Correlation of Michigan neuropathy screening instrument, United Kingdom screening test and electrodiagnosis for early detection of diabetic peripheral neuropathy

Novel therapeutical approaches based on neurobiological and genetic strategies for diabetic polyneuropathy - A review

BACKGROUND

Neuropathy is among the most often reported consequences of diabetes and the biggest cause of morbidity and mortality in people suffering from this life-long disease. Although different therapeutic methods are available for diabetic neuropathy, it is still the leading cause of limb amputations, and it significantly decreases patients' quality of life.

AIM

This study investigates potential novel therapeutic options that could ameliorate symptoms of DN.

METHODOLOGY

Research and review papers from the last 10 years were taken into consideration.

RESULTS

There are various traditional drugs and non-pharmacological methods used to treat this health condition. However, the research in the area of pathogenic-oriented drugs in the treatment of DN showed no recent breakthroughs, mostly due to the limited evidence about their effectiveness and safety obtained through clinical trials. Consequently, there is an urgent demand for the development of novel therapeutic options for diabetic neuropathy.

CONCLUSION

Some of the latest novel diagnostic methods for diagnosing diabetic neuropathy are discussed as well as the new therapeutic approaches, such as the fusion of neuronal cells with stem cells, targeting gene delivery and novel drugs.

Peripheral Neuropathy in Diabetes: What Can MRI Do?

Diabetes peripheral neuropathy (DPN) is commonly asymptomatic in the early stage. However, once symptoms and obvious defects appear, recovery is not possible. Diagnosis of neuropathy is based on physical examinations, questionnaires, nerve conduction studies, skin biopsies, and so on. However, the diagnosis of DPN is still challenging, and early diagnosis and immediate intervention are very important for prevention of the development and progression of diabetic neuropathy. The advantages of MRI in the diagnosis of DPN are obvious: the peripheral nerve imaging is clear, the lesions can be found intuitively, and the quantitative evaluation of the lesions is the basis for the diagnosis, classification, and follow-up of DPN. With the development of magnetic resonance technology, more and more studies have been conducted on detection of DPN. This article reviews the research field of MRI in DPN.

Effect of Diabetic Neuropathy on Reparative Ability and Immune Response System

The effects of diabetes can be divided into short, medium and long term and various human organ systems can be effected. The present study aimed to determine how much the duration of diabetes mellitus (DM) affect the reparative ability of the body, immune response and the development of DM complications. Interleukin 1-β (IL-1β) and Interleukin 6 (IL-6) were monitored as specific indicators of inflammatory reaction and C-reactive protein (CRP), leukocyte count (WBC) and sedimentation rate (ESR) as general markers of inflammatory reaction. Tumour necrosis factor α (TNF-α) and transforming growth factor β1 (TGF-β1) were observed as indicators of reparative ability and polyneuropathy. All interleukins were determined by ELISA and evaluated spectrophotometrically. Michigan Neuropathy Screening Instrument (MNSI) is performed for neuropathy examination. Patients with diabetes mellitus were divided into 3 groups, according to duration of diabetes mellitus. IL-6 levels correlated with clinical stage of diabetic polyneuropathy at p = 0.025 R = 0.402; with CRP at p = 0.0001, R = 0.784 as well as correlation of CRP and MNSI score (R = 0.500, p = 0.034) in a group of patients with DM lasting up to 10 years. The reparative ability of the body is reduced by physiological age and ages of DM duration. The immune response is weakened in DM additionally. The dual activity of cytokines IL-6 and TGF-β1 is present in long-duration Diabetes Mellitus.

Prevalence of peripheral neuropathy and associated risk factors in children with type 1 diabetes

AIM

To detect the prevalence of diabetic polyneuropathy (DPN) in children with type 1 diabetes (T1D) and to identify associated the risk factors.

METHODS

This cross-sectional study evaluated children aged between 2 and 16y with T1D for ≥2 y. Detailed neurological examination, neuropathy symptom score, and nerve conduction studies were done in all children to assess nerve dysfunction. Disease-related factors were evaluated for the prediction of neuropathy.

