Effect of Low Level Laser Therapy on serum vitamin D and magnesium levels in patients with diabetic peripheral neuropathy – A pilot study

BackgroundDiabetic Peripheral neuropathy (DPN) is the most distressing complication of diabetic population leading to loss of sensation, pain, and amputation. Low-level laser therapy (LLLT) has been used to manage nerve injuries as it holds the potential to induce a biostimulatory effect with no side effects. Hence we planned to study the biochemical effect and therapeutic outcomes of LLLT on patients with painful diabetic peripheral neuropathy as a preliminary work.Materials and methodsPre-posttest analysis was done on 40 patients diagnosed with DPN confirmed using 10 g Monofilament test and Michigan Neuropathy Screening Instrument (MNSI). Vibration sensation and pain measured by Vibration perception threshold (VPT) and Numeric pain rating scale (NPRS). All patients were given LLLT (3.1 J/cm²) on plantar and dorsal of the foot for 10 days. Serum samples were collected at baseline and 4 weeks after LLLT to estimate Vitamin D and Magnesium and compared the results.ResultsThere was a significant increase in Vitamin D and Magnesium levels after LLLT. We observed a considerable improvement in the quality of life after LLLT demonstrated by a decrease in VPT and MNSI and a reduction in NPRS in DPN patients.ConclusionIn this study, we found that LLLT improved the QL and hence may be a useful therapeutic option in treating peripheral neuropathic pain in type 2 diabetic patients. The progress in the serum Magnesium and Vit. D levels were proportional to the QL and may be a good indicator of the prognosis of DPN after LLLT.     

Fit for purpose? Footwear for patients with and without diabetic peripheral neuropathy: A cross-sectional study

AimThis paper determines whether patients with and without Diabetic Peripheral Neuropathy use suitable footwear, taking into account that these persons are subject to a significant loss of sensitivity in the feet.MethodsCross-sectional observational study was conducted of 108 participants with diabetes mellitus. Inclusion criteria were at least five years’ progression of diabetes, the ability to walk unaided and no distal amputation of the foot. The presence of DPN was evaluated according to the criteria of the International Working Group on the Diabetic Foot. Foot length was measured using a Brannock® device and internal shoe length was determined using a CEGI® pedometer.ResultsIn relation to adjustment, 21.6% of the shoes examined had no type of closure. The most common form of closure was laces, which were used in 32.4% of the shoes. 92.5% of footwear had internal seams. No significant relationship was found between the presence or otherwise of DPN and the use of appropriate shoe closure (p = 0.304), recommended heel height (p = 0.18), leather material (p = 0.77) and absence of internal seams (p = 0.759).ConclusionsThe majority of our participants living with DPN do not wear fitting shoes. Therefore, it is advisable to evaluate their use of footwear, both in primary health care and in podiatry clinics, to forestall potential complications.     

Screening and diagnosis of diabetic polyneuropathy in clinical practice: A survey among German physicians (PROTECT Study Survey)

AimsWe sought to obtain detailed information on the procedures and appraisal of screening for and diagnosing diabetic sensorimotor polyneuropathy (DSPN) in clinical practice.MethodsThis cross-sectional survey included 574 physicians from 13 federal states across Germany who responded to a tripartite questionnaire.ResultsThe vast majority of the respondents reported to screen for DSPN at least once a year (87 %), while 65 % reported to examine the feet of DSPN patients at least twice a year. However, only 28 % and 20 % of the respondents used questionnaires and scores to assess the severity of neuropathic symptoms and signs, respectively. The rates of participants reporting that they do not use a standardized testing procedure were 58 % for pressure sensation, 62 % for pain sensation, and 54 % for thermal sensation. The rates of respondents reporting that they do not deploy a standardized assessment were 41 % for vibration sensation, 73 % for pressure sensation, 77 % for pain sensation, and 66 % for thermal sensation. Half of the physicians oriented themselves towards clinical guidelines when diagnosing DSPN.ConclusionsDespite relatively high screening rates, the willingness to implement both standardized testing procedures and assessment and to follow guidelines is low among physicians when screening for and clinically diagnosing DSPN.     

