Diabetic Neuropathy: A Position Statement by the American Diabetes Association

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.

Effectiveness of various exercise types in reducing fall risk among older adults with diabetic peripheral neuropathy: A systematic review and meta-analysis

Background

Diabetic peripheral neuropathy (DPN) increases fall risk in diabetics. Due to varying variables used to assess fall risk, the impact of exercise on fall prevention remains inconsistent. This study reviews and compares the effects of different exercises on fall risk among older adults with DPN.

Methods

A comprehensive literature search was conducted in PubMed, EBSCO, Web of Science, and Cochrane Library up to February 17th, 2025. Inclusion criteria were: older adults with DPN; exercise intervention only, an inactive or non-exercising control group, and randomized controlled trials with outcome variables: timed up and go (TUG) time, gait speed, Berg Balance Scale (BBS) score, one-legged standing (OLS) time with eye open (EO) and closed (EC). The mean difference (MD) and 95 % confidence interval (CI) were calculated.

Results

A total of 21 articles included five exercise types: balance exercise (BE), multi-component exercise (ME), strength exercise (SE), whole-body vibration (WBV) and foot-ankle functional training (FT). BE reduced TUG time (MD = -1.47, 95 % CI = -1.79 to -1.15) and increased gait speed (0.11, 0.04-0.18), BBS score (0.93, 0.49-1.37), and OLS time (EO: 2.72, 1.86-3.58; EC:1.58, 1.0-2.17). ME reduced TUG time (-1.71, -2.26 to -1.17) and increased BBS score (2.0, 1.28-2.72) and OLS time (EO: 7.07, 4.35-9.79; EC: 2.61, 1.28-3.94); SE reduced TUG time (-1.45, -2.75 to -0.15) and increased gait speed (0.09, 0.06-0.12); WBV increased OLS time (EO: 1.94, 1.32-2.56; EC: 1.86, 0.16-3.56) but did not affect TUG time or gait speed. FT did not affect TUG time or gait speed.

Conclusions

Exercise reduced fall risks among older adults with DPN. BE and ME were effective in reducing fall risks, followed by SE. WBV improved static balance but failed in dynamic balance. FT showed limited effects on fall prevention and was not recommended.

Artificial intelligence for early detection of diabetes mellitus complications via retinal imaging

Background

Diabetes mellitus (DM) increases the risk of vascular complications, and retinal vasculature imaging serves as a valuable indicator of both microvascular and macrovascular health. Moreover, artificial intelligence (AI)-enabled systems developed for high-throughput detection of diabetic retinopathy (DR) using digitized retinal images have become clinically adopted. This study reviews AI applications using retinal images for DM-related complications, highlighting advancements beyond DR screening, diagnosis, and prognosis, and addresses implementation challenges, such as ethics, data privacy, equitable access, and explainability.

Methods

We conducted a thorough literature search across several databases, including PubMed, Scopus, and Web of Science, focusing on studies involving diabetes, the retina, and artificial intelligence. We reviewed the original research based on their methodology, AI algorithms, data processing techniques, and validation procedures to ensure a detailed analysis of AI applications in diabetic retinal imaging.

Results

Retinal images can be used to diagnose DM complications including DR, neuropathy, nephropathy, and atherosclerotic cardiovascular disease, as well as to predict the risk of cardiovascular events. Beyond DR screening, AI integration also offers significant potential to address the challenges in the comprehensive care of patients with DM.

Conclusion

With the ability to evaluate the patient's health status in relation to DM complications as well as risk prognostication of future cardiovascular complications, AI-assisted retinal image analysis has the potential to become a central tool for modern personalized medicine in patients with DM.

Foot screening and customized health education program for patients with diabetic peripheral neuropathy: A nurse-led, real-world observational study

Background

Research has shown that DPN affects 50 % of individuals with diabetes and, in severe cases, can lead to amputation or death. Interventions led by doctors for DPN have demonstrated limited effectiveness in delaying its onset and progression. Nevertheless, there is an increasing recognition of the significance of nurse-led screening and health education in the early detection and slowing down of DPN.

Method

The present study conducted a retrospective analysis of medical records of 10,191 diabetic patients from 2019 to 2023, who also regularly attended outpatient clinics. Patients with incomplete medical data, transfers, critical conditions or death, existing foot ulcers or amputations, bedridden or uncooperative individuals (5,470 individuals) were excluded, and a total of 4,721 individuals were selected for analysis. The screening and intervention components of the FSCHE program were all led by nurses. A total of 2022 participants received foot screening and customized health education (FSCHE) program, while 2699 participants recevied regular care. The primary outcome is on determining the prevalence rate of DPN among all the included diabetic patients. The data was collected through experimental tests and nurse-led foot screening. Prevalence rates were reported as the number of cases per 1000 individuals. Odds Ratios were calculated to approximate Risk Ratios to determine the effectiveness of the FSCHE program.

Results

The prevalence of DPN in diabetic patients who received the FSCHE program decreased from 557 cases per 1000 individuals in 2019 to 199 cases per 1000 individuals in 2023. The hospitalization duration decreased from 11.2 days to 7.59 days. The risk of DPN in diabetic patients participating in the FSCHE program was 0.741 times higher than that of regular diabetes care (RR [95 % CI]: 0.741 [0.654, 0.840], p < 0.001). The DPN-related risk factors showed promising control results as well.

Conclusions

In this observational study conducted among Chinese patients with diabetes, it was found that the nurse-led FSCHE program effectively manages DPN and its associated risk factors. These results highlight the importance of employing objective screening tools to detect DPN at an early stage, as well as the significance of nurse-led interventions in promoting healthy behaviors and preventing the development and progression of DPN.

Aucubin mitigates the elevation of microglial aerobic glycolysis and inflammation in diabetic neuropathic pain via aldose reductase

BACKGROUND

Treatment of diabetic neuropathy is often limited by side effects. Aucubin, an iridoid glycoside derived from natural plants, exhibits notable anti-inflammatory and antioxidant properties.

AIM

To investigate the effects of aucubin on diabetic neuropathic pain (DNP) and glycolysis and inflammation in microglia.

METHODS

Streptozotocin (STZ) was used to establish a DNP animal model. Blood glucose levels and body weight of mice were measured following STZ administration. Paw withdrawal threshold was calculated for mechanical allodynia. Paw withdrawal latency was recorded for thermal hyperalgesia. The open field test and elevated plus maze was used to assess locomotor activity and anxiety-like behavior. Western blotting was utilized for analysis of protein expression. Immunofluorescence staining was measured for morphometric analysis of microglia. Glycolysis and ATP synthesis in BV-2 cell lines were detected by metabolic extracellular flux analysis. The SwissTargetPrediction and STRING databases were used for comprehensive screening to identify potential target proteins for aucubin. The molecular docking between the possible target proteins and aucubin was investigated using Auto Dock Tool. The BV-2 cell line was transfected with lentiviral AKR1B1-shRNA to further ascertain the function of AKR1B1 in the impact of aucubin on aerobic glycolysis and inflammation during high glucose stimulation.

RESULTS

Aucubin significantly improved pain and anxiety-like behavior in STZ-induced diabetic mice and restored microglial aerobic glycolysis and inflammation. Several public databases and molecular docking studies suggested that AKR1B1, MMP2 and MMP9 are involved in the effect of aucubin on DNP. Aucubin failed to restore aerobic glycolysis and inflammation in the context of AKR1B1 deficiency.

CONCLUSION

Aucubin has potential as a therapeutic agent for alleviating DNP by inhibiting expression of AKR1B1.

Serum Neurofilament Light Chain and Structural and Functional Nerve Fiber Loss in Painful and Painless Diabetic Polyneuropathy

AIMS

To explore associations between the axonal protein neurofilament light chain (NfL) and severity of diabetic polyneuropathy (DPN) and pain.

METHODS

We performed cross-sectional analysis of a subset of the PiNS/DOLORisk cohort of people with DPN with and without neuropathic pain. Biobank samples were analyzed for serum NfL (s-NfL) using single molecule array. DPN was defined by Toronto criteria for probable or confirmed DPN. Painful DPN (PDPN) was evaluated according to IASP criteria. Measures of DPN severity included clinical DPN scales, quantitative sensory testing (QST) and intraepidermal nerve fiber density (IENFD).

RESULTS

Participants with confirmed (N = 172) or probable DPN (N = 29) were included. There was no s-NfL difference between participants with DPN (N = 79, 22.8 ng/L [IQR 17.4; 31.3]) and PDPN (N = 122, 22.2 ng/L [16.0; 34.4]). S-NfL was not associated with pain severity or DPN severity evaluated by clinical DPN scales. Higher s-NfL was associated with lower IENFD (13.6 % [95 % CI 3.1; 22.9], unit = 1 fiber/mm, N = 24) and more pronounced loss of nerve fiber function measured by QST (p-trend = 0.02).

CONCLUSIONS

Higher s-NfL was associated with nerve fiber dysfunction and loss quantified by QST and IENFD, but not with pain or clinical DPN scales. S-NfL may reflect the severity of nerve fiber damage underlying DPN.