RESULTS

Sixty-six children (67% boys) were enrolled. The mean age at the time of diagnosis of T1D was 7.1 ± 2.6 years. The mean duration of diabetes was 4 ± 1.8 years. None of the patients had neuropathy on clinical examination or on the neuropathy symptom score. The prevalence of subclinical DPN was 18.2% (n = 12/66). The type of neuropathy was pure motor (n = 11, 91.6%) and mixed sensorimotor (n = 1, 8.3%). The common peroneal nerve was most commonly affected (n = 6, 50%), followed by the tibial (n = 4, 33.3%) nerve. The most common patterns of nerve involvement were mixed axonal and demyelination (n = 7, 58.3%), followed by axonal (n = 3, 25%) and demyelinating type (n = 2, 16.6%). Children with subclinical DPN had a significant reduction in velocity of tibial, common peroneal, median motor, and ulnar motor nerves; delayed latency in common peroneal, median motor, ulnar motor, and median sensory nerves compared to those without DPN (p value <0.05). A higher body mass index predicted the development of subclinical DPN (p value <0.05).

CONCLUSION

Nearly one-fifth of children with T1D have subclinical neuropathy as early as two years of the disease. A higher body mass index is significantly associated with DPN. Electrophysiological studies should be performed regularly to screen for nerve dysfunction and its progression.

The Role of Neuropathy Screening Tools in Patients Affected by Fibromyalgia

Fibromyalgia syndrome (sFM) is one of the most common causes of chronic pain. This study aimed to assess the presence of small and large fiber impairment in fibromyalgic patients by applying validated scores used in the screening for diabetic neuropathy. The endpoints for the study were the assessment of neuropathy prevalence in sFM patients using the NerveCheck Master (NCM), the Michigan Neuropathy Screening Instrument (MNSI), the Diabetic Neuropathy Symptom (DNS) and the Douleur Neuropathique 4 Questions (DN4). The sample was composed of 46 subjects: subjects with sFM (n = 23) and healthy controls (HC) (n = 23). The positivity rates in each group for DN4 were significantly different (p < 0.001), with a prevalence in symptomatic subjects of 56.3% (n = 9) among sFM individuals. A similar difference was also observed with the DNS total score (p < 0.001). NCM and MNSI did not disclose significant differences between the two groups. This finding seems to confirm the data regarding the prevalence of a neuropathic pain in sFM patients.

Relationship between subclinical hypothyroidism and distal-symmetric diabetic polyneuropathy in type 2 diabetes mellitus referred to Kosar Hospital in Semnan and related indicators in 2019–2020

Introduction:

Diabetes is one of the most common metabolic diseases and one of its important complications is diabetic neuropathy. Due to the relationship between diabetes and thyroid disorders, the present study was performed to determine the association between subclinical hypothyroidism and end-stage diabetic polyneuropathy in patients with type 2 diabetes.

Materials and Methods:

In this descriptive, analytical study, 154 patients with type 2 diabetes referred to Kosar Hospital in Semnan were evaluated. After recording their demographic information, samples were received for biochemical testing. The patients’ neuropathy was then evaluated based on the United Kingdom screening test (UKST). The results were recorded in the data collection form and then analyzed using SPSS Statistics 22 software.

Results:

In this study, 154 patients were studied, including 49 with subclinical hypothyroidism and 105 with euthyroid. The results of the present study showed that the mean age of patients in the subclinical hypothyroid group was 60.08 years and in the euthyroid group was 60.77 years. Mean ± standard deviation (SD) of the patients’ age, blood pressure, duration of diabetes, body mass index, fasting blood sugar (FBS) and Glucose, and 2-hour post prandial (2HPP) were not statistically significant between the two groups. The frequency of neuropathy severity based on clinical signs during examination and symptoms mentioned by the patients in the two groups was statistically significant (P = 0.005 and P = 0.001, respectively). The severity of neuropathy was not significantly associated with thyroid-stimulating hormone (TSH) levels (P > 0.05).

Conclusion:

From the results of the present study, it can be concluded that the severity of neuropathy based on the clinical signs during examination and the symptoms mentioned by the patient in diabetic patients is related to subclinical hypothyroidism. Further studies are recommended.

Diabetic Foot Assessment using Skin Impedance in a Custom Made Sensor-sock

Diabetic peripheral neuropathy (DPN) may lead to several changes in the skin, and some of these may influence the skin impedance spectrum. In the present study we have developed a prototype solution for skin impedance spectroscopy at selected skin sites (big toe pulp, heel and toe ball) that was tested in a pilot study on five patients with DPN and five healthy controls. At the big toe, most of the controls had markedly lower impedance than the DPN group, especially in the range of 1-100 kHz. The separation between the groups seems to be weaker at the heel and weakest at the toeball. The results may indicate that monitoring of the skin impedance spectrum may be a method for detection of skin changes associated with DPN, encouraging further studies with the big toe sensor in particular.