Pulsatility index is better than ankle-brachial doppler index for non-invasive detection of critical limb ischaemia in diabetes

BACKGROUND: Diabetic polyneuropathy of the feet and legs obscures the diagnosis of critical limb ischaemia (CLI) because of lack of pain sensation. Hence, the Fontaine classification does not apply to these patients. Furthermore, many of them will exhibit medial arterial calcification, which invalidates the application of sphygmomanometry. This study was done to evaluate the pulsatility index (P1) assessed at the ankle arteries by colour Doppler ultrasonography as a non-invasive method to diagnose CLI in diabetic polyneuropathy. PATIENTS AND METHODS: 140 legs of 106 diabetic patients were studied who presented with polyneuropathy and painlessness of the feet; of these, 117 feet displayed an ulcer or gangrene. CLI was defined as the need for arterial revascularisation, as indicated by the physicians in charge on the basis of a) a foot lesion Wagner grade 1-5, and b) a positive arteriography. All patients were subjected to 4 vascular assessment techniques: digital subtraction arteriography, ankle-brachial Doppler index, systolic ankle blood pressure, and PI. RESULTS: Of the 140 legs, 61 (44%) were affected by CLI, and 76 (54%) by medial arterial calcification. A PI < 1.2 indicated CLI with a sensitivity of 0.87 and a specificity of 0.62. The sensitivity and specificity of ankle-brachial index < 0.9, and of systolic ankle pressure < 70 mm Hg to predict CLI was 0.71 and 0.42, and 0.30 and 0.89, respectively. CONCLUSIONS: The pulsatility index is a better noninvasive technique than the ankle-brachial Doppler index or the systolic ankle pressure to assess critical limb ischaemia in diabetic polyneuropathy. A pulsatility index < 1.2 at the ankle arteries is a reliable criterion for diagnosis of CLI in diabetic patients with polyneuropathy.     

Effect of photobiomodulation on serum neuron specific enolase (NSE) among patients with diabetic peripheral neuropathy – A pilot study

Background and aimPhotobiomodulation is an emerging therapy for Diabetic peripheral neuropathy (DPN) of which the management is still a dilemma for clinicians. Elevated Neuron Specific Enolase (NSE) is associated with neuropathy. We aimed this study to assess the effect of Low Level Laser Therapy (LLLT) on Serum Neuron Specific Enolase in Type II Diabetes Mellitus patients with DPN.MethodologyPre post interventional study was done on 50 patients with DPN. DPN was confirmed using 10g Monofilament test, Vibration perception threshold (VPT) and Michigan Neuropathy Screening Instrument. All patients were provided with LLLT for 9 min on dorsal and plantar of foot with a dosage of 3.1 J/cm ² for 10 days. A blood sample was collected at baseline and 4 weeks after LLLT for NSE estimation.ResultA significant reduction in serum NSE levels (0.006) after 4 weeks of laser therapy was observed in 42 patients when compared with baseline. A significant reduction in the vibration perception threshold (p = 0.003) and Numeric pain rating scale (p = 0.004) were observed.ConclusionIn this pilot study, we have assessed the effect of LLLT on serum NSE levels among patients with DPN and showed improved quality of life and decrease in serum NSE levels. These findings should be investigated in larger trials.     

One‐stop microvascular screening service: an effective model for the early detection of diabetic peripheral neuropathy and the high‐risk foot

Aims

To evaluate the feasibility of a one‐stop microvascular screening service for the early diagnosis of diabetic distal symmetrical polyneuropathy, painful distal symmetrical polyneuropathy and the at‐risk diabetic foot.