Diabetic neuropathy: cutting-edge research and future directions

Diabetic neuropathy (DN) is a prevalent and debilitating complication of diabetes mellitus, significantly impacting patient quality of life and contributing to morbidity and mortality. Affecting approximately 50% of patients with diabetes, DN is predominantly characterized by distal symmetric polyneuropathy, leading to sensory loss, pain, and motor dysfunction, often resulting in diabetic foot ulcers and lower-limb amputations. The pathogenesis of DN is multifaceted, involving hyperglycemia, dyslipidemia, oxidative stress, mitochondrial dysfunction, and inflammation, which collectively damage peripheral nerves. Despite extensive research, disease-modifying treatments remain elusive, with current management primarily focusing on symptom control. This review explores the complex mechanisms underlying DN and highlights recent advances in diagnostic and therapeutic strategies. Emerging insights into the molecular and cellular pathways have unveiled potential targets for intervention, including neuroprotective agents, gene and stem cell therapies, and innovative pharmacological approaches. Additionally, novel diagnostic tools, such as corneal confocal microscopy and biomarker-based tests, have improved early detection and intervention. Lifestyle modifications and multidisciplinary care strategies can enhance patient outcomes. While significant progress has been made, further research is required to develop therapies that can effectively halt or reverse disease progression, ultimately improving the lives of individuals with DN. This review provides a comprehensive overview of current understanding and future directions in DN research and management.

Prediction of cardiac autonomic dysfunction using heart rate response to deep breathing test among type 2 diabetes mellitus

BACKGROUND

Cardiac autonomic neuropathy (CAN) is an underdiagnosed complication of type 2 diabetes mellitus (T2DM) and a predictor of mortality and cardiovascular morbidity. Hence, CAN screening is essential. The objective of the study was to examine whether cardiac autonomic dysfunction can be predicted using the heart rate response to deep breathing test of cardiac autonomic reflex tests (CARTs) among type 2 diabetes mellitus.

METHODS

The study was a cross-sectional study of T2DM individuals between 40 and 65 years. Each participant underwent a heart rate (HR) response to deep breathing test (CARTs) as per standard guidelines. ANOVA F-test was used to check the difference between the CAN severity and the heart rate response to deep breathing parameters. A post-hoc (Tukey's) test was used to check which groups showed the difference.

RESULTS

Eighty-four participants were screened, of which forty-one were included in the present study. The mean age of the participants was 58.8 ± 4.0 years. The Fisher's test showed a statistically significant difference between groups for the average deep breathing difference (F(3,27) = 16.09, p < 0.001) and the respiratory sinus arrhythmia index (F(3,27) = 7.35, p < 0.001).

CONCLUSION

HR response to deep breathing can be used as a preliminary tool to screen CAN in T2DM to differentiate between normal and the other stages of CAN, which can then be followed by the gold standard tests. Further studies are required to establish HR response to deep breathing as a singular tool using regression analysis.

CLINICAL TRIALS REGISTRATION

The study was registered prospectively in the Clinical Trials Registry- India (CTRI/2023/11/060077) on 21st November 2023.

Significant Impacts of the Body-Mass Index, Blood Pressure, Blood Glucose, and Ankle-Brachial Index on Peripheral Neuropathy Risk in Indonesian With Type 2 Diabetes: A Cross-Sectional Study

Background: Diabetic peripheral neuropathy is associated with morbidity and mortality in people with diabetes mellitus. Aims: In this study, we determined relationships of the body-mass index (BMI), systolic blood pressure, diastolic blood pressure, fasting blood glucose, HbA1c, and ankle-brachial index (ABI) with diabetic peripheral neuropathy risk. Methods: A cross-sectional study was conducted with 1088 Indonesians and data collected using self-reported questionnaires, laboratory examinations, and physical examinations. Instruments included a digital scale, height measurement device, digital sphygmomanometer, Doppler ultrasound, 10-g monofilament, and a 128-Hz tuning fork. Data analysis used the Chi-square test, Fisher Exact, and multiple logistic regression test with significance p < .05. Results: The BMI (p < .001), blood pressure (p < .001), ABI (p < .001), fasting blood glucose (p = .016), and HbA1c (p < .001) were significantly related to peripheral neuropathy risk. The conditions of obesity, hypertension, high ABI, high fasting blood glucose, and high HbA1c significantly increased the risk of peripheral neuropathy. Moreover, participants with ≥4 co-occurring abnormal levels of the BMI, systolic blood pressure, diastolic blood pressure, fasting blood glucose, HbA1c, and ABI had significantly synergistically increased risks of peripheral neuropathy, and the more abnormal conditions there were, the higher the risk of peripheral neuropathy. Conclusions: Abnormalities of the BMI, blood pressure, fasting blood glucose, HbA1c, and ABI significantly and synergistically increased the risk of peripheral neuropathy and can be considered predictors of peripheral neuropathy. Nurses are expected to be aware of these predictors so that they can immediately take appropriate steps if they encounter abnormal conditions by optimizing their role as educators.

Systematic review and critical appraisal of predictive models for diabetic peripheral neuropathy: Existing challenges and proposed enhancements

BACKGROUND

The trend of risk prediction models for diabetic peripheral neuropathy (DPN) is increasing, but few studies focus on the quality of the model and its practical application.

AIM

To conduct a comprehensive systematic review and rigorous evaluation of prediction models for DPN.

METHODS

A meticulous search was conducted in PubMed, EMBASE, Cochrane, CNKI, Wang Fang DATA, and VIP Database to identify studies published until October 2023. The included and excluded criteria were applied by the researchers to screen the literature. Two investigators independently extracted data and assessed the quality using a data extraction form and a bias risk assessment tool. Disagreements were resolved through consultation with a third investigator. Data from the included studies were extracted utilizing the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies. Additionally, the bias risk and applicability of the models were evaluated by the Prediction Model Risk of Bias Assessment Tool.

RESULTS

The systematic review included 14 studies with a total of 26 models. The area under the receiver operating characteristic curve of the 26 models was 0.629-0.938. All studies had high risks of bias, mainly due to participants, outcomes, and analysis. The most common predictors included glycated hemoglobin, age, duration of diabetes, lipid abnormalities, and fasting blood glucose.

CONCLUSION

The predictor model presented good differentiation, calibration, but there were significant methodological flaws and high risk of bias. Future studies should focus on improving the study design and study report, updating the model and verifying its adaptability and feasibility in clinical practice.

Clinical value of serum miR-214-3p expression in the diagnosis of type 2 diabetes mellitus and prediction of its chronic complications

BACKGROUND

The majority of diabetes cases fall into type 2 diabetes mellitus (T2DM), which is prone to chronic complications that have a long-term impact on patients. The aim of this study was to investigate the diagnostic potential of miR-214-3p in T2DM and its predictive value for chronic complications, providing a novel biomarker for the disease.

METHODS

A total of 156 patients with T2DM and 80 non-T2DM individuals were included. Serum miR-214-3p levels were measured by real-time reverse transcription quantitative PCR (RT-qPCR). The correlation of miR-214-3p with hemoglobin A1c (HbA1c) and low-density lipoprotein cholesterol (LDL-C) was analyzed by Spearman's rank correlation. The clinical value of miR-214-3p in T2DM was evaluated using the receiver operating characteristic (ROC) curve and logistic regression analysis.

RESULTS

The serum levels of miR-214-3p were decreased in T2DM patients compared to non-T2DM individuals. A negative correlation was identified between miR-214-3p expression and the levels of HbA1c and LDL-C. miR-214-3p could effectively differentiate T2DM patients from non-T2DM individuals with the area under ROC curve (AUC) of 0.884. Patients with low miR-214-3p expression had a higher incidence of chronic complications. The AUC for miR-214-3p in differentiating between T2DM patients with and without complications was 0.832. Low expression of miR-214-3p was a risk factor linked to the development of chronic complications in patients with T2DM.

CONCLUSION

Serum miR-214-3p was downregulated in T2DM and could differentiate T2DM patients from non-T2DM individuals. miR-214-3p was a promising biomarker for predicting the chronic complications of T2DM.

Interventional effects of exercise on neuropathy in patients with diabetes: a systematic review with meta-analysis

OBJECTIVE

This study aims to systematically evaluate the effects of exercise interventions on neurological dysfunction in diabetic patients, addressing inconsistencies in existing research. It seeks to clarify the impact of different exercise parameters and patient characteristics on nerve function improvements, providing evidence for optimized intervention strategies.

METHODS

A search was conducted using PubMed, Web of Science, The Cochrane Library, and Embase databases for randomized controlled trials related to exercise interventions for neurological dysfunction in diabetic patients. The quality of the included studies was assessed according to the Cochrane Handbook for Systematic Reviews. The study utilized RevMan 5.3 to determine effect sizes and assess heterogeneity. Stata 17.0 was employed to evaluate publication bias in the included studies.

RESULTS

The analysis incorporated 9 randomized controlled trials. The meta-analysis demonstrated that exercise leads to improvements in neurological dysfunction among diabetes patients (SMD = 0.61). Subgroup analysis revealed that an 8-week exercise regimen with moderate intensity was particularly effective in enhancing neurological function (SMD = 1.82, 1.58). Improvements were more pronounced in lower limb nerve conduction velocity (SMD = 0.60), peroneal nerve conduction velocity (SMD = 0.86), and sensory nerve conduction velocity (SMD = 0.59). Patients with a disease duration of 5 years or less showed significant improvement (SMD = 0.62).

CONCLUSION

Exercise effectively improves neurological dysfunction in diabetic patients, with an 8-week, moderate-intensity program showing the greatest benefits, particularly in lower limb and sensory nerve conduction velocity. These findings offer evidence-based guidance for clinical intervention and future research.

