutic

Diabetic neuropathy (DN) is characterized by nerve damage as a consequence of diabetes mellitus. Diabetes causes high blood glucose and triglyceride levels, which destroy the nerve blood vessels over time and trigger DN. Peripheral neuropathy is the most common type of DN, which encompasses a broad range of symptoms. One fourth of patients with diabetes suffer from neuropathic pain, which decreases their quality of life and puts them at high risk for emotional disturbances and depression. Finding an adequate therapy is an essential element in the cure of painful DN (PDN). Since the pathophysiology of this disease still needs to be elucidated, this has led to the development of various in vivo diabetic models. Animal models of DN not only provide insights into this disease but also are significant drivers for treatment assessment and improvement. In this review, we present the major features of the most commonly used chemically and diet-induced models of PDN in rodents and their progress to date, which are utilized for a better understanding of the disease mechanism for finding novel therapeutics. Considering the role of Ca2+ homeostasis in pain, we also review our recent research data on the Na+/Ca2+ exchanger blocker KB-R7943, which is a potential neuropathic pain reliever in a rodent model of DN.

Stem Cells Reprogramming in Diabetes Mellitus and Diabetic Complications: Recent Advances

BACKGROUND

The incidence of diabetes mellitus (DM) is dramatically increasing worldwide, and it is expected to affect 700 million cases by 2045. Diabetes influences health care economics, human quality of life, morbidity, and mortality, which were primarily seen extensively in developing countries. Uncontrolled DM, which results in consistent hyperglycemia, may lead to severe life-threatening complications such as nephropathy, retinopathy, neuropathy, and cardiovascular complications.

METHODOLOGY

In addition to traditional therapies with insulin and oral anti-diabetics, researchers have developed new approaches for treatment, including stem cell (SC) therapy, which exhibits promising outcomes. Besides its significant role in treating type one DM (T1DM) and type two DM (T2DM), it can also attenuate diabetic complications. Furthermore, the development of insulin- producing cells can be achieved by using the different types of SCs, such as embryonic stem cells (ESCs), induced pluripotent stem cells (iPSCs), and multiple types of adult stem cells, such as pancreatic, hepatic, and mesenchymal stem cells (MSC). All these types have been extensively studied and proved their ability to develop insulin-producing cells, but every type has limitations.

CONCLUSION

This review aims to enlighten researchers about recent advances in stem cell research and their potential benefits in DM and diabetic complications.

Beneficial effect of Caesalpinia pulcherrima linn., on diabetic neuropathy, cognitive dysfunction and cardiac complications in streptozotocin-induced diabetic rats

Pharmacological relevance

Caesalpinia pulcherrima L. is used in Indian Traditional Medicinal system to treat Diabetes.

Aim

This study was carried out to evaluate the standardized alcoholic extract of Caesalpinia pulcherrima seed (CPS) in Streptozotocin (STZ)-induced diabetic neuropathic and cardiac complications in rodents.

Materials and methods

HPLC finger printing profile of CPS was performed to identify the bioactive molecules. Two doses of CPS (100 & 200 mg/kg b.w.) was orally administered daily once for six weeks to streptozotocin (50 mg/kg, i.v.)-induced diabetic rats. Every week intervals hot & cold immersion tests were carried to know the effect of CPS on peripheral neuropathy. In addition, blood glucose, body weight, food and water intake were also monitored. At the end of the study, sciatic nerve conduction velocity, diabetic cardiomyopathy and diabetic cognitive parameters were evaluated. Furthermore, histopathological studies of sciatic nerve and aortic strip were also carried out.

Results

HPLC finger print experiment showed the presence of gallic acid and protocatechuic acid. Administration of CPS for six weeks significantly prevented the development of diabetic peripheral neuropathy (DPN), cardiomyopathy and cognitive dysfunction in diabetic rats. The CPS treated rats displayed prominent (P < 0.001) improvement in motor coordination, muscle grip, locomotor activity and memory in diabetic rats. CPS treatment restored elevated systolic, diastolic, mean arterial blood pressure (MABP), and heart rate to near normal in diabetic condition. These observed beneficial effects were well correlated and justified with histopathological studies. In addition, CPS treatment also exhibited significant (P < 0.001) reduction of loss in body weight, and reduce the water and feed intake throughout the study.

Conclusion

Taken together, the present study provided a good insight in the therapeutic efficacy of Caesalpinia pulcherrima seed extract in dealing with diabetic complications. The study also scientifically justifies the ethnomedicinal/traditional claims of the title plant.

Smart Compression Sock for Early Detection of Diabetic Foot Ulcers

The prevention of diabetic foot ulcers remains a critical challenge. This study evaluates a smart compression sock designed to address this issue by integrating temperature, plantar pressure, and blood oxygen sensors and monitoring data recorded by these sensors. The smart sock, developed with input from a certified Pedorthist, was tested on 20 healthy adult participants aged 16 to 53. It includes four temperature sensors and pressure sensors at common ulcer sites (first and fifth metatarsal heads, calcaneus, and hallux), and a blood oxygen sensor on the hallux. The sensors are monitored, and their transduced data are collected and stored through an app installed on a personal cell phone. The mobile app interface is user-friendly, providing intuitive navigation and easy access to the sensors' data. Using repeated measures ANOVA and post hoc tests, we analyzed the impact of various physical activities on physiological changes in the foot. The device effectively detected significant variations in blood oxygen, temperature, and pressure across six activities. Statistical analyses revealed significant differences based on activity type and sensor location. These results highlight the smart sock's sensitivity and accuracy, suggesting its potential to prevent diabetic foot ulcers. Further clinical trials are needed to evaluate its efficacy in a larger, more diverse population.

Development of air therapy as a novel therapeutic branch in the field of rehabilitation

BACKGROUND AND PURPOSE

Developing technology in the field of rehabilitation is vital to accelerate recovery and decrease the side effects of current modalities. Rehabilitation is a challenging science in which the main challenge is not just treating the patient but also to shorten the rehabilitation time and avoid harmful effects. Thus, this review demonstrates the possible design and effects of air therapy as a novel treatment branch besides hydrotherapy, electrotherapy, and manual therapy in the field of rehabilitation.

METHODS

The search was conducted over clinical trials, literature reviews, and systematic reviews on the possible effects of treatments that may have similar effects to the newly developed air therapy. This search was conducted in the Web of Science, Scopus, EBSCO, and Medline databases.

RESULTS

Air therapy could be used to improve the function of mechanoreceptors, improve circulation and microcirculation, decrease pain, the release of trigger points, regain the elasticity of soft tissues, treat acute and chronic inflammations, decrease muscle cramps and spasticity, strengthen muscle, and decrease muscle fatigue and Decreasing muscle fatigue and delayed muscle soreness.

CONCLUSION

Air therapy is a novel treatment modality that can be used effectively in the field of rehabilitation. Air therapy could be a valuable and safe treatment in rehabilitation.

The Role of a Biothesiometer in Early Detection and Management of Diabetic Neuropathy

INTRODUCTION

Diabetic foot ulcers (DFUs) have become a common and serious outcome of diabetes mellitus (DM). Diabetic peripheral neuropathy (DPN) is often underdiagnosed, which impairs the capacity to prevent foot ulceration. The clinical manifestations typically include sensory complaints, which leave patients vulnerable to increased risk of injury without their awareness.

AIM

The current study aims to assess the viability of VPT (vibration perception threshold) testing using a biothesiometer as an early diagnostic tool for detecting diabetic neuropathy and reducing the burden of diabetic foot disease.

MATERIAL AND METHODS

This prospective study was conducted in Dr. D. Y. Patil Medical College, Pimpri, Pune from August 2022 to July 2024 among 50 patients with DFUs. Ethical approval was taken from the Institutional Ethical Committee. An informed consent was obtained from all the study participants. VPT testing using a biothesiometer was done to assess the neurological status of the patient's limbs. A significant difference between the symptomatic and asymptomatic cases was also calculated to evaluate the co-relation of symptoms compared to VPT.

RESULTS

The largest age group among those surveyed is 41-50 with a mean age of 50.72. Males form a slightly larger proportion than females. A total of 22 (44%) ulcers are present over the plantar aspect of the foot. Out of the entire study, 37 (74%) individuals reported Grade II or III neuropathy, and 29 (58%) individuals reported no symptoms of diabetic neuropathy. The majority portion of individuals in the study had an HbA1c ranging from 6.5% to 8%. After an intervention, 44 (88%) patients did not experience a change in their VPT grading after six months.

DISCUSSION

The chi-square test results suggest that the onset period of diabetes in years or the type of treatment history for diabetes does not significantly influence VPT grading among the surveyed individuals. However, individuals with higher HbA1c levels tend to exhibit more severe VPT impairments.

CONCLUSION

Regular monitoring of VPT grading is crucial for early diagnosis of neuropathy, tracking disease progression, and assessing intervention effectiveness. Hence, we recommend all diabetic patients regularly undergo biothesiometry as part of their routine diabetic check-ups to help prevent disease progression and complications like amputations and improve their overall quality of life.

