The role of Sudoscan feet asymmetry in the diabetic foot

The aim of this study was to investigate the role of Sudoscan asymmetry parameters in the diabetic foot.Patients and methodsIn this study we included 165 participants: 84 type 2 diabetes patients divided into three HbA1c matched groups – group 1: newly diagnosed diabetics (n = 31), group 2: people with longer diabetes duration and established neuropathy (n = 33), group 3: patients with diabetic foot ulcer (n = 20), and a control group of 81 people with prediabetes. All subjects underwent peripheral sudomotor evaluation using Sudoscan device (Impeto Medical, Paris).ResultsPatients with diabetic foot had significantly higher Sudoscan feet asymmetry (19.6%) compared to those with only diabetic neuropathy (7.9%), compared to the group with newly diagnosed diabetes (7.44%), and compared to controls (2.5%). This test has shown a good discriminative value (with a threshold of 9.5%) for diabetic foot with area under the ROC curve of 0.955 (p = 0.001). Additionally, in a regression model feet asymmetry proved its predictive value for participants with diabetic foot.ConclusionIn this study Sudoscan feet asymmetry proved to be a novel discriminator and predictor for diabetic foot patients. It might be considered as a marker for early damage in the neuropathy evaluation protocol.     

The steel ball-bearing test: a new test for evaluating protective sensation in the diabetic foot

Aims/hypothesis The aim of the study was to assess a new steel ball-bearing test as a means of evaluating protective sensation in the diabetic foot. Methods Subjects were enrolled for this study as follows: (1) 39 patients (mean age 61.3±9.7 years) with neuropathy and prior neuropathic ulcer (Group A); (2) 36 patients (mean age 63.7±10.1 years) with neuropathy without neuropathic ulcer (Group B); (3) 34 patients (mean age 52.1±10.4 years) without neuropathy (Group C); and (4) 21 healthy volunteers (mean age 46.7±8.7 years) (Group D). Neuropathy was diagnosed by means of neuropathy disability score (NDS). The plantar area over the second metatarsal head of each foot was examined with steel ball-bearings of varying diameters. The smallest diameter that the patient could feel was used to define the ball-bearing score (range 1–6). Results A high ball-bearing score was significantly more frequent in patients with neuropathic ulceration than in neuropathic patients without ulceration and in diabetic patients without neuropathy (p<0.001). A high score was also more frequent in neuropathic patients without ulceration, than in patients without neuropathy (p<0.001). The ball-bearing score was significantly (p=0.01) correlated with the NDS, the monofilament test, the vibration perception threshold and the thermal perception threshold. The ball-bearing test had a sensitivity of 84% and a specificity of 100% for impaired protective sensation due to neuropathy, and a sensitivity of 84.6% and a specificity of 86.1% for detection of patients with prior neuropathic ulceration. Conclusions/interpretation The steel ball-bearing test has a high sensitivity and specificity both for the evaluation of protective sensation and for detection of patients with prior neuropathic ulceration.     

Can a combination of lifestyle and clinical characteristics explain the presence of foot ulcer in patients with diabetes?

AimsThe aim of this study was to identify the biomechanical, neurological and clinical parameters along with other demographics and lifestyle risk factors that could explain the presence of foot ulcer in patients with diabetes in Africa.MethodsA total of 1270 (M/F:696/574) patients; 77(M/F:53/24) with ulcerated vs 1193 (M/F: 643/550) with non-ulcerated feet; participated in this study. A set of 28 parameters were collected and compared between the participants with and without active foot ulcers. Multivariate logistic regression was utilised to develop an explanatory model for foot ulceration.ResultsFoot swelling (χ2(1,n = 1270) = 265.9,P = 0.000,Phi = 0.464) and impaired sensation to monofilament (χ2(2,n = 1270) = 114.2,P = 0.000,Cramer'sV = 0.300) showed strong association with presence of ulceration. A lower Temperature sensitivity to cold stimuli and limited ankle joint mobility were observed to be significant (P < 0.05) contributors to ulceration. The logistic regression model can justify the presence of foot ulceration with 95.3% diagnostic accuracy, 99.1% specificity and 37.3% sensitivity.ConclusionParticipants with ulcerated foot show distinct characteristics in few foot related parameters. Swollen foot, limited ankle mobility, and peripheral sensory neuropathy were significant characteristics of patients with diabetic foot ulcer. One out of three patients with ulcerated foot showed common characteristics that could be justified by the model.     

