Distal Symmetric Polyneuropathy Research Articles

Acupuncture versus sham acupuncture in the treatment of diabetic distal symmetric polyneuropathy (DSPN): Study protocol for a randomized controlled trial

IntroductionDistal symmetrical polyneuropathy is the most common type of diabetic neuropathy. Acupuncture has been used to treat distal symmetrical polyneuropathy; however, previous clinical trials of acupuncture in treating this disorder were limited by methodological defects; therefore, high-quality research is required. This trial aims to assess the efficacy and safety of acupuncture in the treatment of diabetic distal symmetrical polyneuropathy. MethodsThis study is a patient- assessor- blinded, double center, randomized controlled trial. A total of 210 patients with DSPN will be randomly assigned the study group or the control group in a ratio of 1:1. The study group (n = 105) will receive acupuncture, the control group (n = 105) will receive sham acupuncture. In addition, standard anti-hyperglycemic care will be provided to all patients. After baseline assessment, all treatments will be administered 3 times per week for 6 weeks, with a follow-up period of 8 weeks. The primary outcome is the Neuropathy Disability Score. Secondary outcomes are the Nerve Conduction Velocity; the Total Symptom Score; the Beck Depression Inventory II; and the Short-Form Health Survey 36. All outcome measures will be assessed at the baseline, 3 weeks, 6 weeks and 14 weeks. Adverse events will be recorded during this study to assess the safety of treatment. DiscussionThis study will assess the effect of acupuncture on distal symmetrical polyneuropathy and aims to provide clinical evidence for the efficacy of acupuncture in treating this disorder.

Cardiovascular Autonomic Neuropathy and Distal Symmetric Sensorimotor Polyneuropathy: These Two Diabetic Microvascular Complications do not Invariably Co-Exist.

Cardiovascular autonomic neuropathy (CAN) and distal symmetrical sensorimotor polyneuropathy (DSPN) are serious microvascular complications of diabetes mellitus (DM). Their simultaneous development remains disputable. The aim of the present study was to examine the correlation between CAN and the presence/severity of DSPN in DM. Subjects with type 1 (group A: n=51; mean age 40.4 years) and type 2 DM (group B: n=153; mean age 64.6 years) were studied. Evaluation of DSPN was based on neuropathy disability score. Assessment of CAN was based on the battery of 4 standardized cardiovascular autonomic function tests. In group A, patients with moderate/severe DSPN exhibited a 12-fold higher likelihood of CAN in univariate analysis (p=0.035). However, significance was lost after adjustment for gender, age, DM duration, and haemoglobin A1c. In group A, likelihood for CAN did not correlate with the presence of mild DSPN in univariate and multivariate analysis. In group B, likelihood of CAN was similar in patients with mild and in those with moderate/severe DSPN compared with patients without DSPN in univariate and multivariate analysis. In between group comparison CAN was similarly distributed in the 2 groups (p for interaction=0.367), in patients with no, mild and moderate/severe DSPN. CAN does not always co-exist with degrees of DSPN, ranging from mild to moderate/ severe and is similarly distributed in T1DM and T2DM patients with mild and moderate/severe DSPN and in patients without DSPN.

A qualitative study of the experience and impact of neuropathic pain in people living with HIV.

Painful distal symmetrical polyneuropathy is common in HIV and is associated with reduced quality of life. Research has not explored the experience of neuropathic pain in people with HIV from a person-centred perspective. Therefore, a qualitative interview study was conducted to more deeply understand the experience and impact of neuropathic pain in this population. Semistructured interviews were conducted with 26 people with HIV and peripheral neuropathic pain symptoms. Interviews explored the impact of pain and participants' pain management strategies. Interviews were transcribed verbatim and analysed using thematic analysis. Four themes and 11 subthemes were identified. Theme 1 reflects the complex characterisation of neuropathic pain, including the perceived unusual nature of this pain and diagnostic uncertainty. Theme 2 centred on the interconnected impacts of pain on mood and functioning and includes how pain disrupts relationships and threatens social inclusion. Theme 3 reflects the struggle for pain relief, including participants' attempts to "exhaust all options" and limited success in finding lasting relief. The final theme describes how pain management is complicated by living with HIV; this theme includes the influence of HIV stigma on pain communication and pain as an unwanted reminder of HIV. These data support the relevance of investigating and targeting psychosocial factors to manage neuropathic pain in HIV.