Methods

People with diabetes attending retinal screening in hospital and community settings had their feet examined by a podiatrist. Assessment included: Toronto Clinical Neuropathy Score evaluation; a 10‐g monofilament test; and two validated, objective and quick measures of neuropathy obtained using the point‐of‐care devices ‘DPN‐Check’, a hand‐held device that measures sural nerve conduction velocity and amplitude, and ‘Sudoscan’, a device that measures sudomotor function. The diagnostic utility of these devices was assessed against the Toronto Clinical Neuropathy Score as the ‘gold standard’.

Results

A total of 236 consecutive people attending the retinal screening service, 18.9% of whom had never previously had their feet examined, were evaluated. The prevalence of distal symmetrical polyneuropathy, assessed using the Toronto Clinical Neuropathy Score, was 30.9%, and was underestimated by 10‐g monofilament test (14.4%). The prevalence of distal symmetrical polyneuropathy using DPN‐check was 51.5% (84.3% sensitivity, 68.3% specificity), 38.2% using Sudoscan foot electrochemical skin conductance (77.4% sensitivity, 68.3% specificity), and 61.9% using abnormality in either of the results (93.2% sensitivity, 52.8% specificity). The results of both devices correlated with Toronto Clinical Neuropathy Score (P<0.001). A new diagnosis of painful distal symmetrical polyneuropathy was made in 59 participants (25%), and 56.6% had moderate‐ or high‐risk foot. Participants rated the service very highly.

Conclusions

Combined, eye, foot and renal screening is feasible, has a high uptake, reduces clinic visits, and identifies painful distal symmetrical polyneuropathy and the at‐risk foot. Combined large‐ and small‐nerve‐fibre assessment using non‐invasive, quantitative and quick point‐of‐care devices may be an effective model for the early diagnosis of distal symmetrical polyneuropathy.     

The potential of transdermal nitric oxide treatment for diabetic peripheral neuropathy and diabetic foot ulcers

The Center for Disease Control (CDC) estimates that 29 million Americans have diabetes, and 70% of diabetic patients develop diabetic peripheral neuropathy [1,2]. Up to 27% of the direct medical cost of diabetes may be attributed to DPN [3]. A 2013 article from the American Diabetes Association reported a $176 billion direct medical cost of diabetes in 2012 [4]. DPN patients often suffer from shooting and burning pain in their distal limbs and a severe loss of sensation. Diabetic foot ulcers, infections, and amputations may follow. Currently available treatments: tricyclic antidepressants, anticonvulsants such as gabapentin and pregabalin, serotonin and norepinephrine reuptake inhibitor, duloxetine, topical 5% lidocaine (applied to the most painful area) can manage painful symptoms but do not address the underlying pathologies of DPN and diabetic wound ulcers. A combination of pain-reducing medications can provide relief when individual medications fail, and opioids such as tramadol and oxycodone may be administered with these medications to reduce pain [5]. Due to the prevalence of diabetes, DPN, and diabetic foot ulcers, and because of the lack of available effective treatments to directly address the pathology contributing to these conditions, novel treatments are being sought. Our hypothesis is that a deficiency of nitric oxide synthase in diabetic patients leads to a lack of vascularization of the peripheral nerves, which causes DPN; and this could be treated with vasodilators such as nitric oxide. In this paper, the mechanisms of DPN are reviewed and analyzed to elucidate the potential of a transdermal nitric oxide application for the treatment of DPN and diabetic wound ulcers by increasing vasodilation.     

Prevalence and impact on quality of life of peripheral neuropathy with or without neuropathic pain in type 1 and type 2 diabetic patients attending hospital outpatients clinics