Diabetic Foot scientific activities in Endocrinology and Metabolism Research Institute

Introduction

Diabetic Foot (DF) as a common complication of Diabetes should be intensive intervention for prevention, management and rehabilitation. In this regard, Diabetes Research Center of Endocrinology and Metabolism Research Institute (EMRI) of Tehran University of Medical Sciences (TUMS) considered DF as a priority research area to investigate multidimensional aspects of DF care. We are intended to summarize DF research studies affiliated to the EMRI for over the last two decades.

Methods

Three Electronic databases including Web of Science, PubMed, and Scopus were searched until January 2020 to find articles about DF published affiliated to EMRI. The main concepts of search strategies were "diabetes", "Foot". 115 documents retrieved from these databases which screened for inclusion and exclusion criteria. The visualization of the network of co-authorship of authors and co-occurrence of keywords was illustrated and documents were analyzed for content according to the Main areas of DF Research studies.

Result

64 related documents including original articles, reviews, letters, notes, and book chapter have included to this study. According to the objectives of the retrieved studies, DF documents and research studies categorized in the two main groups including DF prevention, classification and risk stratification in addition management of DF.

Conclusion

Despite conducted research and educational activities in DF prevention and management, the following topics would be considered as well: effective offloading treatment, correcting the nutritional status for improving wound healing and novel educational strategies for diabetic foot multi-disciplinary team.

Ultrasound evaluation of peripheral nerves of the lower limb in diabetic peripheral neuropathy

PURPOSE

Comparative evaluation of the cross-sectional area (CSA) of the sural and tibial nerves using ultrasound in diabetic peripheral neuropathy (DPN).

METHOD

This study involved 210 participants divided into 3 groups: type 2 diabetics with DPN, type 2 diabetics without DPN, and controls. Ultrasound evaluation of the sural and tibial nerves was done using a 5-17 MHz linear transducer. The CSA of both the nerves was recorded in both lower limbs. Nerve conduction studies (NCS) were also done in all diabetic patients.

RESULTS

There were 70 participants in each group. All the three groups were gender-matched and no significant difference was observed between CSA values of the sural and tibial nerves between males and females and also in right and left lower limbs within a group. The sural nerve CSA was significantly higher in the DPN group than in diabetic patients without DPN and controls. The sensitivity of the sural nerve CSA was higher than the tibial nerve with a cut-off value of 4.41 mm² for CSA of the sural nerve.

CONCLUSION

The sural nerve CSA at the superior border of lateral malleolus can be used for screening DPN. With well-established cut-off values may result in early initiation of the therapy even in NCS negative cases, thus reducing the morbidity associated with the disease. Ultrasound could be used as a first diagnostic tool for detection of DPN which can be followed by NCS in cases where ultrasound is non-diagnostic.

Role of interdigital sensory nerve conduction study as a noninvasive approach for early diagnosis of diabetic peripheral neuropathy

Purpose

Diabetes mellitus is amongst the most common causes of polyneuropathy worldwide that can eventually terminate to irreversible complications. The remarkable impact of diabetic polyneuropathy as a debilitating condition on the healthcare system and total costs of diabetes care is undeniable. Despite the existence of numerous diagnostic tools such as routine electrophysiologic procedures, its early detection is challenging. This study designed to compare more distal techniques of electrodiagnostic testing, including interdigital sensory nerve conduction studies (NCSs), with conventional approaches and to investigate its role in confirming the early stages of polyneuropathy.

Methods

This cross-sectional study was performed in the Physical Medicine and Rehabilitation Department of Hazrat Fatemeh Reconstruction Surgery Hospital. Thirty one symptomatic diabetic outpatients and 23 asymptomatic nondiabetic subjects included in our study. We performed nerve conduction studies on five sensory nerves consist of the dorsal sural nerve, medial plantar nerve, digital branches of the interdigital nerves to toes I, II, and III (as a new antidromic technique). In this study, all techniques applied with a surface stimulator and pick-up electrodes.

Results

In the group of patients, 9 (29%) and 22 (71%) subjects had impaired and normal routine NCSs, respectively. Interestingly, the results of interdigital nerve studies were abnormal in the 17 out of 22 patients with normal routine NCSs. Also, 11 and 13 subjects had impaired medial plantar nerve and dorsal sural nerve conduction studies, respectively. Accordingly, with this new method, the prevalence of detectable diabetic neuropathy increased from 46% to 83%.