Diabetic Neuropathic Pain and Circadian Rhythm: A Future Direction Worthy of Study

More than half of people with diabetes experience neuropathic pain. Previous research has shown that diabetes patients' neuropathic pain exhibits a circadian cycle, which is characterized by increased pain sensitivity at night. Additional clinical research has revealed that the standard opioid drugs are ineffective at relieving pain and do not change the circadian rhythm. This article describes diabetic neuropathic pain and circadian rhythms separately, with a comprehensive focus on circadian rhythms. It is hoped that this characteristic of diabetic neuropathic pain can be utilized in the future to obtain more effective treatments for it.

Current understanding of the link between angiotensin-converting enzyme and pain perception

The renin-angiotensin system (RAS) is known to affect diverse physiological processes that affect the functioning of many key organs. Angiotensin-converting enzyme (ACE) modulates a variety of bioactive peptides associated with pain. ACE inhibitors (ACEis) have found applications in the treatment of cardiovascular, kidney, neurological and metabolic disorders. However, ACEis also tend to display undesirable effects, resulting in increased pain sensitization and mechanical allodynia. In this review, we provide comprehensive discussion of preclinical and clinical studies involving the evaluation of various clinically approved ACEis. With the emerging knowledge of additional factors involved in RAS signaling and the indistinct pharmacological role of ACE substrates in pain, extensive studies are still required to elucidate the mechanistic role of ACE in pain perception.

Periodontitis and Diabetes Complications: A Danish Population-Based Study

Conflicting evidence suggests a link between diabetes-related microvascular complications and periodontitis. Reliable estimates have been hindered by small sample sizes and residual confounding. Moreover, the combined effects of microvascular complications and dyslipidemia on periodontitis have not been explored. Therefore, this study aimed to investigate the association between individual and combined diabetic microvascular complications (i.e., neuropathy and retinopathy) and moderate/severe periodontitis in a Danish population-based study. In addition, we assessed whether dyslipidemia modified these associations. This study comprised 15,922 participants with type 2 diabetes from the Health in Central Denmark study. Multinomial logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for individual and joint microvascular diabetes complications. The models adjusted for potential confounders, including sociodemographic factors, lifestyle behaviors, and health conditions. Inverse probability of treatment weighting (IPTW) balanced measured confounders between periodontitis and nonperiodontitis participants. Sensitivity analyses tested the findings' robustness by estimating E-values for unmeasured confounding and varying microvascular complication definitions. After IPTW, adjusted models revealed that diabetic neuropathy (OR 1.36, 95% CI 1.14 to 1.63) and retinopathy (OR 1.21, 95% CI 1.03 to 1.43) were significantly associated with moderate/severe periodontitis. Moreover, the coexistence of microvascular complications increased the odds 1.5-fold for moderate/severe periodontitis (OR 1.51, 95% CI 1.23 to 1.85). An effect modification of dyslipidemia on an additive scale was found, indicated by a positive relative excess risk due to interaction of 0.24 for neuropathy, 0.11 for retinopathy, and 0.44 for both complications. Sensitivity analysis ruled out unmeasured confounders and microvascular complication definitions as explanatory factors. Diabetic neuropathy and retinopathy, individually and combined, were associated with moderate/severe periodontitis. In addition, dyslipidemia had an additive positive effect modification on diabetic microvascular complications, elevating the odds of moderate/severe periodontitis. These findings may aid in identifying at-risk subgroups for diabetes-related microvascular complications and periodontitis, optimizing efforts to mitigate disease burden.

Pharmacist-lead screening for diabetic peripheral neuropathy using Michigan Neuropathy Screening Instrument (MNSI)

BACKGROUND

Diabetic peripheral neuropathy (DPN) is highly prevalent among Jordanian patients, mostly are asymptomatic. Early recognition and appropriate management of neuropathy is important to improve symptoms, reduce sequelae, and improve quality of life. This study aims at exploring the role of pharmacists in the early recognition of DPN and providing quick screening for the presence of it among diabetic patients.

MATERIAL AND METHODS

A cross-sectional study was conducted at multi-pharmacy settings, in Irbid, Jordan. Twenty trained pharmacists who had bachelor's degrees in pharmacy participated in data collection. A total of 400 patients with confirmed diagnosis of type 2 diabetes mellitus (DM) according to the World Health Organization diagnostic criteria were recruited. DPN was assessed using the translated Arabic version of Michigan Neuropathy Screening Instrument (MNSI) history version.

RESULTS

The mean MNSI questionnaire score for all participants was 4.40 ± 3.00. Mean age of the patients was 62.6 ± 10.7 years old and duration of diabetes was 8.25 ± 6.9. DN was present in 23.7% of the population. Diabetic patients with neuropathy were older than patients without neuropathy (p < 0.05) and had had diabetes longer (p < 0.05). Poor glycemic control, hypertension and gender, were significantly risk factors for DN (p < 0.05).

CONCLUSIONS

In addition to delivering medications, this study suggests that pharmacists can have a role in screening and counseling about diabetic peripheral neuropathy using a simple objective, and non-invasive tool and also can determine level of damage and risk.

Targeting neuroinflammation in distal symmetrical polyneuropathy in diabetes

Diabetic distal symmetric polyneuropathy is the most common type of peripheral neuropathy complication of diabetes mellitus. Neuroinflammation is emerging as an important contributor to diabetes-induced neuropathy. Long-term hyperglycemia results in increased production of advanced glycation end products (AGEs). AGEs interact with their receptors to activate intracellular signaling, leading to the release of various inflammatory cytokines. Increased release of inflammatory cytokines is associated with diabetes, diabetic neuropathy, and neuropathic pain. Thus, anti-inflammatory intervention is a potential therapy for diabetic distal symmetric polyneuropathy. Further characterization of inflammatory mechanisms might identify novel therapeutic targets to mitigate diabetic neuropathy.

Inter-trial Variation in the Sensitivity of Thermal Threshold Testing for the Diagnosis of Neuropathy in Type 2 Diabetes Mellitus

BACKGROUND

Thermal threshold testing (TTT) is a simple non-invasive approach for diagnosing diabetic neuropathy earlier. Conventionally the TTT is done in all four limbs and at least 6 trials are done to obtain the mean threshold, which is time consuming.

AIM

We propose to assess the validity and reliability of reduced number of trials of TTT in the lower limbs.

MATERIALS AND METHODS

After obtaining ethics approval from the Institute Ethics Committee, 100 patients with type 2 Diabetes Mellitus of both gender between the ages of 35 to 65 years attending medicine OPD were recruited. Neuropathy assessment was done using Temperature threshold testing. At least 6 trials were performed for each site and the mean threshold obtained. The mean of 5 trials, 4 trials and 3 trials were noted for the comparison.

RESULTS

On comparing hot tests of 3 trials with 6 trials had a sensitivity and specificity of 88.7% and 96.6 %. In cold threshold testing, 4 trials and 3 trials showed similar results of sensitivity of 77.8%, specificity of 98.8%. The measures of agreement between the hot trials 6 vs 5 had Kappa value of 0.953, 6vs 4 showed a Kappa value of 0.862 and 6 vs 3 showed Kappa value of 0.819.

CONCLUSION

Hot threshold tests of lower limb are more sensitive than cold thresholds. The 4 trial test is a reliable test and can be performed over 6 trial tests. When time is a factor, three trials are sufficient to diagnose small fibre neuropathy.

The effects of local calf vibration on balance, blood flow, and nerve conductivity in patients with diabetic peripheral neuropathy: a pilot study

OBJECTIVES

This study aimed to evaluate the effects of local calf vibration on balance, blood flow, and nerve conductivity in patients with diabetic peripheral neuropathy (DPN).

METHODS

An open-label controlled trial was designed. Patients with confirmed diagnoses of type 2 diabetes and DPN were enrolled in the study and underwent ten sessions of local calf vibration therapy for the dominant leg. The other leg was considered the control. Balance evaluation, nerve conduction studies, and color Doppler ultrasound were performed before and after the treatment course. The Wilcoxon signed rank test and the Mann-Whitney test were used to evaluate the differences between the test results before and after the intervention and between the intervention and control legs.

RESULTS

Seventeen patients with a mean age of 60.3 ± 5.6 years (11 males) participated in the study. Mean Brief BESTest total scores were significantly improved (14.06 vs. 17.35; P = .01, Cohen's d = 0.743). There were no significant differences between the treated and control legs regarding the nerve conduction and color Doppler ultrasound parameters before and after the intervention (P ≥ .054). Changes in the parameters were also not significantly different between legs (P ≥ .078), except for common peroneal nerve conduction velocity, for which there was a higher increase in its value in the treated legs compared to the control legs (4.17 vs. 0.9, P = .002).

CONCLUSION

Local calf vibration may positively affect balance and lower extremities nerve conduction in patients with DPN, and the findings of this study can be a basis for studies evaluating the efficacy of local calf vibration for treating DPN.

TRPV1: Receptor structure, activation, modulation and role in neuro-immune interactions and pain

In the 1990s, the identification of a non-selective ion channel, especially responsive to capsaicin, revolutionized the studies of somatosensation and pain that were to follow. The TRPV1 channel is expressed mainly in neuronal cells, more specifically, in sensory neurons responsible for the perception of noxious stimuli. However, its presence has also been detected in other non-neuronal cells, such as immune cells, β- pancreatic cells, muscle cells and adipocytes. Activation of the channel occurs in response to a wide range of stimuli, such as noxious heat, low pH, gasses, toxins, endocannabinoids, lipid-derived endovanilloid, and chemical agents, such as capsaicin and resiniferatoxin. This activation results in an influx of cations through the channel pore, especially calcium. Intracellular calcium triggers different responses in sensory neurons. Dephosphorylation of the TRPV1 channel leads to its desensitization, which disrupts its function, while its phosphorylation increases the channel's sensitization and contributes to the channel's rehabilitation after desensitization. Kinases, phosphoinositides, and calmodulin are the main signaling pathways responsible for the channel's regulation. Thus, in this review we provide an overview of TRPV1 discovery, its tissue expression as well as on the mechanisms by which TRPV1 activation (directly or indirectly) induces pain in different disease models.