AimsDiabetic polyneuropathy (DPN) without or with neuropathic pain (DPN-P) is one of the most frequent complications of diabetes. To better delineate their respective prevalences, we conducted a cross-sectional study that included 1111 patients (767 type 2 and 344 type 1 diabetic patients) followed up in diabetic outpatients clinics. The association of DPN and DPN-P with other diabetic complications, the impact on quality of life (QoL) and pain management were also investigated.MethodsTwo validated tools (Neuropen^® and the DN4 questionnaire) were used to diagnose the two conditions. Pain intensity was measured using a visual analogue scale, and participants completed the 12-item Short-Form Health Survey to evaluate the physical and mental components of QoL. Univariate and multivariate models were used for the statistical analyses.ResultsThe prevalence of DPN was 43% (95% CI 40.1–45.9), and was higher in type 2 (50.8%) than in type 1 (25.6%) diabetic patients. The prevalence of DPN-P was 14% (95% CI 12.1–16.2) which, again, was higher in type 2 (17.9%) than in type 1 (5.8%) patients. These prevalences both increased with age and diabetes duration. Nephropathy, obesity, low HDL cholesterol and high triglyceride levels were independently associated with DPN and/or DPN-P. Physical and mental components of QoL were significantly altered by DPN-P, but not DPN. Only half of the DPN-P patients were using analgesic treatment, while 28% were using anticonvulsants or antidepressants.ConclusionDPN and DPN-P are frequent complications of diabetes, especially in type 2, and can be identified with inexpensive and easy-to-use screening tools. Despite its profound impact on QoL, DPN-P remains undertreated.     

Comparative evaluation of four therapeutic regimes in chikungunya arthritis: a prospective randomized parallel-group study

ObjectiveTo evolve a treatment protocol for patients presenting in acute stage of chikungunya by identifying the best regimen from four treatment regimes.Materials and methodsOne hundred and twenty patients diagnosed to have chikungunya arthritis clinically were randomized to one of four groups receiving combinations of aceclofenac (200 mg/day), hydroxychloroquine (400 mg/day) and prednisolone (10 mg/day). Group A received aceclofenac alone; Group B received aceclofenac plus hydroxychloroquine; Group C received aceclofenac and prednisolone and Group D, all three agents. Study medications were given for 6 weeks with weekly follow-ups followed by a 6 weeks drug-free follow-up with visits at week 8 and week 12. Efficacy variables including visual analog scale (VAS) for pain, 20-point modified Barthel index for activities of daily living (ADL) and instrumental activities of daily living (IADL) were assessed and recorded during start of therapy and at all follow-up visits.ResultsSignificant (P < 0.001) reduction in VAS scores and improvement in ADL and IADL scores were observed in groups C and D compared to groups A and B. Between groups A and B there was no significant difference; similarly, between groups C and D also there was no significant difference.ConclusionAddition of prednisolone, and not hydroxychloroquine, to aceclofenac reduced pain and improved the quality of life in patients with acute chikungunya arthritis, compared to aceclofenac given alone in the management of early chikungunya fever. We propose a combination of non-steroidal anti-inflammatory drugs with corticosteroid as the best regimen in treating acute chikungunya cases with arthralgia.     

The utility of Vibratip in accurate identification of loss of protective sensation in the contralateral foot of patients admitted with a diabetic foot ulcer

Background and aimsDiabetic foot ulcer (DFU) is a debilitating complication of type 2 DM. Complexity of foot examination often precludes proper clinical assessment of the foot during routine evaluation. We assessed the utility of novel device, vibratip, both singly and in combination with standard bedside tools for assessment of loss of protective sensation.Methods75 patients admitted with DFU were included in the study. Clinical examination of the contralateral foot was done - temperature perception, vibration, pinprick sensation, Achilles tendon reflex and Neuropathy disability score were assessed. Testing using 10 g Monofilament, Vibratip and biothesiometer were also done. Considering the biothesiometer as the reference standard, three bedside tests (Vibratip, 10 g monofilament and 128 Hz tuning fork) were compared against it singly and in combinations.ResultsWhen compared against biothesiometer, vibratip performed significantly well with a positive predictive value of 90.3% and specificity of 84.2%. Sensitivity, however, was only 50%. On combining bedside tests, the best combination strategy was seen with vibratip and 10 g monofilament, which improved the sensitivity to 62.5%. Combining all three bedside tests further improved sensitivity to 64.3%.ConclusionAll the patients with an at-risk foot may not be identified with vibratip alone. Nevertheless, an abnormal result is almost always associated with loss of protective sensation, and such persons should be suitably educated.LimitationsDue to small size of the study population, it is not possible to generalize the findings to all patients with diabetes mellitus. A larger study would be required to provide more confirmatory findings.     

