Diabetic peripheral neuropathy(DPN),a chronic diabetic microvascular complication with a high incidence among diabetic patients,increases the risk of diabetic foot and amputation.Many methods are available for screening and evaluating DPN,including traditional 10 g monofilament,tuning fork and vibration perception,and tendon reflex tests,which should be combined with some nerve function score systems to improve the detection rate and accuracy for DPN.In recent years,a number of noninvasive new techniques have been developed for the evaluation of nerve injury,such as corneal confocal microscopy,quantitative sensory testing,current perception threshold test,sympathetic sudomotor function evaluation,and quantitative detection of skin advanced glycation end products.This paper reviews these noninvasive methods for screening and evaluating DPN to help clinicians detect and focus on DPN early.
Cornea ; Diabetes Mellitus ; Diabetic Foot ; Diabetic Neuropathies/diagnosis* ; Humans ; Mass Screening ; Microscopy, Confocal

OBJECTIVES: Medically compromised patients often fear required dental surgical procedures that can increase the risk of medical emergency when combined with reduced tolerance for stress. A stress reduction protocol (SRP) helps doctors minimize treatment-related stress and improves patient management with minimum complications. Diabetes and co-morbid hypertension carry 4-fold risk of aggravation of cardiovascular emergencies and 7.2-fold risk of mortality. Diabetic neuropathy can result in difficult diagnosis of myocardial infarction and reduces chances of surviving a myocardial infarction compared with a non-diabetic person. The aim of the study was to assess the feasibility of a protocol for management of patients having both diabetes and hypertension who required minor oral surgery to minimize the rate of cardiovascular emergencies. MATERIALS AND METHODS: A prospective study was conducted in 140 patients having both diabetes and hypertension who required minor oral surgical procedures. A systematic approachable protocol was designed for management of such patients. RESULTS: Among 140 patients, 6 patients (4.3%) had cardiovascular complications, while 3 patients (1 with syncope and 2 with hypertension) did not require any intervention other than observation. Two patients were managed with aspirin and nitroglycerin, and 1 patient had possible myocardial infarction (overall incidence 0.7%) with chest pain, S-T segment elevation on electrocardiogram, and troponin level of 0.60 ng/mL. CONCLUSION: The proposed protocol helps to improve management of patients having both diabetes and hypertension. We recommend that patients with uncontrolled diabetes and uncontrolled hypertension and/or patients having history of cardiovascular complication should be treated in a medical facility with a readily available cardiology unit. This facilitates prompt response to emergency and instant implementation of treatment, helping to reduce morbidity and mortality.
Aspirin ; Cardiology ; Chest Pain ; Diabetic Neuropathies ; Diagnosis ; Electrocardiography ; Emergencies ; Humans ; Hypertension ; Incidence ; Mortality ; Myocardial Infarction ; Nitroglycerin ; Oral Surgical Procedures ; Prospective Studies ; Surgery, Oral ; Syncope ; Troponin

Early recognition and appropriate management of diabetic peripheral polyneuropathy (DPNP) is important. We evaluated the necessity of simple, non-invasive tests for DPNP detection in clinical practice. We enrolled 136 randomly-chosen patients with type 2 diabetes mellitus and examined them with the 10-g Semmes-Weinstein monofilament examination, the 128-Hz tuning-fork, ankle-reflex, and pinprick tests; the Total Symptom Score and the 15-item self-administered questionnaire of the Michigan Neuropathy Screening Instrument. Among 136 patients, 48 had subjective neuropathic symptoms and 88 did not. The abnormal-response rates varied depending on the methods used according to the presence of subjective neuropathic symptoms (18.8% vs. 5.7%, P < 0.05; 58.3% vs. 28.4%, P < 0.005; 81.3% vs. 54.5%, P < 0.005; 12.5% vs. 5.7%, P=0.195; 41.7% vs. 2.3%, P < 0.001; and 77.1% vs. 9.1%, P < 0.001; respectively). The largest abnormal response was derived by combining all methods. Moreover, these tests should be implemented more extensively in diabetic patients without neuropathic symptoms to detect DPNP early.
Diabetes Mellitus ; Diabetes Mellitus, Type 2* ; Diabetic Neuropathies ; Diagnosis ; Humans ; Mass Screening ; Michigan ; Neurologic Examination ; Peripheral Nervous System Diseases* ; Polyneuropathies ; Surveys and Questionnaires