Biomarkers and signaling pathways of diabetic nephropathy and peripheral neuropathy: possible therapeutic intervention of rutin and quercetin

Diabetic nephropathy and peripheral neuropathy are the two main complications of chronic diabetes that contribute to high morbidity and mortality. These conditions are characterized by the dysregulation of multiple molecular signaling pathways and the presence of specific biomarkers such as inflammatory cytokines, indicators of oxidative stress, and components of the renin-angiotensin system. In this review, we systematically collected and collated the relevant information from MEDLINE, EMBASE, ELSEVIER, PUBMED, GOOGLE, WEB OF SCIENCE, and SCOPUS databases. This review was conceived with primary objective of revealing the functions of these biomarkers and signaling pathways in the initiation and progression of diabetic nephropathy and peripheral neuropathy. We also highlighted the potential therapeutic effectiveness of rutin and quercetin, two plant-derived flavonoids known for their antioxidant and anti-inflammatory properties. The findings of our study demonstrated that both flavonoids can regulate important disease-promoting systems, such as inflammation, oxidative stress, and dysregulation of the renin-angiotensin system. Importantly, rutin and quercetin have shown protective benefits against nephropathy and neuropathy in diabetic animal models, suggesting them as potential therapeutic agents. These findings provide a solid foundation for further comprehensive investigations and clinical trials to evaluate the potential of rutin and quercetin in the management of diabetic nephropathy and peripheral neuropathy. This may contribute to the development of more efficient and comprehensive treatment approaches for diabetes-associated complications.

Diabetic Sensorimotor Polyneuropathy: An Overview on Epidemiology, Risk Factors, Classification, Diagnosis, and Treatment

Diabetic distal symmetric sensorimotor polyneuropathy (DSPN) is a common complication of diabetes with devastating consequences. Hyperglycaemia is the major aetiological factor, while emerging data demonstrate that cardiometabolic risk factors also contribute to its development. Diagnosis of DSPN involves interview of medical and neurological history, foot inspection, and sensory and motor function examination with specific tests such as temperature and pinprick perception for small nerve fibers, and vibration and light touch assessments for large nerve fibers. Management includes optimised glycaemic control, treatment of cardiovascular risk factors, and symptomatic treatment aiming at improving life quality. This article provides an overview on epidemiology, risk factors, classification, diagnosis and current treatment of DSPN.

Association of serum NF-κB levels with peripheral neuropathy in type 2 diabetes mellitus patients: a pilot study

OBJECTIVES

Hyperglycaemia-induced inflammation plays a vital role in the development of diabetic peripheral neuropathy (DPN). Recent evidences had reported the involvement of the transcription factor nuclear factor kappa-light-chain-enhancer of activated B cell (NF-κB) in diabetic experimental models. So, this pilot study aimed to evaluate serum NF-κB levels in DPN patients.

METHODS

We recruited 50 T2DM patients, of which 25 were T2DM with neuropathy and 25 were T2DM without neuropathy. In all the participants peripheral neuropathy was diagnosed based on Total neuropathy score (TNS). Serum NF-κB levels were measured by ELISA.

RESULTS

We observed that the serum NF-κB levels were higher in DPN patients in comparison to T2DM patients without neuropathy. On spearman correlation, a positive correlation was found between serum NF-κB levels and TNS in the DPN group (r=0.741, p<0.001). The regression model shows the TNS to be an independent determinant of serum NF-κB levels after adjustment for potential confounders like age, duration of diabetes, and HbA1C (B=81.34; p<0.001).

CONCLUSIONS

NF-κB activation plays a key role in promoting inflammation which is associated with the progression of DPN. In this respect, the study of NF-κB levels in serum may be an additional diagnostic marker for DPN.

Effects of Physical Cues on Stem Cell-Derived Extracellular Vesicles toward Neuropathy Applications

The peripheral nervous system undergoes sufficient stress when affected by diabetic conditions, chemotherapeutic drugs, and personal injury. Consequently, peripheral neuropathy arises as the most common complication, leading to debilitating symptoms that significantly alter the quality and way of life. The resulting chronic pain requires a treatment approach that does not simply mask the accompanying symptoms but provides the necessary external environment and neurotrophic factors that will effectively facilitate nerve regeneration. Under normal conditions, the peripheral nervous system self-regenerates very slowly. The rate of progression is further hindered by the development of fibrosis and scar tissue formation, which does not allow sufficient neurite outgrowth to the target site. By incorporating scaffolding supplemented with secretome derived from human mesenchymal stem cells, it is hypothesized that neurotrophic factors and cellular signaling can facilitate the optimal microenvironment for nerve reinnervation. However, conventional methods of secretory vesicle production are low yield, thus requiring improved methods to enhance paracrine secretions. This report highlights the state-of-the-art methods of neuropathy treatment as well as methods to optimize the clinical application of stem cells and derived secretory vesicles for nerve regeneration.

Serum SARM1 Levels and Diabetic Peripheral Neuropathy in Type 2 Diabetes: Correlation with Clinical Neuropathy Scales and Nerve Conduction Studies and Impact of COVID-19 vaccination

Patients with peripheral neuropathy with type 2 diabetes mellitus (T2DM) are more likely to have functional impairments. Recently, the gene for serum sterile alpha and toll/interleukin receptor motif-containing protein 1 (SARM1), which may contribute to the pathogenesis of Wallerian degeneration, was discovered in mice models of peripheral neuropathy. We set out to assess serum SARM1's activity as a potential biomarker for the early identification of diabetic peripheral neuropathy in T2DM patients while also examining the impact of the COVID-19 vaccine on SARM1 levels. We assessed the cross-sectional relationships between the SARM1 biomarker, clinical neuropathy scales, and nerve conduction parameters in 80 participants aged between 30 years and 60 years. The analysis was carried out after the patients were split into two groups since we discovered a significant increase in SARM1 levels following the second dose of the COVID-19 vaccination, where group A received one dose of the COVID-19 vaccine inoculation, and group B received two doses of the COVID-19 vaccine. SARM1 was correlated significantly (p < 0.05) with MNSIe and NSS in group A and showed a consistent positive correlation with the other neuropathy clinical scales in group A and group B without reaching statistical significance. Additionally, SARM1 was negatively correlated significantly (p < 0.05) with the median sensory amplitude in group A and showed a consistent negative correlation with the six other sensory and motor nerves' potential amplitude in group A and group B without reaching statistical significance. In conclusion, SARM1 showed a consistent correlation with clinical neuropathy scales and nerve conduction parameters after accounting for the influence of COVID-19 vaccination doses.

Association of Hematological Parameters and Diabetic Neuropathy: A Retrospective Study

Background

Diabetic neuropathy (DN) is a common complication of type 2 diabetes (T2DM) and is characterized by persistent inflammation. Hematological parameters have emerged as a novel marker for detecting chronic inflammatory conditions, including diabetes.

Aim

We aim to examine the association between HbA1c levels, which can indicate the presence of diabetic neuropathy, and hematological parameters to explore the possibility of using hematological parameters as a new indicator for DN in T2DM patients.

Methods

This was a retrospective study of 768 (483 males and 284 females) medical records of adult T2DM patients with or without neuropathy who attending the outpatient neuromuscular clinic at King Abdul-Aziz University Hospital from January 2016 to December 2021.

Results

The results showed significant increases in HbA1c levels (p=0.000), lymphocyte levels (p=0.028), and the neutrophil-lymphocyte ratio (NLR) (p=0.011). In the T2DM group, HBA1C levels were found to be positively correlated with age (r=0.306, p=0.000), neutrophil (NEUT) (r=0. 287, p=0.000), platelet (PLT) (r=0. 148, p=0.039), and neutrophil-lymphocyte ratio (NLR) (r=0.306193, p=0.0007), and negatively correlated with gender (r=-0.306193, p=0.0007). In the T2DMN group, HBA1C levels showed a positive correlation with hemoglobin (HB) (r=0.084, p=0.045), PLT (r=0.087, p=0.037), and PLT/mean corpuscular hemoglobin (MCH) ratio (PLT/MCH ratio) (r=0.12, p=0.004), and a negative correlation with age (r=-0.204, p=0.000), gender (r=-0.086, p=0.041), weight (WT) (r=-0.113, p=0.007), Body Surface Area (BSA) (r=-0.09, p=0.031), mean corpuscular volume (MCV) (r=-0.292, p=0.000), and MCH (r=-0.186, p=0.000).

Conclusion

Our study found a significant association between HbA1c, a biomarker for diabetic neuropathy, and various hematological parameters (HB, MCV, MCH, PLT, PLT/MCH ratio) in T2DMN patients. By effectively controlling and monitoring these variables, it may be feasible to prevent or delay the progression of peripheral neuropathy in diabetic patients. However, further research is needed to validate these findings.