REGISTRATION AND PROPOSAL

This study was registered with PROSPEO under No. CRD42024586981; the proposal is available at www.crd.york.ac.uk .

Schwann Cell Protein Kinase RNA-like ER Kinase (PERK) Is Not Necessary for the Development of Diabetic Peripheral Neuropathy but Negates the Efficacy of Cemdomespib Therapy

Diabetic peripheral neuropathy (DPN) is a common complication of diabetes arising in part from glycemic damage to neurons and Schwann cells (SC). While the pathogenic mechanisms of DPN are complex, mitochondrial dysfunction and endoplasmic reticulum (ER) stress contribute to the development of DPN and serve as therapeutic targets for disease modification. Cemdomespib is an orally bioavailable small molecule which alleviates clinical indices of DPN that correlate with improvements in neuronal oxidative stress and mitochondrial bioenergetics. However, the contribution of SC ER stress in the onset of DPN and the therapeutic efficacy of cemdomespib remains unknown. To address this issue, mice expressing a conditional deletion of protein kinase RNA-like ER kinase (PERK) in myelinating SCs (SC-cPERK KO) and control SC-PERKf/f mice were rendered diabetic with streptozotocin. Diabetic SC-PERKf/f and SC-cPERK KO mice developed a similar magnitude of DPN as quantified by the onset of a thermal/mechanical hypoalgesia, decreases in nerve conduction velocity (NCV) and intraepidermal fiber density (iENFD). After 8 weeks of diabetes, daily treatment with 1 mg/kg cemdomespib for an additional 8 weeks significantly improved thermal/mechanical hypoalgesia, NCV, iENFD and decreased markers of ER stress in diabetic SC-PERKf/f mice, but the drug had no effect in diabetic SC-cPERK KO mice. Nrf2 is a PERK substrate and studies using rat SCs subjected to ER stress demonstrated that cemdomespib increased Nrf2 activity. Collectively, these data suggest that activation of SC PERK by diabetes is not necessary for the onset of DPN, but serves as a target in the action of cemdomespib, potentially by increasing Nrf2 activity.

Clinical Characteristics and Development of Complications Differ Between Adult-Onset and Child-Adolescent-Onset Type 1 Diabetes: A Report From a Tertiary Medical Center in Türkiye

Background and Aims: The age-at-onset is of great importance in the heterogeneity of Type 1 diabetes mellitus (T1DM). This study was designed to define clinical and laboratory differences between child-adolescent-onset and adult-onset T1DM at presentation and during follow-up and determine the predicting factors for developing microvascular and macrovascular complications. Material and Methods: This retrospective observational study evaluated T1DM patients who were followed in the diabetes outpatient clinic between January 1, 2000, and December 31, 2019. Results: The study cohort included 490 individuals with T1DM (54.3% female, 58.8% adult-onset, and median follow-up: 5 years). In the adult-onset group, baseline C-peptide and GADA prevalence were higher, whereas presentation with ketoacidosis was 2.3-fold lower compared to the child-adolescent-onset group (p < 0.001). During follow-up, the adult-onset group had a 2.4-fold higher overweight/obesity (p < 0.001) and 1.7-fold higher dyslipidemia/hyperlipidemia (p = 0.002) than the child-adolescent-onset group. In multivariate analysis, fasting glucose (p = 0.024) in adult-onset, dyslipidemia/hyperlipidemia (p = 0.037) in child-adolescent-onset, and diabetes duration (p = 0.008 and p = 0.007) and hypertension (p = 0.001 and p = 0.01) in both groups were associated with increased risk of microvascular complications, whereas age-at-onset (p = 0.024), dyslipidemia/hyperlipidemia (p = 0.03), nephropathy (p = 0.003), and neuropathy (p = 0.001) in adult-onset and age (p = 0.002) and triglycerides (p = 0.013) in child-adolescent-onset groups were associated with increased risk of macrovascular complications. The cutoff C-peptide levels at baseline predicted microvascular complications in the whole cohort and adult-onset group were defined as 0.383 ng/mL (p < 0.001) and 0.41 ng/mL (p = 0.001), respectively. In the Kaplan-Meier analysis, C-peptide (< 0.383 ng/mL) but not age-at-onset predicted future development of microvascular and macrovascular complications (p = 0.003 and p = 0.032). Conclusion: Clinical presentation and prognosis differ in adult-onset and child-adolescent-onset T1DM. Low initial C-peptide may predict the development of microvascular and macrovascular complications.

Neuropad Assessment of Sudomotor Function Across Glycemic Levels in Adults

Purpose

To evaluate the impact of metabolic indicators on plantar sudomotor function and to explore the relationships between metabolic and non-metabolic indicators and sudomotor function in a physical examination cohort using Neuropad.

Methods

In this cross-sectional study, 481 participants were randomly enrolled. Sudomotor function was evaluated using Neuropad and a handheld color analyzer for both qualitative (visual Neuropad) and quantitative (quantitative Neuropad) analyses. The slope (Slope[1-10]) was used as a quantitative measure of sudomotor function.

Additional data included age, BMI (body mass index), FPG (fasting plasma glucose), HbA1c (hemoglobin A1c), blood pressure, lipid levels, and liver and kidney function. Participants were categorized into four blood glucose groups: normoglycemia (FPG <6.1 mmol/L and HbA1c <6%), prediabetes (FPG 6.1-6.9 mmol/L or HbA1c 6.0-6.4%), newly diagnosed diabetes (FPG ≥7.0 mmol/L or HbA1c ≥6.5% with no prior diagnosis, diabetes was diagnosed on the day of the physical examination), and previously diagnosed diabetes.

Results

(1) The previously diagnosed diabetes group presented a lower slope than the normoglycemia group (6.96 vs 8.73) and a greater rate of incomplete color change (71.11% vs 49.01%). With increasing FPG and HbA1c levels, the 10-minute slope decreased progressively (P =0.003, P=0.006). (2) A multivariable linear mixed-effects model adjusted for confounders indicated that previously diagnosed diabetes was an independent predictor of reduced sudomotor function. (3) Adjusting for the same confounders, previously diagnosed diabetes was associated with a 3.480-fold greater risk of incomplete color change than was normoglycemia (OR = 3.480, 95% CI = 1.506-8.042). (4) Age, BMI, ALB, eGFR, and alcohol consumption history were closely associated with sudomotor function.

Conclusion

There is a progressive decline in sudomotor function with increasing blood glucose levels in a physical examination cohort, and previously diagnosed diabetes emerges as an independent risk factor for sudomotor dysfunction.

Development and internal validation of an interpretable risk prediction model for diabetic peripheral neuropathy in type 2 diabetes: a single-centre retrospective cohort study in China

OBJECTIVE

Diabetic peripheral neuropathy (DPN) is a common and serious complication of diabetes, which can lead to foot deformity, ulceration, and even amputation. Early identification is crucial, as more than half of DPN patients are asymptomatic in the early stage. This study aimed to develop and validate multiple risk prediction models for DPN in patients with type 2 diabetes mellitus (T2DM) and to apply the Shapley Additive Explanation (SHAP) method to interpret the best-performing model and identify key risk factors for DPN.

DESIGN

A single-centre retrospective cohort study.

SETTING

The study was conducted at a tertiary teaching hospital in Hainan.

PARTICIPANTS AND METHODS

Data were retrospectively collected from the electronic medical records of patients with diabetes admitted between 1 January 2021 and 28 March 2023. After data preprocessing, 73 variables were retained for baseline analysis. Feature selection was performed using univariate analysis combined with recursive feature elimination (RFE). The dataset was split into training and test sets in an 8:2 ratio, with the training set balanced via the Synthetic Minority Over-sampling Technique. Six machine learning algorithms were applied to develop prediction models for DPN. Hyperparameters were optimised using grid search with 10-fold cross-validation. Model performance was assessed using various metrics on the test set, and the SHAP method was used to interpret the best-performing model.

RESULTS

The study included 3343 T2DM inpatients, with a median age of 60 years (IQR 53-69), and 88.6% (2962/3343) had DPN. The RFE method identified 12 key factors for model construction. Among the six models, XGBoost showed the best predictive performance, achieving an area under the curve of 0.960, accuracy of 0.927, precision of 0.969, recall of 0.948, F1-score of 0.958 and a G-mean of 0.850 on the test set. The SHAP analysis highlighted C reactive protein, total bile acids, gamma-glutamyl transpeptidase, age and lipoprotein(a) as the top five predictors of DPN.

CONCLUSIONS

The machine learning approach successfully established a DPN risk prediction model with excellent performance. The use of the interpretable SHAP method could enhance the model's clinical applicability.

What does nerve ultrasound contribute to the evaluation of diabetic polyneuropathy over time? A prospective follow-up observational study of people with type 2 diabetes

AIMS

Studies using peripheral nerve ultrasound have shown moderate nerve enlargement in individuals with diabetic polyneuropathy (DPN). Neither extent, course, consistency, nor clinical significance of this finding is clear.

METHOD

We examined 156 people with type 2 diabetes mellitus using nerve ultrasound, nerve conduction studies, and clinical scores. 59 received a follow-up examination after one year and 43 patients after two years.