Rastreio de Polineuropatia Diabética Periférica em Doentes Internados

Introdução: A polineuropatia simétrica distal (PNSD) é umacomplicação frequente e catastrófica da diabetes mellitus, massubdiagnosticada. Os autores colocam a hipótese de o internamento ser uma oportunidade de rastreio da PNSD e pretendemcomparar dois métodos de diagnóstico.Material e Métodos: Estudo prospetivo e multicêntrico,que incluiu doentes diabéticos internados nos serviços de medicina interna de dois hospitais, entre maio e outubro de 2015.Foi aplicada a escala MNSI (Michigan Neuropathy Screening Instrument) e o teste SWME (Monofilamento de 10 g-SemmesWeinstein exam) para despiste de PNSD. Uma pontuação > 2no exame clínico da MNSI ou ≤ 7 respostas positivas em 10 noteste SWME, foram consideradas diagnósticas de DSPN.Resultados: Foram incluídos 88 pacientes com idade mediana de 77 (13) anos e 45% homens; a maioria com diabetestipo 2 e 7% tinham diagnóstico prévio de PNSD. A prevalênciade PNSD foi de 75% utilizando o MNSI; o teste SWME foi anormal em 38% destes pacientes. A taxa de concordância entre ostestes foi de 44,3%. Dos pacientes, 92,4% com diagnóstico dePNSD no estudo não tinham diagnóstico prévio.Discussão: O número de subdiagnósticos de PNSD nesteestudo é alarmante. A percentagem de casos subdiagnosticadapode representar um problema de registo ou de escassez derastreio.Conclusão: Neste estudo concluímos que a PNSD é altamente prevalente entre os pacientes hospitalizados, mas profundamente subdiagnosticada. A escala MNSI poderá ser uminstrumento adequado para o rastreio, enquanto o teste SWMEnão deve ser utilizada isoladamente para este propósito.

The Diagnostic Utility of VibraTip for Distal Symmetrical Polyneuropathy in Type 2 Diabetes Mellitus.

IntroductionThe aim of this study was to assess the performance of VibraTip, a device used to test a person’s vibration perception during routine checks for peripheral neuropathy, against two thresholds of the Neuropathy Disability Score (NDS) for diagnosing distal symmetrical polyneuropathy (DSPN) in patients with type 2 diabetes mellitus (T2DM).MethodsOne hundred consecutive subjects with T2DM were enrolled in the study, of whom 54 were men. The mean age was 62.3 years, and the mean T2DM duration was 12.6 years. VibraTip was used at one foot site (on the pulp of the hallux; protocol A) and at three foot sites (pulp of the hallux and first and third metatarsal head; protocol B). NDS thresholds of ≥ 3 and ≥ 6 were used to establish the diagnosis of DSPN.ResultsAgainst the NDS ≥ 3 threshold, VibraTip showed a very high sensitivity (91.3%) and negative predictive value (NPV) (92%) and a high specificity (85.2%) with protocol A, and a very high sensitivity (95.6%) and NPV (96.1%) and a very high specificity (90.7%) with protocol B. Against the NDS ≥ 6 threshold, VibraTip showed a very high sensitivity (100%) and NPV (100%) and a very high specificity (95.2%) with protocol A, and very high sensitivity (100%) and NPV (100%) and very high specificity (96.8%) with protocol B.ConclusionsThe diagnostic performance of VibraTip is very high in patients with T2DM, rendering it a very useful device as a screening tool, particularly for the exclusion of DSPN. VibraTip performs very well at both NDS thresholds, but particularly well at the NDS ≥ 6 threshold. There appears to be no need to examine sites other than the hallux site with Vibratip.

Is folate deficiency a common cause of distal symmetric polyneuropathy in Zambian clinics?