BACKGROUND: Clinical manifestations of diabetic peripheral neuropathy (DPN) vary along the course of nerve damage. Nerve conduction studies (NCS) have been suggested as a way to confirm diagnoses of DPN, but the results have limited utility for evaluating clinical phenotypes. The current perception threshold (CPT) is a complementary method for diagnosing DPN and assessing DPN symptoms. We compared NCS variables according to clinical phenotypes determined by CPT measurements. METHODS: We retrospectively enrolled patients with type 2 diabetes mellitus who underwent both NCS and CPT tests using a neurometer. CPT grades were used to determine the clinical phenotypes of DPN: normoesthesia (0 to 1.66), hyperesthesia (1.67 to 6.62), and hypoesthesia/anesthesia (6.63 to 12.0). The Michigan Neuropathy Screening Instrument (MNSI) was used to determine a subjective symptom score. DPN was diagnosed based on both patient symptoms (MNSI score ≥3) and abnormal NCS results. RESULTS: A total of 202 patients (117 men and 85 women) were included in the final analysis. The average age was 62.6 years, and 71 patients (35.1%) were diagnosed with DPN. The CPT variables correlated with MNSI scores and NCS variables in patients with diabetes. Linear regression analyses indicated that hypoesthesia was associated with significantly lower summed velocities and sural amplitudes and velocities, and higher summed latencies, than normoesthesia. Sural amplitude was significantly lower in patients with hyperesthesia than in patients with normoesthesia. CONCLUSION: NCS variables differed among patients with diabetes according to clinical phenotypes based on CPT and decreased sural nerve velocities was associated with hyperesthesia.
Diabetes Mellitus, Type 2* ; Diabetic Neuropathies ; Diagnosis ; Humans ; Hyperesthesia ; Hypesthesia ; Linear Models ; Male ; Mass Screening ; Methods ; Michigan ; Neural Conduction* ; Peripheral Nervous System Diseases ; Phenotype* ; Retrospective Studies ; Sensory Thresholds ; Sural Nerve

There are potentially many ways of assessing diabetic peripheral neuropathy (DPN). However, they do not fulfill U.S. Food and Drug Administration (FDA) requirements in relation to their capacity to assess therapeutic benefit in clinical trials of DPN. Over the past several decades symptoms and signs, quantitative sensory and electrodiagnostic testing have been strongly endorsed, but have consistently failed as surrogate end points in clinical trials. Therefore, there is an unmet need for reliable biomarkers to capture the onset and progression and to facilitate drug discovery in DPN. Corneal confocal microscopy (CCM) is a non-invasive ophthalmic imaging modality for in vivo evaluation of sensory C-fibers. An increasing body of evidence from multiple centers worldwide suggests that CCM fulfills the FDA criteria as a surrogate endpoint of DPN.
Biomarkers ; Diabetic Neuropathies* ; Diagnosis ; Drug Discovery ; Microscopy, Confocal ; Peripheral Nervous System Diseases ; United States Food and Drug Administration

Diabetic foot is one of the most significant and serious complications of diabetes, and is defined as the foot of diabetic patients with ulceration, infection and/or destruction of the deep tissues, associated with neurological abnormalities and various degrees of peripheral vascular disease in the lower limb. The most significant risk factors for foot ulceration are diabetic neuropathy, peripheral arterial disease, and consequent traumas of the foot. Most diabetic ulcers can be prevented with good foot care and screening for risk factors for a foot at risk of complications. Active foot examination and foot care education are methods to prevent diabetic foot at a minimum cost. I will focus on the recommendations for diagnosis and treatment of diabetic foot.
Diabetic Foot* ; Diabetic Neuropathies ; Diagnosis* ; Education ; Foot ; Foot Ulcer ; Humans ; Lower Extremity ; Mass Screening ; Peripheral Arterial Disease ; Peripheral Vascular Diseases ; Risk Factors ; Ulcer

Diabetic autonomic neuropathy (DAN) is a serious and common complication of diabetes, although it is often overlooked. Abnormal autonomic function tests are often found in peoples with diabetic peripheral neuropathy. Autonomic neuropathies affect the autonomic neurons (parasympathetic, sympathetic, or both) and are associated with a variety of site-specific symptoms. The symptoms and signs of DAN should be elicited carefully during the medical history and physical examination. Major clinical manifestations of DAN include hypoglycemia unawareness, resting tachycardia, orthostatic hypotension, gastroparesis, constipation, diarrhea, fecal incontinence, erectile dysfunction, neurogenic bladder, and sudomotor dysfunction with either increased or decreased sweating. When a patient has signs and symptoms of DAN, various autonomic function tests should be performed. Recognition and management of DAN may improve symptoms, reduce sequelae, and improve quality of life. Clinically relevant diabetic autonomic neuropathies such as cardiovascular, gastrointestinal, genitourinary, and sudomotor dysfunction should be considered in the optimal care of patients with diabetes. The present review summarizes the latest knowledge regarding clinical presentation, diagnosis, and management of DAN.
Constipation ; Diabetic Neuropathies* ; Diagnosis* ; Diarrhea ; Erectile Dysfunction ; Fecal Incontinence ; Gastroparesis ; Humans ; Hypoglycemia ; Hypotension, Orthostatic ; Male ; Neurons ; Peripheral Nervous System Diseases ; Physical Examination ; Quality of Life ; Sweat ; Sweating ; Tachycardia ; Urinary Bladder, Neurogenic