Discussion

We conducted this study intending to demonstrate the application of a new technique for early diagnosis of diabetic polyneuropathy, especially in the presymptomatic and subclinical neuropathies. The digital sensory branches of IDNs known as the most distal sensory nerves, which can be easily evaluated with new antidromic SNAP technique. Our method is simple, non-invasive, suitable, sensitive, and reproducible. There is no need to needle electrode or averaging technique to record an appropriate amplitude of IDN. Thus, it is recommended as a convenient electrophysiological option for early diagnosis of DPN.

Turkish version of the Michigan Neuropathy Screening Instrument in the assessment of diabetic peripheral neuropathy: a validity and reliability study

Background/aim

Diabetic peripheral neuropathy (DPN) is the most common complication of diabetes mellitus (DM). The Michigan Neuropathy Screening Instrument (MNSI) is a simple, brief, and useful screening tool that was designed to assess DPN. The aim of this study was to develop a Turkish version of the MNSI and assess its reliability and validity.

Materials and methods

Eighty-three patients with DM who were divided into two groups according the results of nerve conduction studies (NCS) as having DPN or without DPN were enrolled in this cross-sectional study. The Toronto clinical scoring system, pain detect questionnaire, and NCS were assessed along with the MNSI.

Results

Each section of the MNSI was internally consistent (Cronbach's alpha > 0.70), and the scores of both sections were positively correlated with total MNSI score (r = 0.938; r = 0.908, respectively, p < 0.001). The test-retest reliability of the Turkish version of the MNSI was determined as 0.99 for the total score (intraclass correlation coefficient = 0.996). Using the agreement between MNSI scores and DPN diagnosis by NCS as a gold standard, receiver-operating characteristic (ROC) curve values for section A and section B were estimated as 0.973 and 1.00, respectively. When a cut-off value ≥ 3.0 in section A and a cut-off value ≥ 2.0 in section B were used, we obtained a sensitivity of 97.6% and 100%; a specificity of 63.4% and 97.6%; a positive predictive value of 72.7% and 97.6%; and a negative predictive value of 96.3% and 100%, respectively.

Conclusion

The Turkish version of MNSI is a reliable and valid tool for screening DPN in Turkish patients.

Relationship between diabetic polyneuropathy, serum visfatin, and oxidative stress biomarkers

BACKGROUND

Diabetic polyneuropathy is a very common complication of diabetes. Numerous studies are available in terms of pathogenesis. But examination methods with low reliability are still not standardized and generally time consuming. High-sensitive, easy-to-access methods are expected. Biochemical markers are one of the subjects of research. We aimed to discover a potential biomarker that can be used for this purpose in patients with diabetes who have not yet developed symptoms of neuropathy.

AIM

To determine the place and availability of visfatin and thiol-disulfide homeostasis in this disorder.

METHODS

A total of 392 patients with type 2 diabetes mellitus were included in the study. The polyneuropathy clinical signs were evaluated with the Subjective Peripheral Neuropathy Screen Questionnaire and Michigan Neuropathy Screening Instrument questionnaire and examination. The biochemical parameters, oxidative stress markers, visfatin, and thiol-disulfide homeostasis were analyzed and correlated with each other and clinical signs.

RESULTS

Subjective Peripheral Neuropathy Screen Questionnaire and Michigan Neuropathy Screening Instrument questionnaire with examination scores were correlated with each other and diabetes duration (P < 0.005). Neuropathy related symptoms were present in 20.7% of the patients, but neuropathy related findings were observed in 43.9% of the patients. Serum glucose, glycated hemoglobin, and visfatin were positively correlated with each other. Also, these parameters were positively correlated with the total oxidative stress index. Total and native thiol was positively correlated with total antioxidant status and negatively with oxidant status. Inversely thiol-disulfide positively correlated with higher glucose and oxidant status and negatively with total antioxidant status (P < 0.005). There was no correlation between visfatin and thiol-disulphide (P = 0.092, r = 0.086). However, a significant negative correlation was observed between visfatin and total with native thiol (P < 0.005, r = -0.338), (P < 0.005, r = -0.448).

CONCLUSION

Diagnosis of neuropathy is one of the issues studied in patients with diabetes. Visfatin and thiol-disulfide balance were analyzed for the first time in this study with inspiring results.