The Effect of Intradermal Botulinum Toxin a injections on painful diabetic polyneuropathy

Background and aimsBotulinum toxin type A (BTX-A) have been recently administered to improve Diabetic neuropathies; however, the efficacy of this treatment for relieving pain in painful diabetic polyneuropathy (DPN) has not been studied yet. Herein, we investigated the efficacy of botulinum toxin A (BTX-A) on DPN.MethodsThis prospective, randomized, double-blind, controlled trial was performed in Imam Hossein Medical Center, pain clinic (Tehran, Iran). Diabetic patients (141 cases), between 40 and 70 years old with polyneuropathy in lower limbs were randomly assigned to one of these three groups: 1. Group D1 received 150 units of BTX-A in one foot and normal saline 0.9% in the other foot, 2. Group D2 received BTX-A 150 units in both feet, 3. Group N received normal saline 0.9% in both feet. All injections were performed intradermally using insulin syringes in 20 different points of foot. Visual analogue scale (VAS) and neuropathy pain scale (NPS) were used to compare the groups.ResultsThe improvement of VAS, pain intensity, sharp and hot sensation, sensitive and unpleasant sensation, deep and surface sensation was significant when comparing BTX-A and placebo groups. However, dull and cold sensations improvement (p = 0.114, and p = 0.653; respectively) did not show a significant difference between BTX-A injection and placebo groups. Furthermore, the percentage of changes after treatment indicated that sharp pain was improved more than other complaints (80%, 81%, and 37% for D1, D2, and N groups; respectively).ConclusionIntradermal administration of BTX-A was effective in improving VAS and all of the items of NPS in patients with diabetic polyneuropathy, except for dull and cold sensation.     

A simple new non‐invasive sweat indicator test for the diagnosis of diabetic neuropathy

A simple non‐invasive indicator test (Neuropad^®) has been developed for the assessment of sweating and, hence, cholinergic innervation in the diabetic foot. The present review summarizes current knowledge on this diagnostic test. The diagnostic ability of this test is based on a colour change from blue to pink at 10 min, with excellent reproducibility, which lends itself to patient self‐examination. It has a high sensitivity (65.1–100%) and negative predictive value (63–100%), with moderate specificity (32–78.5%) and positive predictive value (23.3–93.2%) for the diagnosis of diabetic peripheral neuropathy. It also has moderate to high sensitivity (59.1–89%) and negative predictive value (64.7–91%), but low to moderate specificity (27–78%) and positive predictive value (24–48.6%) for the diagnosis of diabetic cardiac autonomic neuropathy. There are some data to suggest that Neuropad can detect early diabetic neuropathy, but this needs further evaluation. It remains to be established whether this test can predict foot ulceration and amputation, thereby contributing to the identification of high‐risk patients. Diabet. Med. 30, 525–534 (2013)     

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).     

Assessment of Simple Bedside Wound Characteristics for a Prediction Model for Diabetic Foot Ulcer Outcomes