Non-invasive and quantitative assessment of sudomotor function for peripheral diabetic neuropathy evaluation

Aims

Perturbation of pain sensation is considered one of the major initiating risk factors for diabetic foot ulcer. Sweat dysfunction leading to abnormal skin conditions, including dryness and fissures, can increase foot ulcer risk. The aim of this study was to evaluate Sudoscan™, a new, quick, non-invasive and quantitative method of measuring sudomotor dysfunction as a co-indicator of the severity of diabetic polyneuropathy (DPN).

Methods

A total of 142 diabetic patients (age 62 ± 18 years, diabetes duration 13 ± 14 years, HbA_1c 8.9 ± 2.5%) were measured for vibration perception threshold (VPT), using a biothesiometer, and for sudomotor dysfunction, using electrochemical sweat conductance (ESC) based on the electrochemical reaction between sweat chloride and electrodes in contact with the hands and feet. Retinopathy status was also assessed, as well as reproducibility between two ESC measurements and the effect of glycaemia levels.

Results

ESC measurements in the feet of patients showed a descending trend from 66 ± 17 μS to 43 ± 39 μS, corresponding to an ascending trend in VPT threshold from < 15 V to > 25 V (P = 0.001). Correlation between VPT and ESC was −0.45 (P < 0.0001). Foot ESC was lower in patients with fissures, while VPT was comparable. Both VPT and foot ESC correlated with retinopathy status. Bland–Altman plots indicated good reproducibility between two measurements, and between low and high glycaemia levels.

Conclusion

Sudoscan™ is a reproducible technique with results that are not influenced by blood glucose levels. Sweating status may be a quantitative indicator of the severity of polyneuropathy that may be useful for the early prevention of foot skin lesions.     

Improved foot sensitivity and pain reduction in patients with peripheral neuropathy after treatment with monochromatic infrared photo energy--MIRE

The medical records of 2239 patients (mean age=73 years) with established peripheral neuropathy (PN) were examined to determine whether treatment with MIRE was, in fact, associated with increased foot sensitivity to the Semmes Weinstein monofilament (SWM) 5.07 and a reduction in neuropathic pain. The PN in 1395 of these patients (62%) was due to diabetes. Prior to treatment with MIRE, of the 10 tested sites (5 on each foot), 7.1+/-2.9 were insensitive to the SWM 5.07, and 2078 patients (93%) exhibited loss of protective sensation defined by Medicare as a loss of sensation at two or more sites on either foot. After treatment, the number of insensate sites on both feet decreased to 2.4+/-2.6, an improvement of 66%. Of the 2078 (93%) patients initially presenting with loss of protective sensation, 1106 (53%) no longer had loss of protective sensation after treatment (P<.0001); 1563 patients (70%) also exhibited neuropathic pain in addition to sensory impairment. Prior to treatment with MIRE, pain measured on the 11-point visual analogue scale (VAS) was 7.2+/-2.2 points, despite the use of a variety of pain-relieving therapeutic agents. After treatment with MIRE, pain was reduced by 4.8+/-2.4 points, a 67% reduction. Therefore, MIRE appears to be associated with significant clinical improvement in foot sensation and, simultaneously, a reduction in neuropathic pain in a large cohort of primarily Medicare aged, community-dwelling patients, initially diagnosed with PN. The quality of life associated with these two outcomes cannot be underappreciated.     