ObjectivesTo evaluate the odds of vitamin B12 and folate deficiencies among Zambian clinic attendees with distal symmetric polyneuropathy (DSP) and age, sex, and HIV matched controls. MethodsCases were adults from clinics in urban/peri-urban Zambia. Controls were enrolled among persons not seeking personal medical care, such as a caregiver or person collecting antiretrovirals without a medical complaint. Participants underwent structured interviews, physician examination, and assessments of complete blood count, renal and liver profiles, serum vitamin B12 and folate, erythrocyte folate, plasma total homocysteine and methylmalonic acid. HIV testing and CD4 counts were performed when appropriate. ResultsAmong 107 consenting matched case-control pairs, 65% were female, 52% HIV positive, with mean age of 47.6 (SD 13.5) years. Among HIV positive participants, mean CD4 count was 484 (SD 221) and 482 (SD 236) for cases and controls, respectively (p = .93). DSP symptoms and severity did not differ by HIV status (p's > 0.05). Height, history of tuberculosis treatment, alcohol use, education, asset index, dietary diversity, and nutritional supplement use did not differ between cases and controls (p's > 0.05). DSP cases had at least 3:1 odds of having low serum folate (p = .0001), severely low erythrocyte folate (p = .014), and elevated total homocysteine (p = .001) levels compared to controls. Markers of vitamin B12 deficiency were not associated with case status (p's > 0.05). ConclusionMarkers of folate deficiency are highly associated with DSP among Zambian clinic attendees. Future studies should consider a broader range of comorbid nutritional deficiencies, and strategies for interventions.

The role of blink reflex R1 latency as an electrophysiological marker in diabetic distal symmetrical polyneuropathy

ObjectiveStudies showed a relatively prolonged blink R1 latency in patients with diabetic distal symmetrical polyneuropathy (DSPN) compared to that without DSPN. We tested the hypothesis that blink R1 latency would provide a diagnostic alternative to nerve conduction studies (NCS) in DSPN and act as a marker of the severity of NCS abnormalities in DSPN. MethodA total of 109 patients with type 2 diabetes underwent blink reflex studies and NCS. We used the composite amplitude scores of nerve conductions (CAS), which consisted of motor (tibial, peroneal and ulnar) and sensory (sural and ulnar) amplitudes for estimating the severity of NCS. ResultsPatients with DSPN had longer blink R1, R2, and contralateral R2 latencies (P < 0.0001, P = 0.001, and P = 0.031, respectively) and higher CAS (P < 0.0001). Area under curve on receiver operating characteristic curve analysis in diagnosing occurrence of DSPN in blink R1 latency was 0.772 (P < 0.0001). Multiple linear regression analysis showed that blink R1 latency was independently associated with CAS. ConclusionBlink R1 latency may be valuable in auxiliary diagnosis and in determining the severity of NCS abnormalities in DSPN. SignificanceBlink R1 latency can be added as a supplemental marker of severity of NCS in DSPN, especially if the patient’s sural amplitudes has a floor effect.

Advances in neurometabolic therapy

Actovegin is a calf blood extract that contains more than 200 biologically active compounds. Experiments have shown that Actovegin reduces the neurotoxic effect of amyloid, neutralizes reactive oxygen species, and normalizes the endothelial function of small vessels. The drug has not been shown to stimulate tumor growth in the neuroblastoma model. Clinical experience with Actovegin suggests that the drug has an undoubted efficacy in treating moderate vascular cognitive impairment and chronic distal symmetric diabetic polyneuropathy and that it is used as additional therapy for primary degenerative and vascular dementia. The clinical efficacy of Actovegin in chronic obliterating diseases of the lowerlimb arteries is being actively studied now.

Sural nerve sensory response in diabetic distal symmetrical polyneuropathy.

The sural sensory nerve action potential (SNAP) amplitude is a measure of the number of axons. We tested the hypothesis that sural SNAP amplitude can be used as a marker in screening, severity evaluation, and follow-up of diabetic distal symmetrical polyneuropathy (DSPN). Patients with type 2 diabetes underwent nerve conduction studies and were followed for 6 years. Composite amplitude scores (CASs) were determined to evaluate DSPN severity. Sural SNAP amplitudes were negatively correlated with CAS (r = -.790, P < .0001), and changes in sural SNAP amplitudes were negatively correlated with those of CAS after controlling for follow-up duration (r = -.531, P = .028). When a patient's baseline sural SNAP amplitude is above zero, it can be used as one measure of DSPN in screening, severity evaluation, and follow-up. However, if the patient's sural SNAP value is zero, CAS can be used as a follow-up measure.