Clinical validation of electrochemical biosensor for the detection of methylglyoxal in subjects with type-2 diabetes mellitus

Methylglyoxal (MG), a highly reactive by-product of glycolysis, is involved in the formation of advanced glycation end-products (AGEs). Elevated levels of MG have been correlated with micro-and macro-angiopathic complications in diabetes, including neuropathy, kidney disease, retinopathy, and cardiovascular disease. Therefore, point-of-care devices for detecting MG may be of great use in the screening of diabetes complications. This study was designed to determine the utility of the developed electrochemical biosensor to measure the level of MG in human plasma from type-2 diabetes mellitus patients. Electrochemical studies were carried out with optimized experimental parameters using the modified Platinum-electrode. Subsequently, clinical studies using 350 blood plasma samples were conducted and the results were validated against the ELISA kit, Normal Glucose Tolerance (NGT), and glycosylated haemoglobin (HbA1c). The MG sensor exhibited a linear range of 1.0-7.5 μM concentration with a sensitivity of 1.02 mA µM-1, a limit of detection of 0.21 µM, a limit of quantification of 0.70 µM and a response time less than 10 s. The sensor showed 90% correlation with ELISA data. The developed biosensor showed a significant correlation with HbA1c and fasting plasma glucose suggesting that it can be used as a point-of-care device to screen for diabetes.

Multifractal Heart Rate Value Analysis: A Novel Approach for Diabetic Neuropathy Diagnosis

Type 2 diabetes mellitus (T2DM) is characterized by several complications, such as retinopathy, renal failure, cardiovascular disease, and diabetic neuropathy. Among these, neuropathy is the most severe complication, due to the challenging nature of its early detection. The linear Hearth Rate Variability (HRV) analysis is the most common diagnosis technique for diabetic neuropathy, and it is characterized by the determination of the sympathetic-parasympathetic balance on the peripheral nerves through a linear analysis of the tachogram obtained using photoplethysmography. We aimed to perform a multifractal analysis to identify autonomic neuropathy, which was not yet manifest and not detectable with the linear HRV analysis. We enrolled 10 healthy controls, 10 T2DM-diagnosed patients with not-full-blown neuropathy, and 10 T2DM diagnosed patients with full-blown neuropathy. The tachograms for the HRV analysis were obtained using finger photoplethysmography and a linear and/or multifractal analysis was performed. Our preliminary results showed that the linear analysis could effectively differentiate between healthy patients and T2DM patients with full-blown neuropathy; nevertheless, no differences were revealed comparing the full-blown to not-full-blown neuropathic diabetic patients. Conversely, the multifractal HRV analysis was effective for discriminating between full-blown and not-full-blown neuropathic T2DM patients. The multifractal analysis can represent a powerful strategy to determine neuropathic onset, even without clinical diagnostic evidence.

Alpha-lipoic acid for diabetic peripheral neuropathy

BACKGROUND

Diabetic peripheral neuropathy (DPN) is a frequent complication in people living with type 1 or type 2 diabetes. There is currently no effective treatment for DPN. Although alpha-lipoic acid (ALA, also known as thioctic acid) is widely used, there is no consensus about its benefits and harms.

OBJECTIVES

To assess the effects of alpha-lipoic acid as a disease-modifying agent in people with diabetic peripheral neuropathy.

SEARCH METHODS

On 11 September 2022, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and two clinical trials registers. We also searched the reference lists of the included studies and relevant review articles for additional references not identified by the electronic searches.

SELECTION CRITERIA

We included randomised clinical trials (RCTs) that compared ALA with placebo in adults (aged 18 years or older) and that applied the study interventions for at least six months. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. The primary outcome was change in neuropathy symptoms expressed as changes in the Total Symptom Score (TSS) at six months after randomisation. Secondary outcomes were change in neuropathy symptoms at six to 12 months and at 12 to 24 months, change in impairment, change in any validated quality of life total score, complications of DPN, and adverse events. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

Our analysis incorporated three trials involving 816 participants. Two studies included people with type 1 or type 2 diabetes, while one study included only people with type 2 diabetes. The duration of treatment was between six months and 48 months. We judged all studies at high risk of overall bias due to attrition. ALA compared with placebo probably has little or no effect on neuropathy symptoms measured by TSS (lower score is better) after six months (mean difference (MD) -0.16 points, 95% confidence interval (CI) -0.83 to 0.51; 1 study, 330 participants; moderate-certainty evidence). The CI of this effect estimate did not contain the minimal clinically important difference (MCID) of 0.97 points. ALA compared with placebo may have little or no effect on impairment measured by the Neuropathy Impairment Score-Lower Limbs (NIS-LL; lower score is better) after six months (MD -1.02 points, 95% CI -2.93 to 0.89; 1 study, 245 participants; low-certainty evidence). However, we cannot rule out a significant benefit, because the lower limit of the CI surpassed the MCID of 2 points. There is probably little or no difference between ALA and placebo in terms of adverse events leading to cessation of treatment within six months (risk ratio (RR) 1.48, 95% CI 0.50 to 4.35; 3 studies, 1090 participants; moderate-certainty evidence). No studies reported quality of life or complications associated with DPN.

AUTHORS' CONCLUSIONS

Our analysis suggests that ALA probably has little or no effect on neuropathy symptoms or adverse events at six months, and may have little or no effect on impairment at six months. All the studies were at high risk of attrition bias. Therefore, future RCTs should ensure complete follow-up and transparent reporting of any participants missing from the analyses.

New Horizons in Diabetic Neuropathies: An Updated Review on their Pathology, Diagnosis, Mechanism, Screening Techniques, Pharmacological, and Future Approaches

BACKGROUND

One of the largest problems for global public health is diabetes mellitus (DM) and its micro and macrovascular consequences. Although prevention, diagnosis, and treatment have generally improved, its incidence is predicted to keep rising over the coming years. Due to the intricacy of the molecular mechanisms, which include inflammation, oxidative stress, and angiogenesis, among others, discovering treatments to stop or slow the course of diabetic complications is still a current unmet need.

METHODS

The pathogenesis and development of diabetic neuropathies may be explained by a wide variety of molecular pathways, hexosamine pathways, such as MAPK pathway, PARP pathway, oxidative stress pathway polyol (sorbitol) pathway, cyclooxygenase pathway, and lipoxygenase pathway. Although diabetic neuropathies can be treated symptomatically, there are limited options for treating the underlying cause.

RESULT

Various pathways and screening models involved in diabetic neuropathies are discussed, along with their possible outcomes. Moreover, both medicinal and non-medical approaches to therapy are also explored.

CONCLUSION

This study highlights the probable involvement of several processes and pathways in the establishment of diabetic neuropathies and presents in-depth knowledge of new therapeutic approaches intended to stop, delay, or reverse different types of diabetic complications.

Therapeutic Potential of Quercetin in Diabetic Neuropathy and Retinopathy: Exploring Molecular Mechanisms

Diabetes mellitus poses a significant health challenge globally, often leading to debilitating complications, such as neuropathy and retinopathy. Quercetin, a flavonoid prevalent in fruits and vegetables, has demonstrated potential therapeutic effects in these conditions due to its antioxidant, anti-inflammatory, and neuroprotective properties. This review summarizes and provides a comprehensive understanding of the molecular mechanisms underlying the efficacy of quercetin in ameliorating diabetic neuropathy and retinopathy. A thorough search was carried out across scientific databases, such as SciFinder, PubMed, and Google Scholar, to gather pertinent literature regarding the effect of quercetin on diabetic neuropathy and retinopathy till February 2024. Preclinical studies indicate that quercetin mitigates neuropathic pain, sensory deficits, and nerve damage associated with diabetic neuropathy by improving neuronal function, reducing DNA damage, regulating pro-inflammatory cytokines, enhancing antioxidant enzyme levels and endothelial function, as well as restoring nerve injuries. In diabetic retinopathy, quercetin shows the potential to preserve retinal structure and function, inhibiting neovascularization, preventing retinal cell death, reducing pro-inflammatory cytokines, and increasing neurotrophic factor levels. Moreover, through modulating key signaling pathways, such as AMP-activated Protein Kinase (AMPK) activation, Glucose Transporter 4 (GLUT 4) upregulation, and insulin secretion regulation, quercetin demonstrates efficacy in reducing oxidative stress and inflammation, thereby protecting nerve and retinal tissues. Despite promising preclinical findings, challenges, such as limited bioavailability, necessitate further research to optimize quercetin's clinical application in order to establish its optimal dosage, formulation, and long-term efficacy in clinical settings.

Assessment of Neuropathy by Temperature Threshold Testing in Type 2 Diabetes Mellitus

INTRODUCTION

Diagnosing diabetic neuropathy is a challenge at times as it is asymptomatic. Diagnosing diabetic neuropathy involves the use of quantitative sensory testing, nerve conduction study, and autonomic testing. Tempearture threshold testing (TTT) can aid in diagnosing small fiber neuropathy at early stages. This study aimed to assess the small fiber neuropathy using TTT in diabetes mellitus (DM) and correlate with age, duration of diabetes, and lipid profile.

MATERIALS AND METHODS

The study was commenced after obtaining ethics approval from the institute ethics committee. The study participants included 100 patients with type 2 DM of both genders between the ages of 40 and 65 years. The glycemic status and lipid profile were noted along with physical examination. Neuropathy assessment was done using Michigan Neuropathy Screening Instrument (MNSI) and TTT.