Diabetic Distal Symmetrical Polyneuropathy: Correlation of Clinical, Laboratory, and Electrophysiologic Studies in Patients with Type 2 Diabetes Mellitus

This cross-sectional study is aimed at determining the prevalence of distal symmetrical polyneuropathy (DSPN) and diabetic peripheral neuropathic pain (DPNP) in participants with type 2 diabetes mellitus (T2DM); finding the risk factors for DSPN and DPNP via biochemical tests; and correlating DSPN and DPNP with the results of electrophysiologic studies, quantitative sensory tests, and neurologic examination. The 145 participants with T2DM enrolled were divided into the DSPN (abnormal nerve conduction studies (NCS) with signs of polyneuropathy), subclinical DSPN (abnormal NCS without signs of polyneuropathy), minimal DSPN (normal NCS with signs of polyneuropathy), and no DSPN groups. The biochemical risk factors of diabetic peripheral neuropathy were investigated. Neurologic examinations, laboratory tests, NCS, vibration threshold tests, and thermal threshold tests were conducted. The modified Michigan Neuropathy Screening Instrument (mMNSI) and Douleur Neuropathique 4 were used to evaluate the severity of DSPN and DPNP, respectively. In all, 30% of participants had DSPN and 11% had DPNP. DSPN correlated strongly with male gender and higher glycohaemoglobin levels; NCS abnormality correlated with higher glycohaemoglobin levels; DSPN severity correlated with NCS of each stimulating nerve. DPNP commonly occurred with clinical and electrophysiologic evidence of DSPN. Symptomatic diabetic polyneuropathy significantly correlated with longer disease duration, higher glycohaemoglobin levels, and abnormal vibration tests. The thermal threshold test combined with nerve conduction tests could detect most of the patients with DSPN, subclinical DSPN, and minimal DSPN. Poor diabetic control was independently associated with the development of DSPN. DPNP was associated with DSPN. The combination of thermal threshold tests with NCS can potentially provide the diagnosis of DSPN.

Clinician Assessment Tools for Patients with Diabetic Foot Disease: A Systematic Review

The amputation rate in patients with diabetes is 15 to 40 times higher than in patients without diabetes. To avoid major complications, the identification of high-risk in patients with diabetes through early assessment highlights as a crucial action. Clinician assessment tools are scales in which clinical examiners are specifically trained to make a correct judgment based on patient outcomes that helps to identify at-risk patients and monitor the intervention. The aim of this study is to carry out a systematic review of valid and reliable Clinician assessment tools for measuring diabetic foot disease-related variables and analysing their psychometric properties. The databases used were PubMed, Scopus, SciELO, CINAHL, Cochrane, PEDro, and EMBASE. The search terms used were foot, ankle, diabetes, diabetic foot, assessment, tools, instruments, score, scale, validity, and reliability. The results showed 29 validated studies with 39 Clinician assessment tools and six variables. There is limited evidence on all of the psychometric characteristics of the Clinician assessment tools included in this review, although some instruments have been shown to be valid and reliable for the assessment of diabetic neuropathy (Utah Early Neuropathy Scale or UENS); ulceration risk (Queensland High Risk Foot Form or QHRFF); diabetic foot ulcer assessment, scoring, and amputation risk (Perfusion, extent, depth, infection and sensation scale or PEDIS and Site, Ischemia, Neuropathy, Bacterial Infection, and Depth score or SINBAD); and diabetic foot ulcer measurement (Leg Ulcer Measurement Tool LUMT).

Classical Therapies Versus Combined Therapies in Diabetic Neuropathy

The aim of our study was to evaluate the classical therapies represented by adequate glycemic control and lifestyle changes versus classical therapies combined with new antioxidant therapies in patients with diabetic neuropathy. We conducted an observational, prospective study, between October 2017 and December 2019, which included a number of 188 patients suffering from diabetic neuropathy. In order to evaluate the response to the therapeutic protocol, we used the MNSI (Michigan neuropathy screening instrument). Responder group was defined as a decrease in MNSI (<7) from baseline to one year. According to this 34.04% (n=64) of patients were responders to classical therapy while a higher number of patients responded to combined therapy (n=73, representing 38.83%). In the group of responders, the subgroups that predicted the prevention of MNSI increase (decrease in the impact of diabetic neuropathy) in the group treated with combined therapy compared to classical therapy, related to clinicopathological features, after one year included: gender female (p=0.0415), body mass index <30kg/m2 (p=0.0335), absence of cardiovascular disease (p=0.0006) and absence of dyslipidemia (p=0.0288). In conclusion, we demonstrated an increased response to combined therapy after one year of treatment. Thus, combined therapy is an alternative for reducing side effects and for increasing efficiency.