Diabetic Peripheral Neuropathies (DPNs) from Basic and Clinical Aspects

Diabetes has been one of the crucial diseases worldwide, which has to be controlled adequately for long years. It has three diabetic complications of micro-angiopathy such as neuropathy, retinopathy and nephropathy. Among them, Diabetic Peripheral Neuropathies (DPNs) are most prevalent to manage in primary care setting. In this article, recent topics concerning DPNs are introduced [1]. DPNs have a variety of symptoms and signs, then DPNs are often described in plural forms [2]. DPNs are classified into two categories, which are local and general. The former includes mononeuropathy and multifocal neuropathy. The latter includes diabetic polyneuropathy (DPN) and others. DPN has Distal Symmetric Polyneuropathy (DSPN) and Diabetic Autonomic Neuropathy (DAN) [2]. For examples, DSPN shows bilateral numbness of extremities and DAN shows Orthostatic Hypotension (OH).

Evaluating the Efficacy of the Treatment with Benfotiamine and Alpha-lipoic Acid in Distal Symmetric Painful Diabetic Polyneuropathy

Distal symmetric painful diabetic neuropathy is the most frequent clinical form of diabetic neuropathy. The condition appears as a result of alteration of the structure and function of nervous fibres as a consequence of hyperglycaemia. Hyperglycaemia determines the metabolism of glucose on alterative pathways and generates increased oxidative stress, mechanisms that cause an accelerated apoptosis of the neurons and a high intensity of lipid peroxidation. Pathogenic treatment of diabetic neuropathy includes limited options, two of them are: Benfotiamine (inhibits the metabolism of glucose on hexosamine pathway, reducing the formation of advanced glycosylation end products) and alpha-lipoic acid (has a scavenger effect on free radical species). The study included 120 patients with distal symmetric painful diabetic neuropathy randomized in 3 treatment groups. We evaluated the effect of oral administration for 8 weeks of Benfotiamine in a dosage of 300mg/day in monotherapy, of alpha-lipoic acid in a dosage of 600 mg/day in monotherapy, respectively of both -in combined therapy - on the parameters that are used to determine the severity of distal symmetric painful diabetic neuropathy: Diabetic Neuropathy Symptoms score, Neuropathy Disability Score and the intensity of lower limb pain on the visual analogue pain scale. All the three therapies were effective with a statistically significant improvement of these parameters, but the combined therapy with alpha-lipoic acid and Benfotiamine was superior to the monotherapy with alpha-lipoic acid or Benfotiamine.

Untangling a case of painfulneuropathy

A 51-year-old right-handed man developed a sensory neuropathy with the sensation of walking on pebbles, and tight cramping pains in the calves requiring amitriptyline. Two months later, he became unsteady...

Fas-mediated apoptosis and peripheral polyneuropathy in type 2 diabetes mellitus

ObjectiveTo evaluate the role of soluble Fas (sFas) and soluble Fas ligand (sFasL) in the pathogenesis of distal symmetrical polyneuropathy (DSPN) in patients with type 2 diabetes mellitus, and to analyze the relationship between these apoptotic markers with clinical parameters and electrophysiologic profile of DSPN, as well as with different diabetic factors among those patients.Patients and methodsThe study included 60 Egyptians with type 2 diabetes mellitus. All patients were evaluated clinically for DSPN by using Michigan Neuropathy Screening Instrument. Electrophysiological diagnosis of DSPN was based on the criteria suggested by the European Standardized Telematic tool to Evaluate Electrodiagnostic Methods group. Diabetic patients were divided into two groups according to the electrophysiological findings: group A included patients with DSPN (N=42), and group B included patients without DSPN (N=18). The severity of DSPN among group A patients was assessed clinically using Toronto Clinical Neuropathy Score and electrophysiologically by the severity score proposed by Hidasi and colleagues. The study also included 30 healthy volunteers as a control group. Serum levels of sFas and sFasL were assessed in all the studied groups.ResultsSerum level of sFas was significantly elevated in diabetic patients with DSPN compared with diabetics without DSPN and nondiabetic control (P=0.029 and 0.000). Receiver operating characteristic (ROC) curve analysis detected that sFas was statistically significant in discriminating between diabetic patients with DSPN from those patients without DSPN with an accuracy of 66%. The cutoff point that has the highest sensitivity (61%) and specificity (62%) was 33.3 ng/ml. Serum level of sFas showed a positive significant correlation with the electrophysiological severity of DSPN (P=0.020). Serum level of sFasL did not show statistically significant difference between all the studied groups.ConclusionFas-mediated apoptosis has an important role in the development of diabetic DSPN and is correlated with its electrophysiological severity.