RESULTS

The prevalence of small fiber neuropathy based on TTT was 63%. The lipid profile was similar in both the groups. The MNSI B scale had significantly higher scores in the neuropathy group. In the neuropathy group, the thresholds for hot were significantly greater in all four limbs and cold were significantly lower. Age and years of DM were positively correlated with the neuropathy. Hot threshold in the lower limb had shown a strong positive correlation.

CONCLUSION

The age and duration of diabetes are independent risk factors for diabetic peripheral neuropathy. Small fiber neuropathy is a prequel to the motor neuropathy. Hot threshold testing in the lower limb is more sensitive than cold threshold testing for diagnosing small fiber neuropathy.

Diabetic Neuropathy: An Overview of Molecular Pathways and Protective Mechanisms of Phytobioactives

Diabetic neuropathy (DN) is a common and debilitating complication of diabetes mellitus that affects the peripheral nerves and causes pain, numbness, and impaired function. The pathogenesis of DN involves multiple molecular mechanisms, such as oxidative stress, inflammation, and pathways of advanced glycation end products, polyol, hexosamine, and protein kinase C. Phytochemicals are natural compounds derived from plants that have various biological activities and therapeutic potential. Flavonoids, terpenes, alkaloids, stilbenes, and tannins are some of the phytochemicals that have been identified as having protective potential for diabetic neuropathy. These compounds can modulate various cellular pathways involved in the development and progression of neuropathy, including reducing oxidative stress and inflammation and promoting nerve growth and repair. In this review, the current evidence on the effects of phytochemicals on DN by focusing on five major classes, flavonoids, terpenes, alkaloids, stilbenes, and tannins, are summarized. This compilation also discusses the possible molecular targets of numerous pathways of DN that these phytochemicals modulate. These phytochemicals may offer a promising alternative or complementary approach to conventional drugs for DN management by modulating multiple pathological pathways and restoring nerve function.

Adaptive Autonomic and Neuroplastic Control in Diabetic Neuropathy: A Narrative Review

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a worldwide socioeconomic burden, and is accompanied by a variety of metabolic disorders, as well as nerve dysfunction referred to as diabetic neuropathy (DN). Despite a tremendous body of research, the pathogenesis of DN remains largely elusive. Currently, two schools of thought exist regarding the pathogenesis of diabetic neuropathy: a) mitochondrial-induced toxicity, and b) microvascular damage. Both mechanisms signify DN as an intractable disease and, as a consequence, therapeutic approaches treat symptoms with limited efficacy and risk of side effects.

OBJECTIVE

Here, we propose that the human body exclusively employs mechanisms of adaptation to protect itself during an adverse event. For this purpose, two control systems are defined, namely the autonomic and the neural control systems. The autonomic control system responds via inflammatory and immune responses, while the neural control system regulates neural signaling, via plastic adaptation. Both systems are proposed to regulate a network of temporal and causative connections which unravel the complex nature of diabetic complications.

RESULTS

A significant result of this approach infers that both systems make DN reversible, thus opening the door to novel therapeutic applications.

Non-invasive blood glucose monitoring technology in diabetes management: review

Diabetes is one of the leading non-communicable diseases globally, adversely impacting an individual's quality of life and adding a considerable burden to the healthcare systems. The necessity for frequent blood glucose (BG) monitoring and the inconveniences associated with self-monitoring of BG, such as pain and discomfort, has motivated the development of non-invasive BG approaches. However, the current research progress is slow, and only a few BG self-monitoring devices have made considerable progress. Hence, we evaluate the available non-invasive glucose monitoring technologies validated against BG recordings to provide future research direction to design, develop, and deploy self-monitoring of BG with integrated emerging technologies. We searched five databases, Embase, MEDLINE, Proquest, Scopus, and Web of Science, to assess the non-invasive technology's scope in the diabetes management paradigm published from 2000 to 2020. A total of three approaches to non-invasive screening, including saliva, skin, and breath, were identified and discussed. We observed a statistical relationship between BG measurements obtained from non-invasive methods and standard clinical measures. Opportunities exist for future research to advance research progress and facilitate early technology adoption for healthcare practice. The results promise clinical validity; however, formulating regulatory guidelines could foresee the deployment of approved non-invasive BG monitoring technologies in healthcare practice. Further, research prospects are there to design, develop, and deploy integrated diabetes management systems with mobile technologies, data analytics, and the internet of things (IoT) to deliver a personalised monitoring system.

Neuroprotective Effects of a Hydrogen Sulfide Donor in Streptozotocin-Induced Diabetic Rats

Diabetic neuropathy is an important long-term complication of diabetes. This study explored the hypothesis that hydrogen sulfide (H2S) ameliorates neuropathic pain by controlling antiapoptotic and pro-apoptotic processes. The effects of a slow-releasing H2S donor, GYY4137, on the expression of antiapoptotic and pro-apoptotic genes and proteins, such as B-cell lymphoma 2 (Bcl2) and Bcl-2-like protein 4 (Bax), as well as caspases, cyclooxygenase (COX)-1 and COX-2, monocytes/macrophages, and endothelial cells, in the spinal cord of male Sprague-Dawley rats with streptozotocin-induced peripheral diabetic neuropathy, were investigated using reverse transcription-PCR, western blot and immunohistochemistry. The antihypoalgesic activities of GYY4137 on diabetic rats were evaluated using the tail flick test. Treatment of diabetic rats with GYY4137 attenuated thermal hypoalgesia and prevented both the diabetes-induced increase in Bax mRNA expression (p = 0.0032) and the diabetes-induced decrease in Bcl2 mRNA expression (p = 0.028). The GYY4137-treated diabetic group had increased COX-1 (p = 0.015), decreased COX-2 (p = 0.002), reduced caspase-7 and caspase-9 protein expression (p < 0.05), and lower numbers of endothelial and monocyte/macrophage cells (p < 0.05) compared to the non-treated diabetic group. In summary, the current study demonstrated the protective properties of H2S, which prevented the development of neuropathy related behavior, and suppressed apoptosis activation pathways and inflammation in the spinal cord. H2S-releasing drugs could be considered as possible treatment options of diabetic peripheral neuropathy.

Decreased corneal subbasal nerve fiber length and density in diabetic dogs with cataracts using in vivo confocal microscopy

OBJECTIVE

To determine whether there is a difference in corneal sensitivity and corneal subbasal nerve plexus (CSNP) morphology in cataractous dogs with diabetes mellitus (DM) versus without DM.

ANIMALS STUDIED

Twenty six domestic dogs with cataracts of various breeds presented for phacoemulsification, 13 with DM and 13 without DM.

PROCEDURE

The inclusion criteria for the study were dogs with bilateral cataracts and no clinical evidence of corneal disease. The diabetic group had documented hyperglycemia and was currently treated with insulin. The non-diabetic group had no evidence of DM on examination and bloodwork. Complete ophthalmic examination, corneal esthesiometry, and in vivo confocal microscopy of the CSNP was performed for both eyes of each dog. The CSNP was evaluated using a semi-automated program and statistically analyzed.

RESULTS

The mean (±SD) CSNP fiber length was significantly decreased in diabetic (3.8 ± 3.0 mm/mm2 ) versus non-diabetic (6.7 ± 1.9 mm/mm2 ) dogs. Likewise, the mean (±SD) fiber density was significantly decreased in diabetic (8.3 ± 3.1 fibers/mm2 ) versus non-diabetic (15.5 ± 4.9 fibers/mm2 ) dogs. The corneal touch threshold was significantly reduced in diabetic (2.1 ± 0.8 cm) versus non-diabetic (2.8 ± 0.4 cm) dogs. There was a non-significant trend towards subclinical keratitis in diabetic (9/13) versus non-diabetic (4/13) dogs.

CONCLUSIONS

Morphological and functional abnormalities of the CSNP were present in dogs with DM, including decreased fiber length, fiber density, and corneal sensitivity. These findings are consistent with diabetic neuropathy and could contribute to clinically significant corneal complications after cataract surgery.

The pathophysiology of diabetic foot: a narrative review

An aging population and changes in dietary habits have increased the incidence of diabetes, resulting in complications such as diabetic foot ulcers (DFUs). DFUs can lead to serious disabilities, substantial reductions in patient quality of life, and high financial costs for society. By understanding the etiology and pathophysiology of DFUs, their occurrence can be prevented and managed more effectively. The pathophysiology of DFUs involves metabolic dysfunction, diabetic immunopathy, diabetic neuropathy, and angiopathy. The processes by which hyperglycemia causes peripheral nerve damage are related to adenosine triphosphate deficiency, the polyol pathway, oxidative stress, protein kinase C activity, and proinflammatory processes. In the context of hyperglycemia, the suppression of endothelial nitric oxide production leads to microcirculation atherosclerosis, heightened inflammation, and abnormal intimal growth. Diabetic neuropathy involves sensory, motor, and autonomic neuropathies. The interaction between these neuropathies forms a callus that leads to subcutaneous hemorrhage and skin ulcers. Hyperglycemia causes peripheral vascular changes that result in endothelial cell dysfunction and decreased vasodilator secretion, leading to ischemia. The interplay among these four preceding pathophysiological factors fosters the development and progression of infections in individuals with diabetes. Charcot neuroarthropathy is a chronic and progressive degenerative arthropathy characterized by heightened blood flow, increased calcium dissolution, and repeated minor trauma to insensate joints. Directly and comprehensively addressing the pathogenesis of DFUs could pave the way for the development of innovative treatment approaches with the potential to avoid the most serious complications, including major amputations.

