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Neuropathy is a frequent complication of diabetes and is most commonly manifest as a sensory neuropathy involving the feet. Although biochemical and experimental animal studies suggest a direct link between the hyperglycemia of diabetes and the development of neuropathy, this link is unproven in humans. Evaluation for neuropathy can usually be accomplished clinically, but in selected cases electromyography is helpful. Other testing methods have a well-defined research note, but their clinical utility is less well established. Treatment of diabetic neuropathy is empirical. Better blood glucose control is attempted and a variety of medications are used to treat the symptoms. Promising treatment methods are being investigated, but none is of proven benefit.
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PMID:Neurologic evaluation and treatment of the diabetic foot. 295 44

The relationship between abnormal peripheral nerve electrophysiology and abnormal cardiovascular autonomic function has been studied in four groups of diabetic subjects, comparable with regard to age, duration, and type of diabetes. Thirty-three had no symptoms of neuropathy, 28 had newly developed painful neuropathy, 24 had chronic painful neuropathy, and 21 had painless neuropathy with associated recurrent foot ulcers. In all three symptomatic groups, electrophysiology and autonomic function were more abnormal than in asymptomatic diabetic subjects. There was a significant overall relationship between peripheral nerve (electrophysiologic) and autonomic (cardiovascular reflex) dysfunction. However, when considered by groups, the degree of cardiovascular reflex abnormality was similar in the three symptomatic groups, whereas electrophysiology was appreciably worse in the foot ulcer group than in patients with painful neuropathy. Thus, patients with painful neuropathy had a higher ratio of autonomic (small fiber) abnormality to electrophysiologic (large fiber) abnormality. By contrast, foot ulceration was associated with the worst electrophysiologic (large fiber) abnormality. Heavier alcohol consumption and more severe retinopathy were also related to foot ulceration. In diabetic subjects with symmetrical sensory neuropathy, the relationship between large fiber and small fiber damage is not uniform. We conclude that there may be different etiologic influences on large and small fiber neuropathy in diabetic subjects and that the predominant type of fiber damage may determine the form of the presenting clinical syndrome.
Diabetes 1986 Feb
PMID:Variable relationship between peripheral somatic and autonomic neuropathy in patients with different syndromes of diabetic polyneuropathy. 300 87

Normal healthy subjects show a reflex rise in precapillary resistance in the skin of the foot when they rise from lying to standing. To investigate the integrity of this reflex in patients with diabetes mellitus blood flow in the plantar region of the big toe was measured, using a laser Doppler flowmeter. The responses of diabetic patients with and without peripheral sensory neuropathy and healthy control subjects matched for age and sex were studied, with the foot at heart level and the foot passively lowered to 50 cm below the heart. In normal subjects mean blood flow recorded during the third to fourth minute of dependency fell to 18.1 (SD 11.9)% of the preceding resting flow determined with the foot at heart level. In the diabetic patients without neuropathy blood flow fell to 28.9 (18.6)% of the preceding resting flow. In the diabetic patients with neuropathy blood flow fell to 53.5 (23.7)% of the preceding resting flow, which was significantly different from the value achieved by the diabetics without neuropathy (p less than 0.02) and the healthy controls (p less than 0.002). Six normal subjects were indirectly heated to release sympathetic tone and achieve the same mean skin temperature of the foot as the diabetic patients with neuropathy, and blood flow fell to 38.7 (24.3)% of the preceding resting flow, a value not significantly different from the response seen in the patients with neuropathy. These findings suggest that the postural control of blood flow in the foot is disturbed in patients with diabetic neuropathy, and this disturbance is compatible with a loss of sympathetic vascular tone. The resultant hyperperfusion on dependency may account for the oedema seen in some patients with neuropathy and may also act as a stimulus for the thickening of capillary basement membranes.
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PMID:Blood flow in the skin of the foot related to posture in diabetes mellitus. 308 Jan 2

The water content of the sural nerve of diabetic patients was quantitatively defined by magnetic resonance proton imaging as a putative reflection of activity of the aldose-reductase pathway. Thirty-nine patients were evaluated, comparing group A, symptomatic diabetic men with sensory neuropathy; group B, similarly symptomatic diabetic men treated with aldose-reductase inhibition; group C, neurologically asymptomatic diabetic men; and group D, control nondiabetic men. Marked increase in hydration of the sural nerve was seen in more than half of the symptomatic diabetic patients. Two of 11 neurologically asymptomatic diabetics had increased nerve hydration, suggesting a presymptomatic alteration of the nerve. Symptomatic diabetics treated with aldose-reductase inhibitors had normal nerve water levels. Increased level of peripheral nerve water represents a new finding in diabetes mellitus. It seems to be related to aldose-reductase activity, involved in the development of neuropathy, and similar to events that occur in other target tissue in human diabetes.
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PMID:Diabetic neuropathy. Structural analysis of nerve hydration by magnetic resonance spectroscopy. 314 35