Diabetic Neuropathy.

Diabetes mellitus is becoming increasingly common worldwide. As this occurs, there will be an increase in the prevalence of known comorbidities from this disorder of glucose metabolism. One of the most disabling adverse comorbidities is diabetic neuropathy. The most common neuropathic manifestation is distal symmetric polyneuropathy, which can lead to sensory disturbances, including diminished protective sense, making patients prone to foot injuries. However, focal, multifocal, and autonomic neuropathies are also common. Diabetic nerve pain and Charcot osteoarthropathy are advanced neuropathic conditions that portend a severe deterioration in quality of life. To combat these symptoms, along with glycemic control and establishment of health care systems to educate and support patients with the complexities of diabetes, there are pharmacologic remedies to ameliorate the neurologic symptoms. Several guidelines and review boards generally recommend the use of tricyclic antidepressants, serotonin/norepinephrine-reuptake inhibitors, α-2-delta ligands, and anticonvulsants as medications to improve painful diabetic neuropathy and quality of life.

Clinician-rated measures for distal symmetrical axonal polyneuropathy: ACTTION systematic review.

Distal symmetrical axonal polyneuropathy (DSP) is due to injury to peripheral sensory, motor, and autonomic nerve fibers, resulting in distal predominant sensory loss, pain, and gait instability. DSP occurs as a complication of multiple medical conditions including diabetes or HIV, or following exposure to various toxins such as chemotherapy. It affects at least 10% of the United States population. Few treatments for DSP are approved by regulatory agencies. Reliable and responsive outcome measures are integral to developing new DSP treatments. Multiple clinician-rated measures that incorporate neuropathy signs exist, however, it is not clear which of these measures performs best for various DSP phenotypes. This systematic review summarizes the content of 18 published measures of DSP identified using PubMed and from personal archives of the authors. The relative percentage of scoring dedicated to motor, reflex, large and small fiber sensory, and autonomic domains varied considerably among measures. The most common neurologic examination items included in the scales were (1) vibration perception (n = 18, 100%), (2) reflexes (n = 16, 89%), (3) pinprick perception (n = 14, 78%), (4) muscle strength (n = 11, 61%), (5) touch-pressure perception (n = 9, 50%), and (6) joint position perception (n = 8, 44%). This review can be used to inform decisions regarding which of the available clinician-rated sign outcome measures would be most appropriate for use in a particular DSP population, based on the domains most affected by that neuropathy or on the domains most likely to be affected by a particular experimental therapy.

Comparative Analysis of Efficacy and Safety of Gabapentin Vs Amitriptyline in Patients of Peripheral Neuropathic Pain in Case of Diabetes Mellitus

Introduction: Diabetes mellitus frequently leads to development of peripheral neuropathies in almost 30-50% of patients and the most common type of neuropathy associated with this condition is Distal Symmetric Sensorimotor Polyneuropathy (DSPN). Gabapentin and Amitriptyline are two drugs frequently used for the treatment of neuropathic pain associated with type 2 diabetes. Aim of the study: The aim of this study was to compare efficacy and safety of Gabapentin and Amitriptyline in subjects of Type 2 diabetes mellitus with peripheral neuropathic pain. Material and Methods: A prospective, open, randomized, parallel group, comparative study was conducted in 60 patients coming to Department of Medicine, Rajindra Hospital attached to Government Medical College Patiala, to evaluate the efficacy and safety of Gabapentin and Amitriptyline in patients with diabetic peripheral neuropathic pain. The patients fulfilling the inclusion criteria were included in the study after taking written informed consent. The patients were divided into two groups of 30 cases each by simple randomization. Group I patients received Gabapentin 300 mg HS by oral route. Group II patients received Amitriptyline 25 mg HS by oral route. Therapeutic efficacy of both drugs, by using Michigan Neuropathy Screening Instrument (MNSI) was compared at the baseline and at the end of 4 months. Any adverse drug reactions of the respective drug observed in patient were also noted. All the observations thus made were statistically analysed using appropriate tests. Results: Baseline characteristics of the patients in two groups such as age, sex, duration of diabetes were similar (p>0.05). The mean age in group I and group II were 53.40±8.41 years and 57.17±8.55 years, respectively. There was statistically significant reduction in mean MNSI scores in questionnaire part and physical examination part in both the groups. Also, there was statistically significant difference between the two drugs in reducing mean MNSI score. Mean difference between two drugs in reducing MNSI score in history part (0.77±0.16, p<0.01) and physical examination part (0.75±0.19, p<0.01) favoured Gabapentin. No. of adverse drug reactions reported were significantly higher in Amitriptyline group, p value (<0.05) for the difference in ADRs between two drugs was statistically significant. Conclusion: In this study, we concluded that both drugs lead to improvement in signs and symptoms of diabetic neuropathy. Gabapentin was proved to be more efficacious than Amitriptyline. Gabapentin treated patient’s mean MNSI score at the study end point was significantly lower as compared to the Amitriptyline treated patient’s end-point score. Adverse drug reactions reported in our study were mild in both the groups and a significantly higher number of adverse effects were reported in the amitriptyline group. Dizziness and somnolence were two most commonly reported adverse drug reactions.