Current evidence for J147 as a potential therapeutic agent in nervous system disease: a narrative review

Curcumin has anti-inflammatory, antioxidant, and anticancer effects and is used to treat diseases such as dermatological diseases, infection, stress, depression, and anxiety. J147, an analogue of curcumin, is designed and synthesized with better stability and bioavailability. Accumulating evidence demonstrates the potential role of J147 in the prevention and treatment of Alzheimer's disease, diabetic neuropathy, ischemic stroke, depression, anxiety, and fatty liver disease. In this narrative review, we summarized the background and biochemical properties of J147 and discussed the role and mechanism of J147 in different diseases. Overall, the mechanical attributes of J147 connote it as a potential target for the prevention and treatment of neurological diseases.

Diabetic neuropathy: Pathogenesis and evolving principles of management

The global rise of prediabetes and diabetes has spawned an epidemic of complications associated with these conditions. Neuropathy is the most common consequence, with distal symmetric polyneuropathy (DSP) being the most prevalent. Diabetic neuropathy (DN) is a debilitating consequence of diabetes mellitus resulting in the highest morbidity and death, besides imposing a substantial financial burden on the patient. Loss of sensory function commencing distally in the lower limbs, accompanied by discomfort and considerable morbidity, characterizes diabetic neuropathy. The clinical evaluation and therapeutic options for diabetic peripheral neuropathy are multifaceted. At least fifty percent of people with diabetes acquire diabetic neuropathy over time. Good glycemic control halts the evolution in individuals with Type 1 diabetes mellitus. These results have prompted fresh attempts to comprehend the origin and develop new guidelines for prevention and treatment. New recommendations have also been established for the treatment of painful DN using separate classes of medications, with an emphasis on avoiding the use of opioids. Although our comprehension of the intricacies of diabetic neuropathy has progressed significantly over the past decade, the unique processes driving the neuropathy in type 1 and type 2 diabetes remain unexplained. Currently, glycemic control and pain management are the only effective therapies. While glucose management significantly reduces neuropathy development in type 1 diabetics, the effect is considerably lower in type 2 diabetics. Evidence supports the use of anticonvulsants and antidepressants for diabetic peripheral neuropathy pain treatment. However, the absence of disease-modifying medications for diabetic DSP necessitates the identification of unrecognized modifiable risk factors. It is imperative to identify the 'missed' risk factors and targets, allowing comprehensive, individualized care for patients.

The effects of voluntary exercise on histological and stereological changes of sciatic nerve, nitric oxide levels, and peripheral neuropathy caused by high-fat diet-induced type 2 diabetes in male rats

This research was conducted to investigate the possible beneficial impacts of voluntary exercise on sciatic tissue, nitric oxide levels, stereological changes, and peripheral neuropathy caused by "high-fat-diet (HFD)"-induced "type 2 diabetes mellitus (T2DM)" in male rats. Rats were put into four experimental groups at random: "healthy control (C), voluntary exercise (VE), diabetic (D), and diabetic rats treated by voluntary exercise (VED)"; each group contain eight animals. Animals in VE and VED groups performed "voluntary exercise (VE)" for ten weeks. Animals in D and VED groups became diabetic after receiving a HFD for four weeks and an intraperitoneal injection (IP) of "streptozotocin (STZ)" (35 mg/kg). In order to evaluate mechanical and thermal algesia, hot plate, tail withdrawal, and von Frey tests were carried out. At the end of this study, serum NOx levels were assessed, and histological and stereological analyses were conducted. Mechanical nociceptive thresholds indicated considerable reduction (p < 0.001) which was followed by a remarkable enhance (p < 0.001) in thermal nociceptive threshold of D group. Tissue changes were also seen in sciatic nerve of D group. Voluntary exercise modified thermal and mechanical sensitivity in diabetic rats. It also improved the damaged sciatic nerve in diabetic animals.

Isolation, characterization, development and evaluation of phytoconstituent based formulation for diabetic neuropathy

Background

Morus alba Linn, referred to as white mulberry, is a potential traditional medicine for diabetes and neuroprotection.

Aim

Isolation, characterization, development and evaluation of phytoconstituent based formulation for diabetic neuropathy.

Material and methods

The stem Bark of M. alba was peeled and subjected to extraction. A phytoconstituent was then isolated by column chromatography and characterized using Mass spectroscopy, FTIR, and NMR. The isolated phytoconstituent was used to formulate a nanoemulsion. Nanoemulsion was also characterized for viscosity, surface tension, refractive index, pH, and particle size. Selected nanoemulsion formulations were then tested for acute oral toxicity and diabetic neuropathy, including behavioral, hematological, histopathological, and biomarker examinations.

Results

The spectral analysis affirmed that the isolated compound was found to be chrysin. A nanoemulsion formulation was made using the chrysin and was characterized and found to be stable during the stability testing and fulfilled all other testing parameters. Then acute oral toxicity study of the formulations was found to be safe. Formulations were found to possess significant results against diabetic neuropathy in rats. Biomarkers were analyzed for their mechanistic involvement in reducing neuropathy in rats, and it was found that the oxidative pathway was considerably restored, suggesting that chrysin causes these effects via this pathway.

Conclusions

Results suggests that isolated phytoconstituent (chrysin) from the bark of Morus alba derived nanoemulsion has protective and beneficial effects by diminishing the oxidative damage against alloxan-induced diabetic neuropathy in rats.

The effects of purslane consumption on glycemic control and oxidative stress: A systematic review and dose-response meta-analysis

Purslane (Portulaca oleracea L.) is a herbal remedy with wide range of pharmaceutic properties. Although the beneficial effect of purslane on the treatment of Type 2 Diabetes Mellitus (T2DM) has been shown, there is an inconsistency among the results of previous studies. Therefore, this study is aimed at conducting a systematic review and meta-analysis on the effect of purslane on glycemic profile and oxidative stress markers. A systematic search was performed in the Scopus, Web of science, PubMed and the Cochrane Library to find articles related to the effect of the purslane on Malondialdehyde (MDA) and Total Antioxidant Capacity (TAC), Fasting Blood Sugar (FBS), Hemoglobin A1c (HbA1c), insulin resistance, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) up to September 2022. Among the 611 initial studies that were identified from searching electronic databases, 16 Randomized Clinical Trials (RCTs) involving 1122 participants (557 cases and 565 controls) were included for data analysis. The results of random-effects modeling demonstrated that purslane consumption significantly reduced FBS (p < .001), MDA (p < .001) and increased TAC (p < .001). However, purslane consumption did not affect HbA1c (p < .109), fasting insulin (p = .298) and HOMA-IR (p = .382). Meta-analyses were performed using both the random- and fixed-effects model where appropriate, and I 2 index was used to evaluate the heterogeneity. This meta-analysis study suggests that purslane has beneficial effects on oxidative stress markers and glycemic parameter. Therefore, it may be a promising adjuvant therapy in T2DM because of its benefits and negligible adverse effects.

Three genes expressed in relation to lipid metabolism considered as potential biomarkers for the diagnosis and treatment of diabetic peripheral neuropathy

Diabetic neuropathy is one of the most common chronic complications and is present in approximately 50% of diabetic patients. A bioinformatic approach was used to analyze candidate genes involved in diabetic distal symmetric polyneuropathy and their potential mechanisms. GSE95849 was downloaded from the Gene Expression Omnibus database for differential analysis, together with the identified diabetic peripheral neuropathy-associated genes and the three major metabolism-associated genes in the CTD database to obtain overlapping Differentially Expressed Genes (DEGs). Gene Set Enrichment Analysis and Functional Enrichment Analysis were performed. Protein-Protein Interaction and hub gene networks were constructed using the STRING database and Cytoscape software. The expression levels of target genes were evaluated using GSE24290 samples, followed by Receiver operating characteristic, curve analysis. And Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis were performed on the target genes. Finally, mRNA-miRNA networks were constructed. A total of 442 co-expressed DEGs were obtained through differential analysis, of which 353 expressed up-regulated genes and 89 expressed down-regulated genes. The up-regulated DEGs were involved in 742 GOs and 10 KEGG enrichment results, mainly associated with lipid metabolism-related pathways, TGF-β receptor signaling pathway, lipid transport, and PPAR signaling pathway. A total of 4 target genes (CREBBP, EP300, ME1, CD36) were identified. Analysis of subject operating characteristic curves indicated that CREBBP (AUC = 1), EP300 (AUC = 0.917), ME1 (AUC = 0.944) and CD36 (AUC = 1) may be candidate serum biomarkers for DPN. Conclusion: Diabetic peripheral neuropathy pathogenesis and progression is caused by multiple pathways, which also provides clinicians with potential therapeutic tools.

Degenerative cervical myelopathy: Where have we been? Where are we now? Where are we going?