RESULTS

Increase of cross-sectional area (CSA) of the peripheral nerves in DPN was rather negligible compared to normative cut-off values. The CSA of the median nerve at the forearm and wrist and the ulnar nerve at the upper arm, forearm and wrist were significantly larger in individuals with DPN compared to those without DPN. People with DPN had significant changes in most parameters of nerve conduction studies. Ultrasound measurements over time showed a slight increase in CSA in the median nerve at the carpal tunnel and a slight decrease in the fibular nerve at the fibular head. Ultrasound pattern sum score slightly decreased in the DPN group over two years.

CONCLUSIONS

Ultrasound measurements alone may be insufficient to detect DPN. Follow up with nerve ultrasound over one or two years was short and did not show substantial changes.

Understanding the Impact of Diabetic Peripheral Neuropathy and Neuropathic Pain on Quality of Life and Mental Health in 6,960 People With Diabetes

OBJECTIVE

Diabetic peripheral neuropathy (DPN) and neuropathic pain impacts quality of life (QoL) and mental health negatively. This cross-sectional survey study aimed to 1) elucidate the associations between painful and painless DPN and QoL, mental health, and socioeconomic factors, 2) assess the prevalence of sensory pain descriptors, and 3) evaluate the association between descriptors and the above factors.

RESEARCH DESIGN AND METHODS

Participants were grouped into people with (n = 1,601) and without (n = 5,359) DPN based on the Michigan Neuropathy Screening Instrument questionnaire. Participants with DPN were subsequently divided into people with (n = 1,085) and without (n = 516) concomitant neuropathic pain based on the modified Douleur Neuropathique en 4 Questions-interview.

RESULTS

The study showed diminished QoL (36-item Short Form Health Survey [SF-36]: 55.1 [interquartile range 36.7, 73.6], 82.2 [63.6, 90.9]) and poorer mental health (Hospital Anxiety and Depression Scale, subscale for anxiety [HADS-A]: 5.00 [2, 9], 2.00 [1, 5]; HADS-subscale for depression [HADS-D]: 4.00 [1, 8], 1.00 [0, 3]) in participants with DPN compared with participants without DPN. The addition of pain diminished QoL (SF-36: 50.7 [34.8, 69.8]) and mental health (HADS-A: 6 [3, 10], HADS-D: 4 [1, 8]) further. The most prevalent pain descriptor in participants with painful DPN were burning pain (73%), while the most prevalent sensory descriptor was pins-and-needles (93%). An interesting finding is the high prevalence of itch (44%). Weak associations with mental health and QoL were present for cold pain, electric pain, and itch.

CONCLUSIONS

An increased focus on differences in QoL, mental health, and pain phenotypes is of importance to move the field forward toward more interdisciplinary, personalized treatment.

Handgrip strength in patients with type 2 diabetes correlates with diabetic polyneuropathy. A single-center, retrospective observational study in Japanese patients

Nerve conduction studies (NCS) are the standard method for diagnosing diabetic polyneuropathy. Because a clear association between handgrip strength and diabetic neuropathy can serve as a screening tool, the present study evaluated the association between handgrip strength and NCS and diabetes-related complications. A total of 436 patients with type 2 diabetes (T2D) who were admitted to our hospital between April 1, 2018 and March 31, 2023, and evaluated using Baba's diabetic neuropathy classification (BDC) were included. The participants were grouped by sex using the grip strength tertile method to assess correlations with the prevalence of diabetic microvascular complications in the high-handgrip group (HG), middle-handgrip group (MG), and low-handgrip group (LG). The percentage of BDC-0 was 65% in the HG, 54% in the MG, and 36% in the LG. Furthermore, none of the participants in the HG had BDC-3/4, whereas 4% in the MG and 15% in the LG had BDC-3/4. The morbidity progression of diabetic neuropathy was seen in the order of LG, MG, and HG (p < 0.001). Patients with T2D and advanced diabetic neuropathy had decreased handgrip strength. Early evaluation of BDC and other NCS should be considered if decreased handgrip strength is evident.

Comparative analysis of the therapeutic effects of pregabalin, gabapentin, and duloxetine in diabetic peripheral neuropathy: A retrospective study

INTRODUCTION

This study aimed to compare the effects of pregabalin, gabapentin, and duloxetine on diabetic peripheral neuropathy (DPN) to guide tailored treatment.

MATERIALS AND METHODS

In this retrospective study, 180 patients with type 2 diabetes and DPN were matched 1:1:1 across three groups based on HbA1c and age, resulting in 60 patients per group. Clinical data were collected, and the painDETECT score was used to evaluate treatment response over six weeks.

RESULTS

After six weeks, the gabapentin group had significantly higher pain scores than the pregabalin (P = 0.002) and duloxetine groups (P < 0.001). The pregabalin group's scores were higher than the duloxetine group's, but not significantly (P = 0.62). Side effects were more frequent with duloxetine (23.3 %) compared to gabapentin (1.7 %) and pregabalin (6.7 %) (P = 0.001). Among those with over 50 % improvement, mean HbA1c levels were 9.42 for gabapentin, 10.43 for pregabalin, and 7.72 for duloxetine. Duloxetine significantly lowered HbA1c compared to gabapentin (P = 0.001) and pregabalin (P = 0.001), with no significant difference between gabapentin and pregabalin (P = 0.45).

CONCLUSION

Duloxetine and pregabalin effectively treat DPN. Gabapentin and pregabalin are suitable for patients with HbA1c over 8.7, while duloxetine is better for those with well-controlled HbA1c. Treatment should consider side effects, adherence, costs, and response time.

LEVEL OF THE EVIDENCE

Level III retrospective cohort study.

Enhanced Sensitivity to Tramadol in Diabetic Neuropathic Pain Compared to Nerve Compression Neuropathies: A Population PK/PD Model Analysis

Neuropathic pain, often associated with diabetic neuropathy or nerve compression injuries, arises from damage or dysfunction in the somatosensory nervous system. Tramadol, frequently prescribed for this pain, has its fraction unbound and that of its active metabolite (M1) significantly altered by diabetes. Yet, dosing adjustments for diabetic neuropathic pain remain underexplored. This study developed a comprehensive population pharmacokinetics/pharmacodynamics (PK/PD) model for tramadol and its major metabolites, focusing on diabetes's impact on PK and PK-PD relationship to identify optimal dosing regimens. Data from patients with chronic neuropathic pain on oral tramadol were used to develop enantiomer-specific population models, considering both total and unbound concentrations. Tramadol's PK was best described by a two-compartment model with Weibull absorption and linear elimination and a one-compartment model with enterohepatic circulation and first-pass metabolism for the active M1. Simulations showed higher unbound fractions of the active M1 in patients with type 1 and type 2 diabetes. Despite a 67% and 14% reduction in the AUC of total (1R,2R)-M1 in patients with type 1 and type 2 diabetes, respectively, the AUC of unbound (1R,2R)-M1 remained consistent. The unbound concentration of the active M1 required to achieve 50% of the maximum pain reduction (IC50) was lower in patients with diabetes, indicating increased sensitivity to the drug. This model-based approach provides valuable dosing guidance, suggesting once-daily dosing treatments in patients with diabetes and twice-daily dosing for patients with neuropathic pain secondary to nerve compression mechanisms.

Epidermal Transient Receptor Potential Vanilloid 1 innervation is increased in patients with painful diabetic polyneuropathy experiencing ongoing burning pain

ABSTRACT

Preclinical studies suggested that Transient Receptor Potential Vanilloid 1 (TRPV1) channels contribute to neuropathic pain in animal models of diabetic polyneuropathy. Patients with painful diabetic polyneuropathy commonly experience ongoing burning pain. This study aimed at evaluating the association between this specific type of pain and TRPV1 intraepidermal nerve fibers in patients with painful diabetic polyneuropathy. We consecutively enrolled 70 patients with diabetic polyneuropathy. Each patient completed the Neuropathic Pain Symptom Inventory (NPSI) to identify the various types of neuropathic pain. All patients underwent a distal leg skin biopsy, with immunostaining of skin nerve fibers using antibodies for the pan-axonal marker Protein Gene Product 9.5 (PGP9.5), TRPV1, Calcitonin Gene-Related Peptide (CGRP), and Substance P. We found that 57% of patients (n = 40) had neuropathic pain symptoms, with ongoing burning pain being the most frequently reported type of pain at the NPSI (70% of patients with pain, n = 28). Patients with ongoing burning pain had higher TRPV1 intraepidermal nerve fiber density and TRPV1/PGP9.5 ratio compared with those with painless polyneuropathy ( P = 0.014, P = 0.013) and painful polyneuropathy with other types of pain ( P < 0.0001, P = 0.024); they also had increased CGRP dermal nerve fiber density compared with patients with painless polyneuropathy ( P = 0.005). Our study showed that ongoing burning pain is associated with an increased expression of intraepidermal TRPV1 fibers, as well as an increased dermal representation of CGRP fibers. These findings suggest that TRPV1 contributes to ongoing burning pain, possibly in conjunction with elevated CGRP expression, highlighting its significance as a therapeutic target for patients with painful diabetic polyneuropathy.