Antiallodynic Effects of Cannabinoid Receptor 2 (CB2R) Agonists on Retrovirus Infection-Induced Neuropathic Pain.

The most common neurological complication in patients receiving successful combination antiretroviral therapy (cART) is peripheral neuropathic pain. Data show that distal symmetric polyneuropathy (DSP) also develops along with murine acquired immunodeficiency syndrome (MAIDS) after infection with the LP-BM5 murine retrovirus mixture. Links between cannabinoid receptor 2 (CB2R) and peripheral neuropathy have been established in animal models using nerve transection, chemotherapy-induced pain, and various other stimuli. Diverse types of neuropathic pain respond differently to standard drug intervention, and little is currently known regarding the effects of modulation through CB2Rs. In this study, we evaluated whether treatment with the exogenous synthetic CB2R agonists JWH015, JWH133, Gp1a, and HU308 controls neuropathic pain and neuroinflammation in animals with chronic retroviral infection. Hind-paw mechanical hypersensitivity in CB2R agonist-treated versus untreated animals was assessed using the MouseMet electronic von Frey system. Multicolor flow cytometry was used to determine the effects of CB2R agonists on macrophage activation and T-lymphocyte infiltration into dorsal root ganglia (DRG) and lumbar spinal cord (LSC). Results demonstrated that, following weekly intraperitoneal injections starting at 5 wk p.i., JWH015, JWH133, and Gp1a, but not HU308 (5 mg/kg), significantly ameliorated allodynia when assessed 2 h after ligand injection. However, these same agonists (2x/wk) did not display antiallodynic effects when mechanical sensitivity was assessed 24 h after ligand injection. Infection-induced macrophage activation and T-cell infiltration into the DRG and LSC were observed at 12 wk p.i., but this neuroinflammation was not affected by treatment with any CB2R agonist. Activation of JAK/STAT3 has been shown to contribute to development of neuropathic pain in the LSC and pretreatment of primary murine microglia (2 h) with JWH015-, JWH133-, or Gp1a-blocked IFN-gamma-induced phosphorylation of STAT1 and STAT3. Taken together, these data show that CB2R agonists demonstrate acute, but not long-term, antiallodynic effects on retrovirus infection-induced neuropathic pain.

Bilateral nerve conduction studies in the evaluation of distal symmetric polyneuropathy.

Nerve conduction studies are used to aid in the diagnosis of distal symmetric polyneuropathy (DSP). It is unclear whether bilateral lower extremity nerve conduction studies (NCS) are needed when evaluating for suspected DSP. We retrospectively analyzed NCS from patients who presented to the University of Michigan electromyography laboratory between July 1, 2016 and December 31, 2017 with symptoms of DSP to assess agreement and correlation between left and right lower extremity NCS parameters. We found significant agreement between abnormalities in individual nerve parameters of the left and right lower extremities of 105 patients, most notably in the sural nerve. In the 53 patients with bilateral sural, peroneal, and tibial studies, there was also significant agreement between whether the left and right met electrodiagnostic criteria for DSP (κ = 0.77). Bilateral lower extremity NCS may have limited utility in the evaluation of suspected DSP. Muscle Nerve, 2019.