Degenerative cervical myelopathy (DCM), a recently coined term, encompasses a group of age-related and genetically associated pathologies that affect the cervical spine, including cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament (OPLL). Given the significant contribution of DCM to global disease and disability, there are worldwide efforts to promote research and innovation in this area. An AO Spine effort termed 'RECODE-DCM' was initiated to create an international multistakeholder consensus group, involving patients, caregivers, physicians and researchers, to focus on launching actionable discourse on DCM. In order to improve the management, treatment and results for DCM, the RECODE-DCM consensus group recently identified ten priority areas for translational research. The current article summarizes recent advancements in the field of DCM. We first discuss the comprehensive definition recently refined by the RECODE-DCM group, including steps taken to arrive at this definition and the supporting rationale. We then provide an overview of the recent advancements in our understanding of the pathophysiology of DCM and modalities to clinically assess and diagnose DCM. A focus will be set on advanced imaging techniques that may offer the opportunity to improve characterization and diagnosis of DCM. A summary of treatment modalities, including surgical and nonoperative options, is then provided along with future neuroprotective and neuroregenerative strategies. This review concludes with final remarks pertaining to the genetics involved in DCM and the opportunity to leverage this knowledge toward a personalized medicine approach.

Neurological Features and Their Association With Gender in Diabetes Mellitus Patients

Introduction Understanding the wide range of clinical signs and symptoms associated with diabetes mellitus (DM) is crucial because people with DM are frequently misdiagnosed, given incorrect care, or poorly controlled. Therefore, the purpose of this study was to evaluate the neurological symptoms associated with type 1 and type 2 DM patients with respect to patient gender. Methods This was a cross-sectional multicenter study that was conducted at different hospitals using a non-probability sampling method. The duration of the study was eight months, from January 2022 to August 2022. The study involved 525 type 1 and type 2 DM patients with an age range from 35 to 70 years. Demographic details such as age, gender, socioeconomic status, past medical history, presence of comorbidities, type, and duration of DM, and neurological features were recorded as frequencies and percentages. A Chi-square test was used to determine the association between neurological symptoms associated with type 1 and type 2 DM and gender. Results The study findings showed that of 525 diabetic patients, 210 (40.0%) were females and 315 (60.0%) were males. The mean male and female mean ages were 57.36±14.99 and 50.52±14.8 years, respectively, with a significant difference with respect to gender (p<0.001). The prevalence of neurological manifestations showed that irritability or mood swings were reported by most of the male 216 (68.6%) and 163 (77.6%) female diabetic patients, with a significant association noticed (p=0.022). Moreover, a significant association was observed between both genders in terms of swelling of feet, ankles, hands, and eyes (p=0.042), confusion or difficulty in concentration (p=0.040), burning pain in feet or legs (p=0.012), and muscular pain or cramps in legs or feet (p=0.016).  Conclusion This study concluded that the prevalence of neurological manifestations was high among diabetic patients. Most of the neurological symptoms were significantly more pronounced in female diabetic patients. Moreover, most of the neurological symptoms were associated with the type (type 2 DM) and duration of DM. The presence of hypertension, dyslipidemia, and smoking also influenced some neurological manifestations.

Mechanisms underlying altered neuromuscular function in people with DPN

Diabetes alters numerous physiological functions and can lead to disastrous consequences in the long term. Neuromuscular function is particularly affected and is impacted early, offering an opportunity to detect the onset of diabetes-related dysfunctions and follow the advancement of the disease. The role of physical training for counteracting the deleterious effects of diabetes is well accepted but at the same time, it appears difficult to reliably assess the effects of exercise on functional capacity in patients with diabetic peripheral neuropathy (DPN). In this paper, we will review the specific characteristics of various neuromuscular dysfunctions associated with diabetes according to the DPN presence or not, and their changes over time. We present several propositions regarding the onset of neuromuscular alterations in people with diabetes compared to people with DPN. It appears that motor unit loss and neuromuscular transmission impairment are among the main mechanisms explaining the considerable degradation of neuromuscular function in the transition from a diabetic to neuropathic state. Rate of force development and contractile properties could start to decrease with the onset of preferential type II fiber atrophy, commonly reported in people with DPN. Finally, M_max amplitude could decrease with neuromuscular fatigue only in people with DPN, reflecting the fatigue-related neuromuscular transmission impairment reported in people with DPN. In this review, we show that the different neuromuscular parameters are altered at different stages of diabetes, according to the presence of DPN or not. The precise evaluation of these parameters might participate in adapting the physical training prescription.

The receptor for advanced glycation end products and its ligands' expression in OVE26 diabetic sciatic nerve during the development of length-dependent neuropathy

Type 1 diabetes (T1D) may affect the peripheral nervous system and alter the expression of proteins contributing to inflammation and cellular cytoskeleton dysfunction, in most cases leading to the development of diabetic length-dependent neuropathy (DLDN). In the present study, we performed immunohistochemistry (IHC) to probe the expression of the receptor for advanced glycation end products (RAGE); its key ligands, high-mobility group box 1 (HMGB1), S100 calcium-binding protein B (S100B), and carboxymethyl-lysine (CML - advanced glycation end products (AGE)); and its cytoplasmic tail-binding partner, diaphanous related formin 1 (DIAPH1) and associated molecules, beta-actin (ACTB) and profilin 1 (PFN1) proteins in sciatic nerves harvested from seven-month old FVB/OVE26 mice with genetically-mediated T1D. We found that the amount of RAGE, HMGB1, and S100B proteins was elevated in diabetic vs the non-diabetic groups, while the amount of DIAPH1, ACTB, as well as PFN1 proteins did not differ between these groups. Moreover, our data revealed linear dependence between RAGE and HMGB1 proteins. Interaction criss-cross of selected sets of proteins in the sciatic nerve revealed that there were connected in a singular network. Our results indicate that T1D may alter expression patterns of RAGE axis proteins and thus contribute to DLDN.

Association of C-peptide level with peripheral neuropathy in type 2 diabetes: An observational cross-sectional preliminary study

BACKROUND AND AIMS

Peripheral neuropathy is the most common microvascular complication of diabetes mellitus. In subjects with type 1 diabetes (T1D) relationship of C-peptide levels and neuropathy has been observed in several studies, however, there are very few studies in type 2 diabetes (T2D) subjects. In this study we aim to assess the association of C-peptide levels with peripheral neuropathy in Indian subjects with T2D.

METHOD

One hundred patients of T2D were included in this study. Clinical and laboratory parameter was assessed for all participants. The C-peptide level was measured by fluorometric enzyme immunoassay method. Assessment of diabetic peripheral neuropathy was based on diabetic neuropathy symptom score and the diabetic neuropathy examination scores.

RESULTS

Total 100 patients completed the study. Mean age of subjects was 60.03 years and male: female ratio was 1.17. Peripheral neuropathy was detected in 47% of subjects evaluated. Subjects were further divided in to neuropathy group and no-neuropathy group for analysis. Age in neuropathy group was significantly higher than no-neuropathy group [65.62 ± 10.5 vs 55.08 ± 9.41 yrs (p-value <0.0001)] and similarly duration of T2D was significantly higher in neuropathy group [10.11 ± 6.13 vs 4.16 ± 3.7 yrs (p-value <0.0001)]. Importantly mean fasting C-peptide (2.27 ± 0.98 vs 3.12 ± 0.84 ng/ml) and mean post meal C-peptide (4.27 ± 1.34 vs 5.33 ± 0.89 ng/ml) were significantly lower in neuropathy group compared to no-neuropathy group. An association of HbA1c level and neuropathy was statistically not significant (p = 0.793).

CONCLUSION

Serum C-peptide concentrations are associated with peripheral neuropathy in T2DM patients, independent of the degree of glycemic control.

Role of tubulin post-translational modifications in peripheral neuropathy

Peripheral neuropathy is a common disorder that results from nerve damage in the periphery. The degeneration of sensory axon terminals leads to changes or loss of sensory functions, often manifesting as debilitating pain, weakness, numbness, tingling, and disability. The pathogenesis of most peripheral neuropathies remains to be fully elucidated. Cumulative evidence from both early and recent studies indicates that tubulin damage may provide a common underlying mechanism of axonal injury in various peripheral neuropathies. In particular, tubulin post-translational modifications have been recently implicated in both toxic and inherited forms of peripheral neuropathy through regulation of axonal transport and mitochondria dynamics. This knowledge forms a new area of investigation with the potential for developing therapeutic strategies to prevent or delay peripheral neuropathy by restoring tubulin homeostasis.

Antidiabetes study of Spondias mombin (Linn) stem bark fractions in high-sucrose diet-induced diabetes in Drosophila melanogaster

Objective

The onset of insulin resistant diabetes has been associated with a high-sucrose diet in vertebrates and invertebrates. However, various parts of Spondias mombin reportedly possess antidiabetic potential. However, the antidiabetic efficacy of S. mombin stem bark in high-sucrose diet-induced Drosophila melanogaster model has not been explored. In this study, the antidiabetic and antioxidant effects of the solvent fractions of S. mombin stem bark were evaluated using in vitro, in vivo, and in silico methods.

Methods

Successive fractionation of S. mombin stem bark ethanol extract was performed; the resulting fractions were subjected to in vitro antioxidant and antidiabetic assays using standard protocols. The active compounds identified from the high-performance liquid chromatography (HPLC) study of the n-butanol fraction were docked against the active site of Drosophila α-amylase using AutoDoc Vina. The n-butanol and ethyl acetate fractions of the plant were incorporated into the diet of diabetic and nondiabetic flies to study the in vivo antidiabetic and antioxidant properties.