Point-of-care ultrasound defines gastric content in elective surgical patients with type 2 diabetes mellitus: a prospective cohort study

BACKGROUND

Delayed gastric emptying and the resultant "full stomach" is the most important risk factor for perioperative pulmonary aspiration. Using point-of-care gastric sonography, we aimed to investigate the prevalence of full stomach and its risk factors in elective surgical patients with type 2 diabetes.

METHODS

Type 2 diabetic and non-diabetic elective surgical patients were included from July 2017 to April 2018 in a 1:1 ratio. The study was retrospectively registered at July 2017, after enrollment of the first participant. Gastric ultrasound was performed 2 h after ingesting clear fluid or 6 h after a light meal. Full stomach was defined by the presence of gastric content in both semi-recumbent and right lateral decubitus positions. For patients with full or intermediate stomach, consecutive ultrasound scan was performed until empty stomach was detected. Logistic regression analyses were used to identify risk factors associated with full stomach.

RESULTS

Fifty-two type 2 diabetic and fifty non-diabetic patients were analyzed. The prevalence of full stomach was 48.1% (25/52) in diabetic patients, with 44.0% for 2-h fast after clear fluid and 51.9% for 6-h fast after a light meal, significantly higher than 8% (4/50) in non-diabetic patients (P = 0.000). The average time to empty stomach in diabetic patients was 146.50 ± 40.91 mins for clear liquid and 426.50 ± 45.25 mins for light meal, respectively. Further analysis indicated that presence of diabetes-related eye disease was an independent risk factor of full stomach in diabetic patients (OR = 4.83, P = 0.010).

CONCLUSIONS

Almost half of type 2 diabetic patients have a full stomach following the current preoperative fasting guideline. Preoperative ultrasound assessment of gastric content in type 2 diabetic patients is suggested, especially for those with diabetes -related eye disease.

TRIAL REGISTRATION

The trial was registered at www.clinicaltrials.gov with registration number NCT03217630 . Retrospectively registered on 14th July 2017.

Vitamin B12 deficiency and diabetic neuropathy in patients taking metformin: a cross-sectional study

OBJECTIVE

Vitamin B12 deficiency resulting from metformin use has been demonstrated in multiple studies. In this study, we aimed to evaluate the prevalence of vitamin B12 deficiency in patients with chronic metformin use and the relationship between vitamin B12 deficiency and diabetic neuropathy.

METHODS

A cross-sectional study was conducted with 162 patients. Vitamin B12 levels were measured by chemiluminescence immunoassay. Diabetic neuropathy was evaluated by patient record, nerve conduction and Michigan test for the diagnosis of diabetic neuropathy. Additional data, including demographic characteristics were collected. A linear regression model was used to evaluate variables that correlated with vitamin B12 levels and diabetic neuropathy.

RESULTS

Low vitamin B12 levels were found in 7.3% (95% CI: 4.0-12%) of patients. In those with diabetic neuropathy, altered (low and borderline) vitamin B12 level was 64% (95% CI: 47-78%) compared to 17% (95% CI: 10-26%) in patients without diabetic neuropathy (coefficient: -110.8; CI 95%: -165.8, -59.7). Those taking a higher metformin dose had lower levels of vitamin B12 (coefficient: -0.061; CI 95%: -0.09, -0.024). In addition, female patients had higher levels of vitamin B12 compared to men (coefficient: 49.1; CI 95%: 2.3-95).

CONCLUSIONS

Vitamin B12 deficiency is highly prevalent, especially in patients with diabetic neuropathy. In this study an inverse correlation was found between diabetic neuropathy and the plasma level of vitamin B12. Higher doses of metformin and male sex were factors related to lower levels of vitamin B12.

Insights for Care: The Healthcare Utilisation and Cost Impact of Managing Type 2 Diabetes-Associated Microvascular Complications

INTRODUCTION

The increasing prevalence of type 2 diabetes (T2DM) in the UK imposes a significant burden on the National Health Service (NHS). Despite the availability of effective treatments, the loss of glycaemic control over time results in significant comorbidities, including nephropathy, neuropathy and retinopathy. The cost of treating these microvascular complications has not been well documented, and this study aimed to provide an accurate assessment of the healthcare resource utilisation (HCRU) associated with managing T2DM and its complications.