A previous investigation of IST in Rochester, Minnesota, from 1960 through 1979 yielded an incidence of 1.1/100,000 person-years. The rate in women was almost three times higher than that in men. Thyroid disorders, other endocrine disorders, right-hand preference, symptomatic ovarian cysts, other disorders of the female genito-reproductive system, emotional depression, cerebral aneurysm, and family history of diabetes mellitus were common. In 347 cases of IST personally evaluated (151 seen between 1969-1971, a sample of 49 seen in 1978, and 147 other cases evaluated in 1985) the female-to-male ratio was 1.6:1. The mean age at onset was 43.5 years for women and 42 years for men, and the distributions of age at onset were virtually identical for the two sexes. Thyroid disorder was prevalent in all three referral patients samples. The increased frequency of thyroid disorder was due to a high overall frequency in female patients, 28.4% (95% confidence interval, 22.3-34.4%). Thyroid disorders were 4.5 times more frequent in women with IST than in men with IST. In the control population of 61 patients with peripheral sensory neuropathy, in which sex distribution and mean age at onset of symptoms were comparable to those in IST patients, the incidence of thyroid disorder overall was only 8.2% (in women, 6.6%). Only 12 of the 347 referral IST patients were non-right-handers. Five of these 12 were female patients (2.3% of the 215 women; 95% confidence interval, 0.3-4.3%), significantly below the anticipated frequency (10%) or the observed frequency (10% and 15.16%) in two attempted control populations. Light eyes seem to be unusually common in IST patients, as are personal and family histories of essential tremor. These results may reflect shared biologic risk factors which relate age, gender or estradiol/testosterone function, cerebral anatomic and chemical lateralization, endocrinopathy including elevated thyrotropin levels, immune status, emotional depression, common cells of origin in the neural crest, race, and familial occurrence to IST and other focal dystonias and essential tremor.
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PMID:Spasmodic torticollis: clinical and biologic features and their implications for focal dystonia. 340 May 4

Risk factors for vibratory perception threshold abnormalities were studied in 200 diabetic patients between the ages of 21 and 70 years and 62 control subjects of similar age. Vibratory perception (measured with the Biothesiometer) was absent over one or both halluces in 18 percent of the patients. In a stepwise multiple logistic regression analysis, height was the variable most strongly associated with absent vibratory perception (coefficient +/- SE, 0.501 +/- 0.097/inch; p less than 0.0001). Duration of diabetes (p less than 0.001), age (p less than 0.05), and ethanol use (p less than 0.05) were also associated. The prevalence of absent vibratory perception in the lower, middle, and upper thirds of the height distribution was 0.05, 0.08, and 0.40, respectively. Among the control subjects, there was no association of vibratory perception with either height or ethanol use. These data strongly suggest that body stature is a major risk factor for diabetic sensory neuropathy.
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PMID:Body stature as a risk factor for diabetic sensory neuropathy. 372 1

The prevalence of diabetic complications is reported from a cross-sectional study of rural diabetic subjects in Western Australia. Logistic-regression analysis has been used to discover potential risk factors associated with each complication. A distinction has been made between time-related variables (age, age at diagnosis, duration of diabetes) and other risk variables. We have attempted to identify the major time-related risk variables for each complication and then examined the effect of other risk variables after accounting for the major time-related variables. The important time-related variables were found to be duration of diabetes for retinopathy, age for macrovascular disease, duration and age at diagnosis of diabetes for sensory neuropathy, and age for renal impairment. When matched on these important time-related variables, the overall prevalences of complications for insulin-dependent (IDDM) compared with non-insulin-dependent (NIDDM) diabetic patients were essentially the same. An exception is renal impairment, for which IDDM patients had a higher prevalence than did NIDDM patients of the same age. After allowing for time-related variables, the analysis also demonstrates positive independent associations between diabetic control (glycosylated hemoglobin) and retinopathy and between diabetic control and macrovascular disease. Plasma cholesterol (positively) and high-density lipoprotein cholesterol (negatively) were related independently to both macrovascular disease and renal impairment. Very few differences in the risk-factor profiles for complications were found for IDDM compared with NIDDM patients after allowing for time-related variables.
Diabetes 1986 Dec
PMID:Prevalence of diabetic complications in relation to risk factors. 377 Mar 11