Blood flow in the foot,polyneuropathy and foot ulceration in diabetes mellitus

Summary Comparable groups of diabetic patients asymptomatic of neuropathy (Group A), with chronic painful polyneuropathy (Group B) and painless polyneuropathy causing recurrent foot ulceration (Group C) were studied for differences in pedal blood flow, peripheral somatic and autonomic neuropathy and vascular calcification. Blood flow abnormalities detected by doppler waveform analysis, and consistent with reduced peripheral vascular resistance, were found in all three diabetic patient groups. The abnormalities were of similar severity in Group A and B but generally more marked in Group C. Tests of peripheral somatic nerve function became progressively more abnormal from Group A to Group C. Autonomic neuropathy was equally severe in Groups B and C, although mild abnormalities were recorded in diabetic patients asymptomatic of neuropathy. A similar pattern was seen for vascular calcification in the tarsal and metatarsal arteries: marked in both neuropathic groups (B and C) but mild in Group A. It was concluded that abnormal blood flow consistent with reduced peripheral vascular resistance is very common in the feet of diabetic patients whether or not they are symptomatic of neuropathy, and is most severe in those with chronic painless polyneuropathy and recurrent foot ulceration. No clear relationship was found between autonomic nerve dysfunction and the degree of abnormality of blood flow.     

Association of diabetic foot ulcers with chronic vascular diabetic complications in patients with type 2 diabetes

ContextDiabetes mellitus is a common disease which is prevalent globally, presenting with chronic complications and constitutes a major risk to the patient. Diabetic foot ulcers are the single biggest risk factor for non-traumatic lower limb amputations in persons with diabetes. We aimed to screen for the chronic vascular diabetic complications in patients with diabetic foot ulcers (DFUs) and to assess the association of diabetic foot ulcers with these complications in the study group.Subjects and methodsThis cross-sectional study included 180 type 2 diabetic patients (aged 30–70 years) with diabetic foot ulcers who attended the Outpatient Clinic of Diabetes in Alexandria Main University Hospital. Full diabetic foot examination was done to all study subjects. DFUs were assessed using University of Texas Diabetic Wound Classification System. HbA1c, LDL-C, serum creatinine, and urinary albumin creatinine ratio (ACR) were measured for all study subjects. Estimated glomerular filtration rate (eGFR) was calculated using CKD-EPI equation. Fundus examination was done for all study subjects.ResultsThe prevalence of diabetic kidney disease (DKD) and diabetic retinopathy (DR) was 86.1% and 90% respectively among the study group. 86.7% of patients had neuropathic DFUs, 11.1% of them had ischemic DFUs and 2.2% had neuro-ischemic DFUs. Regarding diabetic peripheral neuropathy (DPN) and peripheral arterial disease (PAD) as risk factors for developing DFU, the prevalence of both of them respectively was 82% and 20% among the study group. There was statistically significant association between both DKD, DR and peripheral neuropathy. There was also statistically significant association between both DKD, DR and peripheral arterial disease (PAD).ConclusionChronic vascular diabetic complications are common among type 2 diabetic patients with diabetic foot ulcers. There is statistically significant association between these complications and diabetic peripheral neuropathy (DPN) and peripheral arterial disease (PAD).     

Comparison of foot pain and foot care among rheumatoid arthritis patients taking and not taking anti-TNF�� therapy: an epidemiological study

Epidemiological studies report foot pain affects more than 90% of people with rheumatoid arthritis (RA). Most data about foot involvement in RA were collected prior to the availability of novel treatments such as biologics. The objective of this study is to compare the prevalence of foot symptoms, frequency of foot examination, and access to foot care services among RA patients currently treated with anti-TNFα to those not receiving biologics. This study is a cross-sectional epidemiological study: a 28-item self-administered questionnaire was posted to 1,040 people with RA throughout the UK. Overall, 585 (55%) useable replies were received, and 120 (20.5%) respondents were currently taking anti-TNFα medication. Prevalence of current foot pain was 99% among the biologics group compared with 76% not treated with biologics. Stiffness, swelling, and numbness in the feet were all significantly more common in the anti-TNFα group (P < 0.05). Most respondents (90%) taking biologics discussed their foot pain with their rheumatologist, but only 70% were receiving podiatry (compared to 78% not taking anti-TNFα). Subjects reported that their feet were examined significantly less frequently (P < 0.001) than their hands. Foot complaints are common in this group, and allied health professions could enhance rheumatological care by undertaking foot assessment.     