METHODS

This retrospective cohort study utilised electronic medical records from patients with T2DM from the Heart of England Foundation Trust (HEFT), which captures data from patients using secondary care services. Patients were diagnosed with microvascular complications based on ICD-10 or OPCS codes. HCRU over a 2-year period was based on NHS Tariffs for healthcare services for inpatient, accident and emergency, and dialysis clinic usage.

RESULTS

The study cohort comprised 26,629 patients with T2DM who used HEFT services during the study period, 22.6%, 20.8% and 3.1% of whom had comorbid nephropathy, retinopathy or neuropathy, respectively. While the prevalence of diabetes in the overall HEFT population was reported to be 7% in 2012, diabetes and its associated complications accounted for more than 30% of secondary care costs. Furthermore, while patients with diabetes represent only 17% of HEFT inpatients, they account for more than 20% of service usage. The economic burden of microvascular complications increased substantially with the severity of the condition, with the overall cost exceeding £70 million over the 2-year period.

CONCLUSION

This study of patients with T2DM in a typical secondary care provider in the UK showed that avoiding the progression of microvascular complications could provide substantial cost savings through targeted interventions that improve outcomes and lower resource use.

FUNDING

Merck Sharp & Dohme Limited.

Acupuncture for the treatment of lower limb diabetic peripheral neuropathy: a systematic review

OBJECTIVE

To examine evidence for acupuncture interventions in the management of diabetes-related peripheral neuropathy (DPN) symptoms.

METHODS

Five electronic databases were searched up to June 2017 for studies that included participants with symptoms of DPN, used an acupuncture intervention, and reported before-and-after DPN-related outcome measures. Two reviewers independently performed the data extraction. The level of homogeneity was assessed, and studies were appraised using the Cochrane Risk of Bias tool, the STRICTA guidelines for acupuncture reporting and the NICMAN scale for acupuncture quality.

RESULTS

Ten studies with 432 participants were included: three randomised controlled trials (RCTs), two pilot RCTs, three uncontrolled clinical trials, one quasi-RCT and one prospective case series. Improvements in DPN pain symptoms were reported by all studies. Heterogeneity of outcome measures prevented a meta-analysis. Variations were found in needle retention time and point selection, as well as total number and frequency of treatments. Common acupuncture point selections were ST36 and SP6. Half of the studies used local point selection. Studies conducted outside China had better acupuncture reporting and quality according to the STRICTA checklist and NICMAN scales, respectively. Risk of bias was high or unclear in the majority of studies for all domains except attrition bias.

CONCLUSIONS

Acupuncture for DPN appears to improve symptoms. However, the application of acupuncture varies greatly, and the quality of included studies was generally low. Available studies have varying methodologies and different outcome measures. Further, suitably powered studies using appropriate DPN outcome measures are required.

Special Considerations in the Management of Diabetic Ankle Fractures

PURPOSE OF REVIEW

Ankle fractures and diabetes mellitus are both increasing in prevalence. Patients with both diabetes and an ankle fracture have been shown to have an increased rate of complications which can be catastrophic. The purposes of this review are to identify factors placing patients at an increased risk and offer guidance on the management of these injuries, in order to reduce potential complications.

RECENT FINDINGS

Non-operative management of unstable ankle fractures in patients with diabetes results in an unacceptably high rate of complications. Operatively managed patients with uncomplicated diabetes seem to fair as well as patients without diabetes. Thus, it is important to recognize patients as either complicated or uncomplicated at the onset of their treatment based on comorbidities. There is limited evidence to guide the management of ankle fractures in patients with diabetes, in particular those deemed complicated. Non-operative management of unstable fractures in diabetic patients should be avoided.

Cross-cultural adaptation and measurement properties of the Brazilian Version of the Michigan Neuropathy Screening Instrument

BACKGROUND

The Michigan Neuropathy Screening Instrument is an easy-to-use questionnaire aimed at screening and detecting diabetic polyneuropathy.

OBJECTIVE

To translate and cross-culturally adapt the MNSI to Brazilian Portuguese and evaluate its measurement properties.

METHODS

Two bilingual translators translated from English into Brazilian Portuguese and made a synthetic version. The synthetic version was back translated into English. A committee of specialists and the translator checked the cultural adaptations and developed a pre-final questionnaire in Brazilian Portuguese (prefinal version). In pretesting, the prefinal version was applied to a sample of 34 subjects in which each subject was interviewed to determine whether they understood each item. For the later assessment of measurement properties, 84 subjects were assessed.