COVID-19 and neuropathy in type 2 diabetes

This study investigated the risk factors for COVID-19 and its impact on diabetic peripheral neuropathy (DPN) in patients with type 2 diabetes (T2D). Patients with T2D underwent assessments with the NICE post-COVID questionnaire, DN4 questionnaire, vibration perception threshold (VPT), and corneal confocal microscopy (CCM) before and 11.0 ± 8.9 months after developing COVID-19. Of 76 participants with T2D, 35 (46.1%) developed COVID-19, of whom 8 (22.9%) developed severe COVID-19 and 9 (25.7%) developed long-COVID. The development of COVID-19 was associated with lower systolic blood pressure (P < 0.05). The presence and severity of DPN were not associated with developing COVID-19, severe COVID-19, or long-COVID (P = 0.42-0.94). Women were eight times more likely to develop long-COVID (P < 0.05) and elevated body weight, LDL, and VPT were associated with the development of long-COVID (P < 0.05 - 0.01). The long-COVID group exhibited significant changes in triglycerides and LDL (P < 0.05 for both) and body weight (P < 0.01) at follow-up. Their impact on clinical and neuropathy measures was comparable in patients with and without COVID-19 (P = 0.08-0.99). There was a significant reduction in corneal nerve measures (P < 0.05-0.0001) in patients with and without COVID-19. A low systolic blood pressure, altered lipids, body weight, higher VPT, and gender may determine the impact of COVID-19 in patients with T2D, but there was no evidence of an impact of COVID-19 on the development or progression of DPN.

Can Spinal Cord Stimulation be Considered as a Frontier for Chronic Pain in Diabetic Foot?

Chronic pain in the diabetic foot (DF) is a common complication of diabetes, bringing a significant burden to patients, their families, and even society. There is no very effective treatment for it, traditional treatments such as medication, lumbar sympathetic nerve block, and alternative therapies are often not very effective and have more adverse effects. The emergence of neuromodulation technology has brought new hope for the treatment of DF, among which spinal cord stimulation (SCS) is a hotspot in current research and has achieved remarkable efficacy in the study of DF treatment by blocking pain signaling and improving circulation and other mechanisms. This article reviews the SCS technique and clinical trails of SCS for chronic DF pain, and describes the prospects and current challenges of SCS.

A single blinded randomized controlled trial assessing the effect of photobiomodulation therapy on neuron specific biomarkers in type II diabetes mellitus patients with peripheral neuropathy

BACKGROUND

Diabetic peripheral neuropathy is one of the most devastating complications of long-term diabetes mellitus, associated with functional limitations and poor quality of life.

MATERIALS AND METHODS

Two hundred subjects were randomized into intervention and control group, with one hundred in each arm. The intervention arm received photobiomodulation therapy for ten days, with Low -Level Helium-Neon Laser at a wavelength of 632.8 nm of dosage 3.1 J/cm2 for 9 min on both the dorsal and plantar surfaces of the foot, while the control group received sham laser. Patients were assessed at day 0 of treatment and four weeks after treatment for all the clinical and neuropathy-specific biomarkers. Serum levels of Neuron specific enolase (NSE), Calcitonin gene related peptide (CGRP) Nerve Growth Factor (NGF) for monitoring neuronal changes and monofilament test, Biothesiometer, Numeric Pain Rating Scale (NPRS) to analyze vibration sensation, and pain score. The neuropathic quality of life was assessed using the Norfolk Quality of Life Questionnaire- Diabetic Neuropathy (Norfolk QOL-DN).

RESULT

Trial found significant changes in serum NSE (p < 0.001), CGRP(p < 0.001), MNSI(p < 0.001), VPT(p < 0.001), NPRS(p < 0.001), and NQL(p < 0.001) in the intervention group four weeks after receiving photobiomodulation therapy, whereas no changes in NGF levels(p = 0.937). This was in correlation with improved neuropathic pain and quality of life.

CONCLUSION

Serum levels of NSE and CGRP may be good indicators of effectiveness of photobiomodulation in reducing neuropathic pain and other symptoms in individuals with DPN. Reduced neuropathic symptoms, improved protective sensation of foot and quality of life, and reduced neuropathic pain was observed in intervention group.

Raster Scan Optoacoustic Mesoscopy for detecting microvascular complications in diabetes mellitus: A narrative brief review

Diabetes mellitus (DM) may lead to microvascular and macrovascular complications. Screening for these complications is crucial, and so non-invasive methods with high-dissemination potential are needed. Diabetic peripheral neuropathy (DPN) is particularly challenging to screen due to the lack of reliable clinical markers and endpoints. In this context, Raster Scan Optoacoustic Mesoscopy (RSOM) emerges as a highly promising technique that offers hybrid, non-invasive imaging of optical absorption using light-induced ultrasound waves within tissue without the use of contrast agents. RSOM provides high-resolution visualisation of micro-vasculature and other tissue structures along with functional information. The technique has already assessed microvasculature loss as a function of diabetes progression and used it to characterise DPN severity. RSOM has also shown that cutaneous vessels in the mesoscopic range (mean diameters of 30-40 µm) are most prominently affected by DM and that the mean number of cutaneous vessels was lower in subjects with DM than in healthy participants (p < 0.001 and p < 0.05, respectively). Although experience is still limited, we present an overview of the novel technique in relation to its potential for detecting early DM onset and development of microvascular complications.

Prevalence and risk factors of painful diabetic neuropathy: A systematic review and meta-analysis

Painful diabetes-related peripheral neuropathy (PDPN) is a common and debilitating complication of diabetes, contributing significantly to morbidity and healthcare costs. This systematic review and meta-analysis aim to determine the global prevalence of PDPN among individuals with diabetic peripheral neuropathy (DPN) and to identify associated risk factors. A comprehensive search of four English and three Chinese databases was conducted for observational studies on PDPN prevalence up to June 22, 2024. Of the 41 studies included, the pooled global prevalence of PDPN was 46.7 % (95 % CI, 41.8-51.7). In subgroup analysis, significant statistical differences were observed in prevalence estimates between different diagnostic methods for neuropathic pain, with neuropathic-specific pain scales indicating higher rates (P = 0.03). Studies with mean diabetes duration of less than 10 years or more than 15 years reported higher prevalence (P < 0.01). Significant risk factors for PDPN included older age (OR = 1.02, 95 % CI, 1.01-1.04), female gender (OR = 1.58, 95 % CI, 1.19-2.11), BMI ≥ 30 kg/m2 (OR = 1.62, 95 % CI, 1.43-1.83), longer diabetes duration (OR = 1.05, 95 % CI, 1.01-1.08), and nephropathy (OR = 1.32, 95 % CI, 1.24-1.40). Targeted screening and standardized diagnostic tools are urgently needed to enhance PDPN management and mitigate its burden globally.

Dellon decompression of the tarsal tunnel: An effective approach to improving blood flow, promoting ulcer healing and recovery of sensibility in diabetic patients

We hypothesized that tibial nerve decompression would improve sympathetic nerve function, leading to increased blood flow, enhanced plantar sensitivity, and reduced healing time for diabetic neuropathic ulcers. This prospective study involved 20 patients with non-healing diabetic neuropathic ulcers averaging 17.1 months in duration. Patients had good glycemic control and positive Tinel sign at the tarsal tunnel, with average ulcer size of 10.49 cm². Preoperatively, sensory symptoms were assessed using the Michigan Neuropathy Screening Instrument (MNSI) and two-point discrimination test, ulcer characteristics using DMIST scale, and blood flow via Doppler ultrasonography of the posterior tibial artery. "Dellon Decompression" of the 4 medial ankle tunnels was performed. At the 9-month follow-up, MNSI scores decreased significantly from a mean of 11.85 to 5.15 (p < 0.001). Positivity of the Tinel sign, quantified using the visual analog scale, dropped from a mean of 7 to 2 (p < 0.0001). Significant improvements in sensory function of the medial, lateral plantar, and calcaneal nerves were observed (p < 0.001). Doppler ultrasonography showed blood flow in the posterior tibial artery increased from 1.72 to 2.48 cm³/s at 6 months, with further improvement at 9 months (p < 0.0001). At 9 months, 55% of patients had completely healed ulcers, with 45% showing an 83.25% reduction in ulcer size (p < 0.0001). No infections or new ulcers occurred postoperatively. In conclusion, Dellon decompression of the 4 medial ankle tunnels can enhance blood flow in diabetic neuropathy, improves wound healing in the foot's plantar area, and emphasizes the crucial role of enhanced blood flow and sensitivity in promoting foot ulcer healing in diabetic patients.

Cutaneous manifestations of diabetes mellitus: a narrative review

Diabetes mellitus is a highly prevalent human endocrine disorder. Skin lesions are reported in approximately one-third of all diabetes mellitus patients. The clinical presentation and frequency vary according to the subtype of diabetes mellitus, metabolic control, and clinical course, with certain skin diseases occurring before diagnosing hyperglycemia. In this regard, the correct definition of cutaneous manifestations associated with diabetes mellitus can help define the etiology of hyperglycemia as well as the need to optimize glycemic control. In this narrative review, the most common cutaneous diseases observed in diabetes mellitus are discussed, including pruritus, acanthosis nigricans, necrobiosis lipoidica, bullosis diabeticorum, scleroderma diabeticorum, granuloma annulare, diabetic dermopathy, skin reactions due to device use, diabetic foot ulcers, recurrent cutaneous infections in diabetes mellitus and other dermatoses associated with hyperglycemia. The epidemiology, pathophysiology, differential diagnosis, and treatment of this disease are discussed. Therefore, knowledge and recognition of the most common dermatological lesions in patients with diabetes mellitus are essential for both endocrinologists and primary care physicians.