THE ASSESSMENT OF MICRO AND MACRO VASCULAR COMPLICATIONS IN PEOPLE WITH SYSTEMIC HYPERTENSION ASSOCIATING UNCONTROLLED TYPE 2 DIABETES

Objective: to assess the percentage of complications in patients with systemic hypertension associating uncontrolled type 2 diabetes Design and method: SH diabetic patients (SH for more than 8 years) with T2DM duration at least 5 years. SH was diagnosed previous to DM. The subjects were assessed between January 2016 and end October 2018 in a cross sectional study. All the patients were evaluated by clinical examination (including exam for polyneuropathy), paraclinical exams (HbA1c in the last 3 months, fasting plasma glucose - FPG, glomerular filtration rate), cardio and ophthalmological examination (ECG, echocardiography, ocular fundus). Results: 166 adult T2DM patients, 46% male, mean age 59.2 years, mean duration of T2DM 7.6(3.9) years, mean duration of SH 9.3 years. average HbA1c 8.5 %, FPG: 224.9 mg/dl were included. Patients were treated for DM with metformin (88.5%), sulphonilureas (81%), and alpha glucosidase inhibitors (9.4%) in monotherapy or combination. The blood pressure was well controlled in all patients. The microvascular complication of these T2DM patients were: retinopathy in 18.5% of the patients, chronic kidney diseases (declining glomerular filtration rate) in 10.8% and neuropathy (defined as distal symmetrical polyneuropathy) in 57.4%. 10.6% of the patients had previous stroke, 9.4% previous myocardial infarction, 42.9% ischemic heart disease (ECG changes in almost 64% of them), 9.8% heart failure, and 16.4% peripheral arterial disease. Conclusions: : It is well known that most of the complications in diabetes arise from damages to small blood vessels and narrowing of large arteries (atherosclerosis) due to chronic hyperglycemia and hypoglycemic episodes. Our study confirm the observation that microvascular complications affect more diabetic patients than macrovascular complications. The most frequent microvascular complication was polyneuropathy due to neuronal damage cause by vasa vasorum injury. It is absolutely necessary to screen more often these patients and to maintain their glycemic control on long term, avoiding also hypoglycemic episodes.

Prevalence and Determinants of Painful and Painless Neuropathy in Type 1 Diabetes Mellitus.

Aims: To evaluate (1) the prevalence of diabetic distal symmetrical sensory–motor polyneuropathy (DSPN) and painful DSPN among patients with type 1 diabetes mellitus (DM1) aged over 18 years and (2) the determinant factors of neuropathy and pain in those patients.Materials and Methods: An epidemiological, cross-sectional, observational study was performed; 330,386 people were included, and a total of 444 people were diagnosed with DM1. After exclusion of possible confounders, 360 patients were assessed for painless and painful DSPNs using neurological examination and questionnaires for neuropathy and pain. Odds ratio (OR) and confidence intervals (95% CI) were estimated using multinomial logistic regression models. The analysis was based on a framework with four conceptual levels that consider feasible pathways between several risk factors: (1) socio-demographic factors and diabetes duration, (2) patient habits, (3) co-morbidities, and (4) metabolic factors and disease complications.Results: The prevalence of DSPN and painful DSPN were 42.8 and 18.9%, respectively. Diabetes duration was positively associated with painful (OR = 1.107, 95% CI: 1.107–1.139) and painless DSPN (OR = 1.069, 95% CI: 1.043–1.096). Education level was negatively associated with painful DSPN (OR = 0.889, 95% CI: 0.826–0.957). Sex (female) was positively associated only with painless DSPN (OR = 1.769, 95% CI: 1.007–3.107). Being a current or former smoker was positively associated only with painless DSPN (OR = 1.940, 95% CI: 1.069–3.518). Hypertension was positively associated with painful DSPN (OR = 2.474, 95% CI: 1.110–5.512) and painless DSPN (OR = 2.565, 95% CI: 1.252–5.256). Glycated hemoglobin (HbA1c) was positively associated only with painless DSPN (OR = 1.193, 95% CI: 1.018–1.399).Conclusions: Diabetes duration and hypertension have a direct impact on the development of painful and painless DSPN. However, female sex and HbA1c have a direct effect only on the development of painless DSPN, and education level has an indirect effect on the development of painful DSPN. Therefore, it can be concluded that different etiological factors have different contributions to the development of neuropathy and pain.