RESULTS

A final Brazilian Portuguese version of the instrument was produced after obtaining 80% agreement (SEM<0.01%) among diabetic patients and specialists. We obtained excellent intra-rater reliability (ICC_3,1=0.90), inter-rater reliability (ICC_2,1=0.90) and within-subject reliability ICC_3,1=0.80, excellent internal consistency (Cronbach's alpha>0.92), reasonable construct validity for the association between the MNSI and Neuropathy Symptom Score (r=0.46, p<0.05) and excellent association between the MNSI and Neuropathy Disability Score (r=0.79, p<0.05). We did not detect floor and ceiling effects (<9.5% of patients with maximum scores).

CONCLUSIONS

The Brazilian Portuguese version of the MNSI is suitable for application in the Brazilian diabetic population and is a reliable tool for the screening and detection of DPN. The MNSI can be used both in clinical practice and also for research purposes.

Assessment of diabetic polyneuropathy in Zanzibar: Comparison between traditional methods and an automated point-of-care nerve conduction device

•

We screened for signs of neuropathy in a diabetes population in Zanzibar.

•

Nerve conduction study by NC-stat DPNCheck found neuropathy in 45%.

•

Monofilament results suggestive of neuropathy in 61%.

•

Compared to nerve conduction study, monofilament had a 59% specificity.

•

Hyperglycaemia and hypertension are highly prevalent risk factors in this population.

Aim

Scant information is available about the prevalence of diabetic polyneuropathy, as well as the applicability of screening tools in sub-Saharan Africa. We aimed to investigate these issues in Zanzibar (Tanzania).

Methods

One hundred consecutive diabetes patients were included from the diabetes clinic at Mnazi Mmoja Hospital. Clinical characteristics were recorded. Further, we investigated: a) self-reported numbness of the lower limbs, b) ten-point monofilament test, c) the Sibbald 60-s Tool and d) nerve conduction studies (NCS, using an automated handheld point-of-care device, the NC-stat DPNCheck).

Results

Mean age was 54 years, 90% had type 2 diabetes, and with 9 year average disease duration. Mean HbA1c was 8.5% (69 mmol/mol), blood pressure 155/88 mmHg. Sixty-two% reported numbness, 61% had positive monofilament and 79% positive Sibbald tool. NCS defined neuropathy in 45% of the patients. Only the monofilament showed appreciable concordance with the NCS, Cohen’s κ 0.43.

Conclusions

The patient population was characterised by poor glycaemic control and hypertension. In line with this, neuropathy was rampant. The monofilament test tended to define more cases of probable neuropathy than the NCS, however specificity was rather low. Plantar skin thickening may have led to false positives in this population. Overall concordance was, however, appreciable, and could support continued use of monofilament as a neuropathy screening tool. The NC-stat DPNCheck could be useful in cases of diagnostic uncertainty or for research purposes in a low resource setting.

Plantar fascia enthesopathy is highly prevalent in diabetic patients without peripheral neuropathy and correlates with retinopathy and impaired kidney function

BACKGROUND

Aim of this study was to evaluate the prevalence of plantar fascia (PF) enthesopathy in Type 2 diabetes mellitus (T2DM) patients without distal peripheral neuropathy (DPN).

METHODS

We recruited 50 T2DM patients without DPN and 50 healthy controls. DPN was excluded using the Michigan Neuropathy Screening Instrument (MNSI). All patients underwent a bilateral sonographicevaluation of the enthesealportion of the PF.

RESULTS

PF thickness was significantly higher in T2DM patients (p<0.0001). T2DM patients presented a higher prevalence of entheseal thickening (p = 0.002), enthesophyte (p = 0.02) and cortical irregularity (p = 0.02). The overall sum of abnormalities was higher in T2DM patients (p<0.0001), as was the percentage of bilateral involvement (p = 0.005). In a logistic regression analysis, retinopathy predicted entheseal thickening (OR 3.5, p = 0.05) and enthesophytes (OR 5.13, p = 0.001); reduced eGFR predicted enthesophytes (OR 2.93, p = 0.04); body mass index (BMI) predicted cortical irregularity (OR 0.87, p = 0.05); mean glucose predicted enthesophyte (OR 1.01, p = 0.03); LDL cholesterol predicted cortical irregularity (OR 0.98, p = 0.02).

CONCLUSIONS

Our data suggest that T2DM is associated with PF enthesopathyindependently of DPN.