Comprehensive review on diabetic foot ulcers and neuropathy: Treatment, prevention and management

Diabetic foot (DF) is a major public health concern. As evident from numerous previous studies, supervision of DF ulcer (DFU) is crucial, and a specific quality check-up is needed. Patients should be educated about glycaemic management, DFUs, foot lesions, proper care for injuries, diet, and surgery. Certain reasonably priced treatments, such as hyperbaric oxygen and vacuum-assisted closure therapy, are also available for DFUs, along with modern wound care products and techniques. Nonetheless, DF care (cleaning, applying antimicrobial cream when wounded, and foot reflexology), blood glucose monitoring to control diabetes, and monthly or quarterly examinations in individuals with diabetes are effective in managing DFUs. Between 50% and 80% of DF infections are preventable. Regardless of the intensity of the lesion, it needs to be treated carefully and checked daily during infection. Tissue regeneration can be aided by cleaning, dressing, and application of topical medicines. The choice of shoes is also important because it affects blood circulation and nerve impulses. In general, regular check-ups, monitoring of the patient's condition, measuring blood glucose levels, and providing frequent guidance regarding DFU care are crucial. Finally, this important clinical problem requires involvement of multiple professionals to properly manage it.

Polymorphic variants and risk of diabetic peripheral neuropathy in patients with type 2 diabetes mellitus: systematic review and meta-analysis

BACKGROUND

Neuropathy is a frequent complication of diabetes mellitus, a disease that is growing exponentially worldwide. Genetic research has emerged as an important tool for better understanding its predisposition, although a systematic synthesis of existing evidence is needed to better comprehend its association. The objective of this review was to determine the association between polymorphic variants identified through massive genomic testing and the risk of peripheral diabetic neuropathy in patients with type 2 diabetes mellitus.

METHODS

Inclusion criteria were case-control, cohort, and cross-sectional studies examining polymorphic variants and diabetic neuropathy (DNP) risk in type 2 diabetes, studies using GWAS, EWAS, or microarray for identifying genetic polymorphisms, studies involving adults, and articles in English or Spanish. Exclusion criteria included case reports, case series, ecological studies, editor letters, reviews, or secondary studies and conference abstracts. Exhaustive search in PubMed, Scopus, and Web of Science databases, using keywords. Risk of bias was determined through Newcastle-Ottawa scale. A qualitative synthesis of the results was performed (frequency), including meta-analysis where applicable (forest plot and funnel plot).

RESULTS

The searching strategy identified 370 studies, from which 7 were chosen for the systematic review, included 9478 participants. The quality of the studies was mostly good, but a significant heterogeneity in methods was found. We identify a significant association between peripheral neuropathy and plenty of single nucleotide variants (SNVs). Just the SNV rs10555080 in the gene THEG5 showed a higher likelihood of neuropathy (OR:1,34; IC 95%: 1,19 - 1,49).

DISCUSSION

This study faced limitations due to heterogeneity in DNP definitions, genotyping methods, and a focus on white and Arab populations, limiting generalization. Only English and Spanish articles were included, potentially excluding relevant research in other languages. Multiple SNVs were identified through genomic testing that were associated with peripheral diabetic neuropathy in patients with type 2 diabetes mellitus; however, the SNVs were not similar between studies.

TRIAL REGISTRATION

This research received no funding and was registered in PROSPERO (ID CRD42024505256).

Surface electromyography for characterizing neuromuscular changes in diabetic peripheral neuropathy

PURPOSE

Distal symmetric polyneuropathy (DSP) is the most common diabetic neuropathy (75% of all diabetic neuropathies), potentially leading to plantar ulcers and lower limb amputation. Early detection of at-risk individuals is essential for timely intervention. This study aimed to evaluate different surface EMG (sEMG) parameters from isometric and dynamic exercises as biomarkers for early DSP detection and monitoring.

METHODS

The study involved 61 participants (34 controls and 27 cases with low, moderate and high levels of severity). sEMG signals were recorded from four lower-limb muscles (tibialis anterior, medial gastrocnemius, extensor digitorum brevis, and flexor digitorum brevis) and characterized by their amplitude, frequency, complexity and shape.

RESULTS

Significant sEMG differences were found between controls and diabetic patients at low and moderate/high DSP risk, especially in the extensor digitorum and flexor digitorum muscles during isometric and dynamic exercises. Diabetic patients showed lower amplitude and complexity, with higher frequency, peakedness, and asymmetry.

CONCLUSION

Parameters like root mean square, sample entropy, and central shape distance effectively distinguished between groups, highlighting changes in motor unit recruitment and muscle quality. Dynamic and isometric exercises emphasized their complementary roles in assessing muscle function, supporting sEMG's potential as a non-invasive tool for monitoring neuromuscular changes in diabetes.

Association Between FAM134B and Diabetic Peripheral Neuropathy in Type 2 Diabetes: A Double-Center Case-Control Study

Purpose

The role of FAM134B in neurological diseases has received significant attention; however, its role in diabetic peripheral neuropathy (DPN) remains unexplored. This study investigated the association between plasma FAM134B levels and DPN while assessing its diagnostic value.

Methods

The study included 128 inpatients with type 2 diabetes divided into DPN (n = 68) and non-DPN (n = 60) groups. FAM134B expression was determined via qRT-PCR analysis of plasma FAM134B mRNA level. All clinical data were retrieved from the Hospital Information System. SPSS and R were used for statistical analyses.

Results

Plasma FAM134B mRNA levels were significantly higher in the DPN than in the non-DPN group (p < 0.001). Increased FAM134B mRNA levels were strongly linked to increased odds of DPN, with the highest quartile showing a significant risk elevation (Odds Ratio [OR] = 21.42, 95% Confidence Interval: 4.86-96.46, p < 0.001). Restricted cubic spline analysis confirmed a non-linear relationship, thereby identifying a critical threshold of FAM134B mRNA levels at 2.53, above which the risk sharply increased (adjusted OR = 3.11, p = 0.006). Subgroup analysis showed consistent associations across most subgroups, with a notable difference in males (p = 0.038). The diagnostic performance was moderate (Area Under the Curve [AUC] = 0.756). While adding FAM134B mRNA to the model did not dramatically improve the AUC, it significantly enhanced reclassification metrics (Net Reclassification Improvement = 0.165, Integrated Discrimination Improvement = 0.095, p < 0.05), thereby highlighting its clinical value.

Conclusion

Increased FAM134B expression positively correlated with the odds of DPN, and may act as a promising target for diagnostic and therapeutic interventions.

New Markers for the Assessment of Microvascular Complications in Patients with Metabolic Syndrome

Background: Metabolic syndrome is a complex disorder characterized by the coexistence of multiple risk factors, including dysglycemia, hypertension, dyslipidemia, and visceral obesity. Both metabolic syndrome and diabetes mellitus are closely associated with the onset of microvascular complications such as retinopathy, polyneuropathy, and nephropathy. Methods: This narrative review analyzed 137 studies published up to 2025, retrieved from PubMed and Crossref databases. The objective was to identify and evaluate potential biomarkers that could facilitate the early detection of microvascular complications in patients with metabolic syndrome. Results: Several biomarkers demonstrated a strong correlation with microvascular complications in individuals with metabolic syndrome. These findings suggest their potential role in early diagnosis and risk assessment. Conclusions: The identification of reliable biomarkers may enhance early detection and targeted interventions for microvascular complications in metabolic syndrome. Further research is essential to validate these markers and establish their clinical applicability in routine medical practice.

Nonpharmaceutical treatment of distal sensorimotor polyneuropathy in diabetic patients: an unblinded randomized clinical trial

BACKGROUND

For Diabetic polyneuropathy, the most prevalent form of polyneuropathy, there is a lack of evidence-based treatment options. Current approaches include pain management, alpha-lipoic acid, and antidepressants. Physical interventions, such as electrical stimulation (four-chamber galvanic bath) have been suggested but have limited supporting evidence. Heated granular stone therapy is another option to consider.

METHODS

An unblinded randomized controlled trials was conducted in 68 diabetic patients with distal sensorimotor polyneuropathy undergoing rehabilitation for diabetes mellitus as a primary or secondary diagnosis in the Paracelsus-Harz-Clinic (Quedlinburg, Germany). Patients were randomized into either the intervention group receiving heated granulated stone footbaths, or the control group receiving four-chamber galvanic baths. The primary endpoint was the assessment of any change in polyneuropathy using a vibration sensation test (Rydel-Seiffer scale, 8/8) from admission to discharge, analyzed by t-test and multivariable regression. Additionally, serum TNF-α and IL-6 as potential markers for polyneuropathy were compared over time using paired t-test.

RESULTS

The mean age of the patients was 66.8 ± 7.8 years; 63.2% were male and mean BMI was 32.2 ± 6.4 kg/m2. Of the patients, 98.5% suffered from type 2 diabetes (one patient with type I diabetes); 82.4% were receiving oral antidiabetic medication; and 58.8% were insulin dependent. Distal sensorimotor polyneuropathy improved in both groups. The sum score increased from 16.7 to 22.6 in the study group and from 20.3 to 23.6 in the control group. A t-test showed a non-significant difference in the change of sum score between the treatment groups (2.6 points, p = 0.092), but adjusting for potential risk factors favors the intervention group (p = 0.043). Both analyzed markers decreased over time in each treatment group with IL-6 showing a clinical and significant reduction in the control group (p = 0.03).