Diabetic peripheral neuropathy (DPN) is one of the most common complications of diabetes and is diagnosed as the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes. The prevalence of DPN was reported at 33.5% of type 2 diabetes patients by the Korean diabetes neuropathy study group. Early diagnosis is recommended to prevent diabetic foot ulcers, amputation, or disability. A questionnaire asking about symptoms and neurologic examination of feet is commonly used as a screening tool. However, complete diagnostic tests for DPN are not well established because of incomplete understanding of the pathogenetic mechanisms leading to the nerve injury, the various clinical manifestations, and the unclear natural history. Therefore, DPN has not been paid sufficient attention by clinicians. The roles of glycemic control and management of cardiovascular risk factors in the prevention and treatment of neuropathic complications are well known. Pathogenetically oriented or symptomatic agents are other options, though such treatments do not always produce a satisfactory outcome. Therefore, DPN remains a challenge for physicians to screen, diagnose, and treat. There have been recent advances in understanding the mechanisms underlying DPN and in the development of new diagnostic modalities and treatments. In this review, diagnosis and management of DPN will be discussed.
Amputation ; Diabetes Complications ; Diabetic Foot ; Diabetic Neuropathies ; Diagnosis* ; Diagnostic Tests, Routine ; Early Diagnosis ; Foot ; Humans ; Mass Screening ; Natural History ; Neurologic Examination ; Peripheral Nerves ; Peripheral Nervous System Diseases* ; Prevalence ; Risk Factors ; Ulcer

Diabetic neuropathy is a complex and common disorder with multiple etiologies and affects about 43.1% of the Korean diabetes population. Good glycemic control slows progression of diabetic neuropathy in subjects with type 1 diabetes but seems to provide little benefit in subjects with type 2 diabetes. Moreover, neuropathy has been shown to develop in humans at stages of prediabetes and in the absence of overt hyperglycemia. Given the increasing incidence of both type 1 and type 2 diabetes and obesity and the impact of diabetic neuropathy on the quality of life of patients, a strategy for early diagnosis and discovery of an effective treatment is important for prevention and progression of diabetic neuropathy. Approximately 14.4% of Korean diabetics with neuropathy have associated pain, and management of this pain has been unsuccessful for many clinicians and patients. Choice of the correct drug(s), dosage, and patient management seems to be based on individualized conditions and needs. Overall, for good management and prevention for diabetic foot morbidities, early and proper diagnosis of diabetic neuropathy is essential, and simple and precise diagnostic methods must be developed.
Diabetic Foot ; Diabetic Neuropathies* ; Diagnosis ; Early Diagnosis ; Humans ; Hyperglycemia ; Incidence ; Obesity ; Pain Management ; Prediabetic State ; Quality of Life

Cardiac autonomic neuropathy (CAN) is a common and most neglected complication of diabetes, estimated to be roughly 8% in recently diagnosed patients and greater than 50% in patients with chronic disease history. The insulin resistance (IR) itself is bidirectionally associated with increased risk of type 2 diabetes mellitus (T2DM) and CAN is a predisposing factor. The primary objective of the present study was aimed to find a correlation of triglyceride glucose index (TyG index) in CAN patients along with the prevalence of CAN in T2DM patients as a secondary objective. This prevalence study was conducted on 202 patients visiting the diabetic clinic of Hamdard Institute of Medical Sciences and Research, Jamia Hamdard (HIMSR) teaching hospital in New Delhi, India who fulfilled the inclusion criteria. The Ewings autonomic function test was used for diagnosis of CAN. TyG index was calculated for patients based on fasting levels of glucose and triglyceride. The CAN was diagnosed in 62 participants out of 202 T2DM patients (overall prevalence 30.7%). The mean ± standard deviation (SD) for TyG index was 10.3 ± 0.2 and 9.5 ± 0.2 in CAN positive, T2DM patients, respectively. The difference of TyG index, in CAN positive and T2DM patients, was highly significant (P < 0.001). Further correlation analysis was performed to find an association of TyG index, duration, and age with patient groups. TyG index showed a positive correlation with heart rate during deep breathing (HRD), heart rate variation during standing (HRS), blood pressure (BP) response to handgrip and BP response to standing. Our finding highlights the TyG index, low-cost IR index, might be useful as an alternative tool for the early screening of patients at a high risk of diabetic neuropathy.
Blood Pressure ; Causality ; Chronic Disease ; Cross-Sectional Studies ; Diabetes Mellitus, Type 2* ; Diabetic Neuropathies ; Diagnosis ; Fasting ; Glucose* ; Heart Rate ; Hospitals, Teaching ; Humans ; India ; Insulin Resistance ; Mass Screening ; Prevalence ; Respiration ; Triglycerides*