This report summarizes the major design features, methods, and baseline characteristics of patients enrolled in a Veterans Administration Cooperative Study. In eleven V.A. centers, 231 male diabetic patients who had either a recent amputation for gangrene (N = 207) or active gangrene (N = 24) were randomly assigned to a group which received aspirin (325 mg t.i.d.) plus dipyridamole (75 mg t.i.d.) (N = 110) or two placeboes t.i.d. (N = 121). Major end point were vascular death and amputation of the opposite extremity for gangrene. Forty-one percent of the 563 patients screened were enrolled during a 39 month period. Enrollment errors were found in 8.7%. Historically, the two groups were well matched regarding the following variables: age, duration of diabetes, insulin therapy, previous oral agent therapy, hypertension, myocardial infarction, congestive heart failure, renal disease, sensory neuropathy, and smoking. The drug therapy group had an increased frequency of a history of cerebrovascular disease (19% vs 7%, p = 0.01). The groups were well matched regarding amputation site, obesity, extent of lower extremity vascular disease, retinopathy, and neuropathy upon examination. Their baseline fasting values of glucose, cholesterol, triglycerides, and creatinine were also comparable. We conclude that this study should provide definitive data on the efficacy of these antiplatelet agents in preventing further vascular disease in this patient group. It should also provide new prospective data on the natural history of vascular disease, and the association of vascular risk factors with subsequent vascular events in this patient population.
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PMID:V.A. Cooperative Study on antiplatelet agents in diabetic patients after amputation for gangrene: III. Definitions and review of design and baseline characteristics. 390 83

A Specialist Clinic was commenced in August 1983, from the Medical School at Universiti Sains Malaysia, Penang, Malaysia to assess: 1) the present control and 2) the incidence of complications in a diabetic population already receiving primary health care at Penang General Hospital. The ethnic groups among the diabetics were Chinese (39%), Malays (26%) and Indian (35%). There was a greater percentage of Indians than would be expected from the ethnic distribution of the population of Penang. The results of the first 100 (43 males and 57 females) non-insulin dependent diabetic patients are reviewed. The mean age was 54 years, 41% had relatives with diabetes, and all were taking oral agents. The diet comprehension and compliance were poor. 65% of the group, 54% of males and 75% of females were obese. The mean blood glucose was 11 m.mols/l (fasting) and 12.8 m.mols/1 (2 hours post prandial). The complications seen in the 100 diabetics were: albuminurea 41, skin infection 37, cataracts 35, hypertension 32, peripheral sensory neuropathy 32, retinopathy 22, ischaemic heart disease 19, autonomic neuropathy 10, impaired renal function 4 (urea or creatinine elevated), foot ulcer 2 and gangrene 1. Urinalysis for glucose at the Clinic showed very little correlation with blood glucose at the same time. Nine out of 43 males admitted to impotence on questioning. Comparisons of findings in Penang were made with recent studies in Singapore and Hong Kong.
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PMID:Findings among 100 type 2 diabetics in a clinic in Penang, Malaysia, 1983-84. 403 86

The vibratory perception threshold, an indicator of sensory neuropathy, was measured in young type I diabetic patients (N = 55) and nondiabetic control subjects (N = 34) of similar age. Values were significantly higher in the diabetic patients (P less than 0.01), and 20% had values greater than that of any control subject. This difference was most marked among those postpubertal and persisted with allowances for age and gender in an analysis of covariance. Although the vibratory perception threshold was not related to hemoglobin A1 in younger diabetic patients (Tanner stage less than 5), there was a highly significant positive relationship in postpubertal patients (r = 0.72, P less than 0.001). There were also associations of the vibratory perception threshold with age in diabetic and control subjects (r = 0.44 and r = 0.43, respectively, P less than 0.01 for both) and with diabetes duration (r = 0.36, P less than 0.01). These data indicate that vibratory perception threshold abnormalities occur early in the course of type I diabetes mellitus; however, they are more evident in those patients who are postpubertal. In addition, they suggest that the association between the vibratory perception threshold and glycemia may be modified by developmental factors.
Diabetes Care
PMID:The vibratory perception threshold in young diabetic patients: associations with glycemia and puberty. 407 49


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