CONCLUSION

Diabetic patients with distal sensorimotor polyneuropathy benefit from physical treatment with administration of electrical stimulation (four-chamber galvanic bath) or a therapy with heated granulated stones three times a week. Our results indicate that heated stone therapy may be a potential treatment option. However, further research is required to understand the underlying biological processes.

TRIAL REGISTRATION

The study was registered in clinical trials.gov (identifier: NCT05622630, registration date: 18/11/2022).

Association between lipoprotein(a) and diabetic peripheral neuropathy in patients with type 2 diabetes: a meta-analysis

BACKGROUND

Diabetic peripheral neuropathy (DPN) is a common complication of type 2 diabetes (T2D). Lipoprotein(a) [Lp(a)], a known cardiovascular risk factor, has been hypothesized to influence the development of DPN. This meta-analysis aimed to investigate the relationship between Lp(a) levels and DPN in patients with T2D.

METHODS

Following PRISMA 2020 guidelines, a systematic search of PubMed, Embase, Web of Science, Wanfang, and CNKI databases was performed up to October 12, 2024. Observational studies assessing blood Lp(a) levels in T2D patients with and without DPN or evaluating the association between Lp(a) and DPN risk were included. Data synthesis utilized a random-effects model to calculate standardized mean differences (SMDs) and odds ratios (ORs) with corresponding 95% confidence intervals (CIs).

RESULTS

Eleven studies with 18,022 patients were included. Patients with DPN had significantly higher Lp(a) levels than those without DPN (SMD: 0.10, 95% CI: 0.02-0.19, p = 0.01; I² = 43%). High Lp(a) levels were associated with DPN (OR: 1.31, 95% CI: 1.07-1.60, p = 0.009; I² = 62%). Subgroup analyses according to study design, mean age of the patients, methods for measuring Lp(a) concentration, cutoff values of a high Lp(a), and study quality scores showed consistent results (p for subgroup difference all > 0.05). A high Lp(a) was associated with DPN in studies from Asian countries, but not in those from European countries (p for subgroup difference = 0.001).

CONCLUSION

Elevated Lp(a) levels are associated DPN in T2D patients, particularly in studies from Asian countries.

Diagnostic Testing for Patients With Peripheral Neuropathy

This cross-sectional study compares the diagnostic testing for patients with peripheral neuropathy of patients from 1998 to 2007 with patients in 2019.

Association of PTX3 Genetic Variants With Development of Diabetic Neuropathy

BACKGROUND/AIM

Pentraxin 3 (PTX3), initially discovered as a key player in the defense against infectious pathogens, is crucial for inflammation and tissue regeneration. This study aimed to explore the impact of PTX3 gene variants on the development and progression of diabetic neuropathy (DN).

MATERIALS AND METHODS

The potential impact of PTX3 gene variants on the susceptibility to DN was examined by genotyping four single-nucleotide polymorphisms (SNPs) of the PTX3 gene (rs1840680, rs2305619, rs3816527, and rs2120243) in a study involving 730 DN cases and 861 diabetic controls with normal neurologic function.

RESULTS

We demonstrated that diabetic subjects homozygous for the minor allele at rs1840680 [AA; adjusted odds ratio (AOR)=1.486; 95% confidence interval (CI)=1.050-2.103; p=0.02] or rs2120243 (AA; AOR=1.483; 95%CI=1.051-2.091; p=0.025) were more likely to develop neurologic complications compared to those homozygous for the corresponding major allele. Further stratification revealed that this correlation with DN risk was observed specifically in males but not in females. In addition, another SNP of the PTX3 gene, rs2305619, was found to be associated with the risk for DN in males (AA vs. GG, AOR=1.686; 95%CI=1.086-2.617, p=0.020), indicating a sex-specific impact of PTX3 gene polymorphisms on damage to the nerves in diabetic patients. Furthermore, DN patients homozygous for the minor allele of rs1840680 (AA), particularly males, had higher levels of LDL-cholesterol than those homozygous for the reference allele (GG) (p=0.034).

CONCLUSION

PTX3 gene polymorphisms are associated with dyslipidemia and nerve damage in diabetic patients in a sex-specific manner.

Implementation of Pharmacist Driven Gabapentinoid Titration for Diabetic Peripheral Neuropathy in a Primary Care Setting

Previous studies suggest that patients with diabetic peripheral neuropathy (DPN) frequently do not receive the minimum effective doses of a gabapentinoid according to guidance from national organizations. There is opportunity to assess the implementation of pharmacist intervention for patients not meeting minimum effective gabapentinoid dosing for DPN. This prospective, single site quality improvement project was conducted at a primary care clinic and included patients with DPN prescribed a gabapentinoid by their primary care provider (PCP) at a dose lower than minimum effective dosing. Pharmacists assessed patient-reported pain ratings, adverse effects, and renal function for appropriate dosing and titrated to minimum effective dosing based on clinical judgment. All patients that were followed through week 13 had a clinically significant improvement in pain. No patients met a 50% reduction in patient-reported pain rating scales on guidance-directed minimum effective dosing. No patients were able to meet the minimum effective dose. The majority of patients declined pharmacist services due to neuropathy being controlled on the current gabapentinoid dose. This study supports the ability for pharmacists to assess patient specific factors for adequate dosing, titration, and deprescribing recommendations for analgesic medications in diabetic peripheral neuropathy.

Screening tools for diabetic foot ulcers: a narrative review

The prevalence of diabetic foot ulcers (DFUs) is 4 to 10% among people with diabetes mellitus. DFUs are associated with increased morbidity and mortality as well as reduced quality of life and have a significant impact on overall healthcare expenditure. The main predisposing factors for DFU are diabetic neuropathy, peripheral arterial disease, and trauma. The fact that a range of tests can be used to identify patients at risk for DFU often causes confusion among practitioners regarding which screening tests should be implemented in clinical practice. Herein we sought to determine whether tests of somatic nerve function, such as pinprick sensation, thermal (cold/hot) test, ankle reflexes, vibration perception, 10-g monofilament, Ipswich touch test, neuropathy disability score, and nerve conduction studies, predict the development of DFUs. In addition, we examined whether sudomotor function screening tests, such as Neuropad, sympathetic skin response, and other tests, such as elevated plantar pressure or temperature measurements, can be used for DFU screening. If not treated properly, DFUs can have serious consequences, including amputation, early detection and treatment are vital for patient outcomes.

Assessment of nerve conduction velocity slowing and its association with the severity of diabetic polyneuropathy, duration of diabetes and glycemic control in diabetic patients

Objective

This study aimed to investigate the nerve conduction velocity in diabetic patients and its association with diabetes duration, control and severity of diabetic polyneuropathy.

Methods

This prospective, observational study involved a hundred and thirty-nine patients who underwent nerve conduction studies in the Neurology Department at Liaquat National Hospital during the years June 2023 till May 2024. In all patients, the medical history was taken by direct interview regarding demographics, diabetes duration and recent HbA1c. For the assessment of diabetic polyneuropathy, the NDS-neuropathy disability score was used. The acquired data was entered into SPSS Statistics software for analysis of significant associations between these variables. Statistical significance was defined as a P-value below 0.05.

Results

In this study, we investigated 139 patients with a mean age of 62.20±12.03 years, comprising 60.4% males. The mean HbA1c was 7.46±1.09%, and the mean duration of diabetes was 10.78±7.75 years. Most patients (75.5%) had poor glycemic control, with 92.8% having Type-II diabetes. The mean neuropathy disability score was 5.63±2.39, with 80.6% of patients experiencing neuropathy. Nerve conduction velocity slowing was detected in 54.7% of the patients. Notably, significant associations were found between nerve conduction velocity slowing and diabetes duration (p=0.019), and neuropathy disability score (p=0.000).

Conclusion

Our findings indicate that male gender, poor glycemic control, and a longer duration of diabetes are associated with slowing of nerve conduction velocity. Additionally, the severity of neuropathy, as measured by the Neuropathy disability score, further strengthens these associations, highlighting its significance in assessing diabetic neuropathy progression.

Cardiovascular autonomic neuropathy is associated with SLEDAI in patients with systemic lupus erythematosus

INTRODUCTION

As a prevalent and severe complication of systemic lupus erythematosus (SLE), cardiovascular autonomic neuropathy (CAN) has garnered increasing attention. Reports suggested that CAN may be related to the disease activity of SLE. This study aims to explore whether Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) is associated with CAN and to evaluate its diagnostic value for CAN.

METHOD

Altogether, 144 patients with SLE from the Rheumatology Department of Nanjing Drum Tower Hospital were included. Each patient underwent assessment with the SLEDAI and cardiovascular reflex tests (CARTs). Patients were classified into three groups: non-CAN, early-CAN and diagnosed-CAN based on the CARTs results. The relationship of CARTs and SLEDAI were analyzed using SPSS 26.0.

RESULTS

After being divided into three groups, there were significant differences in SLEDAI among them. With increasing SLEDAI score (P < 0.05), both CARTs scores and four individual parameters score increased significantly, both before and after adjusting for influencing factors (P < 0.05). Besides, in Logistic regression analysis, it identified that SLEDAI as an independent risk factor for CAN (OR = 1.227, 95%CI = 1.143-1.316, P < 0.001). Finally, after accounting for the influence of glucocorticoids, a significant positive correlation between CARTs and SLEDAI remained (P < 0.05).