Association between preoperative pain intensity of MTP joint callosities of the lesser toes and fore-mid-hindfoot deformities in rheumatoid arthritis cases

Objectives: To determine whether preoperative pain intensity in callosities of the lesser toe metatarsopharangeal (MTP) joint was associated with the grade of fore-mid-hindfoot deformities, because rheumatoid arthritis (RA) foot deformity includes the whole part of foot, and curiously differences between cases in the pain intensity of MTP joint callosities are often observed.

Methods: We evaluated 24 feet that had undergone forefoot surgery [August, 2014 – December, 2015] for painful lesser toe MTP joint deformity (callosities) in RA cases. A preoperative self-administered foot evaluation questionnaire (SAFE-Q) and pressure distribution information for foot function were also investigated. X-rays of the whole lower extremities and foot at weight-bearing were used to check fore-mid-hindfoot deformities.

Results: Group M (mild) [n?=?9] included patients with the pain visual analog scale (VAS) less than 40?mm, while group S (severe) [n?=?15] included patients whose VAS was over 40?mm. Group M showed stronger hindfoot valgus and pronated (abducted) deformity, and group M showed higher pressure on the first MTP joint compared with group S.

Conclusions: These observations reconfirm that hindfoot valgus deformity and/or pronated (abducted) foot deformity affects the forefoot loading distribution, subsequently the pain of callosities in lesser toe MTP joints could be decreased.     

Comparative study between biofeedback retraining and botulinum neurotoxin in the treatment of anismus patients

Purpose  Anismus is a significant cause of chronic constipation. This study came to revive the results of BFB training and BTX-A injection in the treatment of anismus patients. Materials and methods  Forty-eight patients with anismus (33 women; mean age 39.6 ± 15.9) were included in this study. All patients fulfilled Rome II criteria for functional constipation. All patients underwent anorectal manometry, balloon expulsion test, defecography, and electromyography (EMG) activity of the EAS. All patients had non-relaxing puborectalis muscle. The patients were randomized into two groups. Group I patients received biofeedback therapy, two times per week for about 1 month. Group II patients were injected with BTX-A. Follow-up was conducted weekly in the first month then monthly for about 1 year. Results  In the BFB training group, three patients quit before the end of sessions with no improvement; initial improvement was recorded in 12 patients (50%) while long-term success was recorded in six patients (25%). In the BTX-A group, clinical improvement was recorded in 17 patients (70.83%), but the improvement persisted only in eight patients (33.3%). There is a significant difference between BTX-A group and BFB group regarding the initial success, but this significant difference disappeared at the end of follow-up. Manometric relaxation was achieved significantly post-BFB and post-BTX-A injection with no significant difference between the two groups. Conclusions  Biofeedback training has a limited therapeutic effect on patients suffering from anismus. BTX-A injection seems to be successful for temporary treatment of anismus.     

Predictors of diabetes foot complications among patients with diabetes in Saudi Arabia

AimsTo identify risk factors and clinical biomarkers of prevalent diabetes foot complications, including foot ulcers, gangrene and amputations among patients with diabetes in Jeddah, Saudi Arabia.Methods598 diabetes patients from Jeddah participated in the current study. Patients were considered to have diabetes foot complications if they reported diagnosis of foot ulcers or gangrene or amputations in a questionnaire administered by a physician and confirmed by clinical exams. Information on socio-demographic and lifestyle variables was self-reported by patients, and several clinical markers were assessed following standard procedures.ResultsThe prevalence of diabetes foot complications in this population was 11.4%. In the multivariable model without adjustment for PAD (peripheral artery disease) and DPN (diabetes peripheral neuropathy), non-Saudi nationality, longer diabetes duration and insulin use was significantly associated with higher diabetes foot complications prevalence. Each 1 g/L increase of hemoglobin was associated with 2.8% lower prevalence of diabetes foot complications. In the multivariable model adjusting for PAD and DPN, the previously observed associations except for nationality were no longer significant. Patients with both DPN and PAD had 9.73 times the odds of diabetes foot complications compared to the patients with neither condition.ConclusionIn this population, longer diabetes duration, insulin use, lower hemoglobin levels and non-Saudi nationality were associated with higher prevalence of foot complications. These associations were largely explained by the presence of DPN and PAD except for non-Saudi nationality. Diabetes patients with both DPN and PAD had nearly 10-fold increased risk of foot complications than those with neither condition.     