Results

The results obtained revealed that n-butanol and ethyl acetate fractions had the highest in vitro anti-oxidant capacity by inhibiting 2,2-diphenyl-1-picrylhydrazyl (DPPH), ferric reducing antioxidant power, and hydroxyl radical followed by significant inhibition of α-amylase. HPLC analysis revealed the identification of eight compounds with quercetin having the highest peak followed by rutin, rhamnetin, chlorogenic acid, zeinoxanthin, lutin, isoquercetin, and rutinose showing the lowest peak. The fractions restored the glucose and antioxidant imbalance in diabetic flies, which is comparable with the standard drug (metformin). The fractions were also able to upregulate the mRNA expression of insulin-like peptide 2, insulin receptor, and ecdysone-inducible gene 2 in diabetic flies. The in silico studies revealed the inhibitory potential of active compounds against α-amylase with isoquercetin, rhamnetin, rutin, quercetin, and chlorogenic acid having higher binding affinity than the standard drug (acarbose).

Conclusion

Overall, the butanol and ethyl acetate fractions of S. mombin stem bark ameliorate type 2 diabetes in Drosophila. However, further studies are needed in other animal models to confirm the antidiabetes effect of the plant.

Exaggerated exercise pressor reflex in male UC Davis type 2 diabetic rats is due to the pathophysiology of the disease and not aging

Introduction: Studies in humans and animals have found that type 2 diabetes mellitus (T2DM) exaggerates the blood pressure (BP) response to exercise, which increases the risk of adverse cardiovascular events such as heart attack and stroke. T2DM is a chronic disease that, without appropriate management, progresses in severity as individuals grow older. Thus, it is possible that aging may also exaggerate the BP response to exercise. Therefore, the purpose of the current study was to determine the effect of the pathophysiology of T2DM on the exercise pressor reflex independent of aging. Methods: We compared changes in peak pressor (mean arterial pressure; ΔMAP), BP index (ΔBPi), heart rate (ΔHR), and HR index (ΔHRi) responses to static contraction, intermittent contraction, and tendon stretch in UCD-T2DM rats to those of healthy, age-matched Sprague Dawley rats at three different stages of the disease. Results: We found that the ΔMAP, ΔBPi, ΔHR, and ΔHRi responses to static contraction were significantly higher in T2DM rats (ΔMAP: 29 ± 4 mmHg; ΔBPi: 588 ± 51 mmHg•s; ΔHR: 22 ± 5 bpm; ΔHRi: 478 ± 45 bpm•s) compared to controls (ΔMAP: 10 ± 1 mmHg, p < 0.0001; ΔBPi: 121 ± 19 mmHg•s, p < 0.0001; ΔHR: 5 ± 2 bpm, p = 0.01; ΔHRi: 92 ± 19 bpm•s, p < 0.0001) shortly after diabetes onset. Likewise, the ΔMAP, ΔBPi, and ΔHRi to tendon stretch were significantly higher in T2DM rats (ΔMAP: 33 ± 7 mmHg; ΔBPi: 697 ± 70 mmHg•s; ΔHRi: 496 ± 51 bpm•s) compared to controls (ΔMAP: 12 ± 5 mmHg, p = 0.002; ΔBPi: 186 ± 30 mmHg•s, p < 0.0001; ΔHRi: 144 ± 33 bpm•s, p < 0.0001) shortly after diabetes onset. The ΔBPi and ΔHRi, but not ΔMAP, to intermittent contraction was significantly higher in T2DM rats (ΔBPi: 543 ± 42 mmHg•s; ΔHRi: 453 ± 53 bpm•s) compared to controls (ΔBPi: 140 ± 16 mmHg•s, p < 0.0001; ΔHRi: 108 ± 22 bpm•s, p = 0.0002) shortly after diabetes onset. Discussion: Our findings suggest that the exaggerated exercise pressor reflex and mechanoreflex seen in T2DM are due to the pathophysiology of the disease and not aging.

Diabetic neuropathy: Past, present, and future

BACKGROUND

A sedentary lifestyle and an unhealthy diet have considerably increased the incidence of diabetes mellitus worldwide in recent decades, which has generated a high rate of associated chronic complications.

METHODS

A narrative review was performed in MEDLINE, EMBASES and SciELO databases, including 162 articles.

RESULTS

Diabetic neuropathy (DN) is the most common of these complications, mainly producing two types of involvement: sensorimotor neuropathy, whose most common form is symmetric distal polyneuropathy, and autonomic neuropathies, affecting the cardiovascular, gastrointestinal, and urogenital system. Although hyperglycemia is the main metabolic alteration involved in its genesis, the presents of obesity, dyslipidemia, arterial hypertension, and smoking, play an additional role in its appearance. In the pathophysiology, three main phenomena stand out: oxidative stress, the formation of advanced glycosylation end-products, and microvasculature damage. Diagnosis is clinical, and it is recommended to use a 10 g monofilament and a 128 Hz tuning fork as screening tools. Glycemic control and non-pharmacological interventions constitute the mainstay of DN treatment, although there are currently investigations in antioxidant therapies, in addition to pain management.

CONCLUSIONS

Diabetes mellitus causes damage to peripheral nerves, being the most common form of this, distal symmetric polyneuropathy. Control of glycemia and comorbidities contribute to prevent, postpone, and reduce its severity. Pharmacological interventions are intended to relieve pain.

Clinical Utility of Boston-CTS and Six-Item CTS Questionnaires in Carpal Tunnel Syndrome Associated with Diabetic Polyneuropathy

Diabetic polyneuropathy (DPN) is the most frequent complication of diabetes. Carpal tunnel syndrome (CTS), one of the most common neuropathies, is a chronic compression of the median nerve at the wrist. In our prospective cross-sectional study, we enrolled patients with type 2 diabetes presenting with signs and symptoms suggestive of DPN (n = 53). We aimed to compare two clinical scales: the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) and the six-item CTS symptoms scale (CTS-6), with nerve conduction studies (NCS) for detecting CTS in patients with DPN. Carpal tunnel syndrome and DPN were clinically evaluated, and the diagnosis was confirmed by NCS. Depending on the NCS parameters, the study group was divided into patients with and without DPN. For each group, we selected patients with CTS confirmed through NCS, and the results were compared with the BCTQ and CTS-6 scales. The clinical evaluation of CTS performed through BCTQ and CTS-6 was statistically significantly different between patients with and without CTS. When comparing the BCTQ questionnaire with the NCS tests, we found area under the curve (AUC) = 0.76 (95% CI 0.65-0.86) in patients with neuropathy and AUC = 0.72 (95% CI 0.55-0.88) in patients without neuropathy. At the same time, the AUC values of the CTS-6 scale were 0.76 (95% CI 0.61-0.88) in patients with neuropathy and 0.70 (95% CI 0.51-0.86) in patients without neuropathy. Using multiple logistic regression, we demonstrated that DPN increased the chances of detecting CTS using the two questionnaires. The Boston Carpal Tunnel Syndrome and CTS-6 questionnaires can be used in the diagnosis of CTS in diabetic patients with and without DPN but with moderate AUC. The presence of DPN increased the chances of detecting CTS using the BCTQ questionnaire and the CTS-6 scale.

Effect of Cognitive-Behavioral Therapy or Mindfulness Therapy on Pain and Quality of Life in Patients with Diabetic Neuropathy: A Systematic Review and Meta-Analysis

OBJECTIVES

This study aimed to evaluate the effectiveness of cognitive behavioral therapy (CBT) and mindfulness therapy (MT) for pain relief and quality of life (QOL) in patients with diabetic neuropathy.

REVIEW/ANALYSIS METHODS

Four databases were systematically searched from their respective inception dates to 29 June 2021. Relevant randomized controlled trials (RCTs) were screened and assessed for risk of bias. Eight RCTs evaluating CBT or MT were included. Statistical analysis was performed using Review Manager 5.4.

RESULTS

Eight RCTs involving 384 patients with painful diabetic neuropathy (PDN) tested psychological interventions, including three CBT and five MT studies. The results showed that patients' pain severity (standardized mean difference [SMD] = -0.60, 95% confidence interval [CI; -0.93 to -0.27], P = .0003) and QOL (SMD = -0.43, 95% CI [-0.83 to -0.04], p = .03) were improved immediately after treatment. Besides, the pain intensity (SMD = -0.67, 95% CI [-1.37 to 0.03], p = .06), pain interference (SMD = -0.75, 95% CI [-1.20 to -0.30], p = .001) and depressive symptoms (SMD = -0.62, 95% CI [-0.96 to -0.28], p = .0003) were superior to the control group after follow up. The subgroup analysis results of different intervention type showed that the CBT group could immediately improve pain (SMD = -0.44, 95% CI [-0.78 to -0.10], p = .01) after treatment. However, there was no statistically significant difference in the CBT group after follow-up (SMD = -0.15, 95% CI [-0.52 to 0.22], p = .42).

CONCLUSIONS

Cognitive behavioral therapy or MT is effective for treating pain in patients with diabetic peripheral neuropathy, improving the QOL, and reducing depressive symptoms. However, large-scale, multi-centre, rigorously designed RCTs are needed to further verify the long-term effects.