CONCLUSIONS

As the gold standard in the diagnosing CAN, CARTs and four parameters are significantly correlated with SLEDAI. Furthermore, SLEDAI is also an independent risk factors for its development. In conclusion, this research demonstrated that SLEDAI is a dependable indicator for the onset and progression of CAN. Key Points • This study is the first to demonstrate a strong association between SLEDAI and cardiovascular autonomic neuropathy, identifying SLEDAI as a risk factor for CAN in SLE patients. • This study offers a convenient and rapid method for the clinical evaluation of CAN in SLE patients, providing significant value in assessing cardiovascular complications.

Neuropathy and the metabolic syndrome

Obesity and the metabolic syndrome (MetS) are major global health challenges that contribute significantly to the rising prevalence of type 2 diabetes (T2D) and neuropathy. Neuropathy, a common and disabling complication of T2D, is characterized by progressive distal-to-proximal axonal degeneration, driven in part by mitochondrial dysfunction in both neurons and axons. Recent evidence points to the toxic effects of saturated fatty acids on peripheral nerve health, with studies demonstrating that these fats impair mitochondrial function and bioenergetics, leading to distal axonal loss. Conversely, monounsaturated fatty acids are found to be neuroprotective, restoring mitochondrial function and preventing neuropathy. These findings suggest that dietary factors play a crucial role in the pathogenesis of neuropathy associated with metabolic dysregulation and emphasize the need for lifestyle interventions and therapies that target these newly identified mechanisms.

The Role of Inflammation in the Pathogenesis of Diabetic Peripheral Neuropathy: New Lessons from Experimental Studies and Clinical Implications

Diabetic peripheral neuropathy (DPN) is one of the most frequent complications of diabetes mellitus (DM). Its pathogenesis is still not entirely clear. Inflammation is increasingly being appreciated as a key factor in its development and progression. The aim of this review was to outline current evidence from experimental research on the role of inflammation in the pathogenesis of DPN and to suggest emerging clinical implications. Beyond commonly assessed interleukins, chemokines and tumour necrosis factor alpha (TNFα), several novel underlying mechanisms and potential therapeutic targets have been unravelled. Pathogenesis is also influenced by dietary patterns, such as iron supplementation. Furthermore, the impact of the inflammasome nucleotide-binding oligomerisation domain-like receptor pyrin domain-containing protein 3 (NLPR3) is gaining importance. The same holds true for inflammatory pathways, such as the Toll-like receptor (TLR)-associated pathways or the phosphatidylinositol 3-kinase/protein kinase B (PI3K/AKT) pathway. SIRTuins are also of importance. DPN is associated with changes in macrophage polarisation. In addition, several metalloproteinases are emerging as contributors, although data is still limited. Finally, miRNAs (e.g. miR146a) are strongly linked with DPN by acting in several inflammatory pathways. However, we still need confirmation of preliminary research findings. It is hoped that new knowledge will lead to new therapeutic approaches, including stem cell-based or exosome-based therapies.

Unraveling the link between magnesium and diabetic neuropathy: Evidence from in vitro to clinical studies

Diabetic neuropathy (DN) is one of the major complications of diabetes and the most common cause of neuropathic pain. Although the underlying pathological mechanisms remain unclear, several studies have produced conflicting results regarding the link between magnesium (Mg) concentration and DN. This ambiguity raises questions about the potential benefits of Mg supplementation in individuals with DN. Therefore, this comprehensive review summarizes and discusses the evidence from clinical, in vitro, and in vivo studies on the association between Mg and DN. Several findings indicate that Mg depletion is linked to the presence of neuropathy in diabetic patients. Additionally, low Mg concentration may contribute to the onset or worsening of DN by promoting axonal degeneration through various pathways. Furthermore, multiple studies have shown that Mg supplementation can have neuroprotective effects. These findings suggest potential as an alternative or complementary therapy for preventing and treating DN in the future.

Vitamin D receptor FokI polymorphism as a risk factor for painful diabetic neuropathy in type 2 diabetes mellitus patients

Painful diabetic neuropathy (PDN) is a common complication in patients with type 2 diabetes mellitus (T2DM) with disruption of vitamin D (VD) activity as one of the risk factors. Active VD exerts its biological functions through the vitamin D receptor (VDR), which polymorphisms in the VDR gene can impair. This study aims to establish VDR FokI and ApaI polymorphisms as risk factors for PDN. This case-control study used samples from T2DM patients with and without PDN. Neuropathic pain was diagnosed using the DN4 questionnaire, while FokI and ApaI polymorphisms were examined using the Polymerase Chain Reaction-Restriction Fragment Length Polymorphism method. Other factors examined included gender, hypertension, current insulin use, obesity, HbA1c levels, and dyslipidemia. A total of 64 subjects were involved in the study. The FokI polymorphism (CT+TT genotype) was a significant risk factor for PDN (OR 4.20; 95% CI [1.47-11.94]; p = 0.012). The T allele in the FokI polymorphism significantly increased the risk of PDN by 2.8 times (OR 2.78; 95% CI [1.28-6.01], p = 0.014). The ApaI polymorphism was not significantly associated with PDN. Diabetes duration ≥4.5 years and uncontrolled diabetes were other significant risk factors for PDN. Multivariate analysis identified three significant variables: FokI polymorphism (OR 5.00; 95% CI [1.37-18.24], p = 0.015), insulin use (OR 4.95; 95% CI [1.37-17.87], p = 0.015), and uncontrolled diabetes (OR 3.47; 95% CI [1.03-11.69], p = 0.045). The VDR FokI polymorphism with the T allele is a significant genetic risk factor for PDN in T2DM patients. The VDR ApaI polymorphism was not a significant risk factor for PDN.

Assessing the Effects of Pulsed Electromagnetic Therapy on Painful Diabetic Distal Symmetric Peripheral Neuropathy: A Double-Blind Randomized Controlled Trial

BACKGROUND

Significant complications of diabetes include pain and the loss of sensation in peripheral limbs. Pain management of diabetic symmetric peripheral neuropathy (DSPN) remains challenging. This study reports on utilizing pulsed electromagnetic field therapy (PEMF) to reduce pain and improve skin perfusion pressure (SPP) in subjects with DSPN.

METHODS

A randomized, sham-controlled, double-blind, clinical trial was conducted on subjects afflicted with foot pain associated with DSPN. Following informed consent, 182 subjects with diabetes and confirmed DSPN were entered into the trial for a period of 18 weeks. Subjects were randomized into active PEMF treatment or nonactive sham and instructed to treat to their feet for 30 minutes, twice daily and report daily pain scores. Some patients in the active arm experienced a transient low field strength notification (LFSN) due to improper pad placement during treatment. Skin perfusion pressure measurements were also collected at two and seven weeks to assess peripheral arterial disease effects via measurement of local microcirculatory flow and blood pressure.

RESULTS

Patients in the active arm who did not receive an LFSN experienced a clinically significant 30% reduction in pain from baseline compared to sham (P < .05). Though not statistically significant, SPP in the active group trended toward improvement compared to sham.

CONCLUSIONS

Pulsed electromagnetic field therapy appears effective as a nonpharmacological means for reduction of pain associated with diabetic peripheral neuropathy and holds promise for improvement of vascular physiology in microcirculatory dysfunction associated with diabetic peripheral arterial disease.

Diabetic kidney disease and cardiac autonomic neuropathy: insights on exercise rehabilitation

Patients with Diabetic Kidney Disease (DKD) suffer from various complications of diabetes mellitus, including autonomic neuropathy. Cardiac autonomic nervous system dysfunction is a common disorder in patients with diabetes mellitus and Chronic Kidney Disease (CKD), and is associated with an increased risk of arrhythmias and cardiovascular morbidity and mortality. Although the effects of exercise training have been thoroughly studied in different patient populations with CKD or diabetes mellitus, few studies have investigated the effects of exercise on cardiac autonomic nervous system activity in patients with DKD. This narrative review aims to summarize the evidence regarding the effects of exercise training on cardiac autonomic nervous system modulation in DKD patients.

Barriers and new opportunities in developing effective therapies for diabetic neuropathy: International expert consensus recommendations

BACKGROUND

Diabetic neuropathy (DN) affects up to half of individuals with type 1 and type 2 diabetes. Despite evidence that improving metabolic and cardiovascular health can slow its progression, DN remains a significant clinical challenge due to the lack of disease-modifying therapies and effective pain management strategies. This consensus aimed to identify gaps and recommend strategies to address these challenges.

METHOD

A workshop, initiated by Steno Diabetes Centre Copenhagen and the Danish Diabetes and Endocrinology Academy, conducted a gap analysis based on insights from clinical studies, observational cohorts, and clinical practice. Online invitations targeted experienced clinicians, researchers, and drug developers committed to improving DN treatment through innovative clinical trials. Thirty-five participants from six countries reached consensus via a Delphi process on key steps to advance DN therapy.

RESULT

Four critical barriers and needs were addressed: (1) Translating bench research to clinical practice, (2) Enhancing clinical trial design, (3) Improving outcome measures, and (4) Identifying effective treatments for painful DN.

CONCLUSION

Successful interventional trials require robust outcome measures to capture clinically meaningful changes in DN phenotypes, providing the basis for developing effective, disease-modifying treatments.