Association of apolipoprotein-CIII (apoC-III), endothelium-dependent vasodilation and peripheral neuropathy in a multi-ethnic population with type 2 diabetes

BackgroundDiabetic peripheral neuropathy (DPN) is a common complication of Type 2 diabetes (T2D). Apart from hyperglycemia, its pathogenesis is poorly understood. Apolipoprotein-CIII (apoC-III) associated with triglyceride metabolism, is a risk factor for cardiovascular disease. Its role in DPN is not well-established. We studied the associations of apoC-III, endothelial function and DPN.MethodsIn patients with T2D, anthropometric data, fasting blood, and urine were collected for biochemistry and urine albumin/creatinine measurements (uACR). Endothelial function assessments were performed by laser Doppler flowmetry/imaging. DPN was considered present if there was an abnormal finding in monofilament (≤ 8 of 10 points) or neurothesiometer testing ≥ 25 V on either foot. Plasma apoC-III was assessed by ELISA.ResultsMonofilament and neurothesiometer readings were measured in 1981 patients, mean age 57.4 ± 10.8 years old. DPN prevalence was 10.8% (n = 214). Patients with DPN compared to those without, were significantly older (p < 0.0001), with longer duration of T2D (p < 0.0001), had higher BMI (p = 0.006), higher glucose (p = 0.015) and HbA1c (p < 0.0001), Systolic blood pressure (SBP) (p < 0.0001), lower eGFR (p < 0.0001), higher urine ACR (p < 0.0001), poorer endothelium-dependent and endothelium-independent vasodilation (both p < 0.0001), higher VCAM-1 (p < 0.0001) and higher apoC-III [285.3 (195.2–405.6) vs 242.9(165.0–344.0) μg/ml]. After adjustment, log transformed apoC-III, remained independently associated with the presence of DPN (B = 0.965, SE = 0.397, p = 0.015).ConclusionPlasma apoC-III is higher in patients with DPN. Apart from its known association with lipids and macrovascular complications, this study suggests its association with DPN. Whether regulating apoC-III metabolism may be an important new therapeutic approach to managing dyslipidemia and microvascular complications in T2D remains to be proven in future mechanistic and clinical studies.     

Vibration perception threshold and the law of mobility in diabetic mellitus patients

BackgroundDiabetic neuropathy is a family of nerve disorders with progressive loss of nerve function in 15% of diabetes mellitus (DM) subjects. Vibration Perception Threshold (VPT) is one of the modalities of testing loss of protective sensation. Law of mobility for VPT is well known for normal subjects, but not for diabetic subjects. This is a pilot study to evaluate and plot the law of mobility for VPT among DM subjects.MethodsWe used biothesiometer to find the VPT of several areas in upper and lower extremities for normal and diabetic subjects. VPT of normal and diabetic subjects for different foot areas from proximal to distal is evaluated for 30 subjects. All the subjects are screened for peripheral artery occlusive disease with ankle brachial pressure index (0.9 or above). VPT values of different areas are arranged in a proximal to distal order for the analysis.ResultsVPT values monotonically decrease from proximal to distal areas. Vierodt's law of mobility holds well for normal subjects in both feet areas. The law of mobility does not hold good for the DM subjects in one or both feet areas.ConclusionsThe VPT value of diabetic subjects reveals that the law of mobility do not holds good for diabetic subjects in foot areas. Though the number of subjects is small, all the subjects defied the law.