Background:Evidence-based learning systems built on prediction models can support wound care community nurses (WCCNs) during diabetic foot ulcer care sessions. Several prediction models in the area of diabetic foot ulcer healing have been developed, most built on cardiovascular measurement data. Two other data types are patient information (i.e. sex and hemoglobin A1c) and wound characteristics (i.e. wound area and wound duration); these data relate to the status of the diabetic foot ulcer and are easily accessible for WCCNs. The aim of the study was to assess simple bedside wound characteristics for a prediction model for diabetic foot ulcer outcomes.Method:Twenty predictor variables were tested. A pattern prediction model was used to forecast whether a given diabetic foot ulcer would (i) increase in size (or not) or (ii) decrease in size. Sensitivity, specificity, and area under the curve (AUC) in a receiver-operating characteristics curve were calculated.Results:A total of 162 diabetic foot ulcers were included. In combination, the predictor variables necrosis, wound size, granulation, fibrin, dry skin, and age were most informative, in total an AUC of 0.77.Conclusions:Wound characteristics have potential to predict wound outcome. Future research should investigate implementation of the prediction model in an evidence-based learning system.     

Sensitivity and specificity of von Frey's hairs for the diagnosis of peripheral neuropathy in patients with type 2 diabetes mellitus

ObjectiveThe aim was to evaluate von Frey's hairs as a diagnostic tool for peripheral neuropathy in type-2 diabetes patients with symptoms typical for diabetic neuropathy with respect to nerve conduction studies (NCSs) and a combination of clinical examination and NCS.Patients and Methods65 patients with type-2 diabetes (33 men) with mean age 62.1 (SD 6.5) years, mean diabetes duration 17.5 (SD 9) years and mean symptom duration 5.2 (SD 4.3) years were examined with the set of von Frey's hairs. Diabetic neuropathy was diagnosed trough Neuropathy Disability Score (NDS). NCSs were performed on ulnar, peroneal, tibial and sural nerves.ResultsSensitivity of von Frey's hairs vs. NCS as the gold standard ranged from 37% to 79% and specificity from 65% to 87%. Sensitivity vs. combination of NDS and NCS ranged from 38% to 85% and specificity from 62% to 85%.ConclusionsVon Frey's hairs have moderate sensitivity and specificity for diagnosis of neurophysiological and also clinical neuropathy. Being a fast and easy-to-perform procedure, they could be appropriate as a screening test in clinical practice.     

Score reproducibility and reliability in differentiating small bowel subepithelial masses from innocent bulges

AimsThe primary aim of this study was to assess the reliability, intra- and inter-observer variation of the SPICE, Mucosal protrusion angle (MPA) and SHYUNG scores in differentiating a subepithelial mass (SEM) from a bulge.MethodsThis retrospective multicentre study analysed the 3 scores, radiological studies, enteroscopy and/or surgical findings.Results100 patients with a potential SEM (mean age 57.6years) were recruited with 75 patients having pathology. In patients with a SEM the mean SPICE score was 2.04 (95% CI 1.82–2.26) as compared to 1.16 (95% CI 0.81–1.51) without any pathology (AUC 0.74, p<0.001), with a fair intra-observer agreement (Kappa 0.3, p<0.001) and slight inter-observer agreement (Kappa 0.14, p<0.05). SPICE had a 37.3% sensitivity and 92.0% specificity in distinguishing between a SEM and bulge, whereas MPA<90? had 58.7% and 76.0% respectively, with poor intra-observer(p = 0.05) and interobserver agreement (p = 0.64). The SHYUNG demonstrated a moderate intra-observer (Kappa 0.44, p<0.001) and slight inter-observer reliability (Kappa 0.18, p<0.001). The sensitivity of an elevated SHYUNG score (≥4) in identifying a SEM was 18.7% with a specificity of 92.0% (AUC 0.71, p = 0.002).ConclusionsThough these scores are easy to use, they have, at best, slight to moderate intra and inter-observer agreement. Their overall diagnostic performances are limited.     

The quality and relevance of peripheral neuropathy data on a diabetic clinical information system.

Routinely collected peripheral neuropathy data entered on a diabetic clinical information system since 1979 have been audited for completeness, consistency, accuracy (inter-observer variation), validity by comparison with biothesiometry, and relevance by life table analysis for foot ulceration. Peripheral neuropathy was defined by a neuropathy disability score > or = 4. The data were 98% complete. Forty-nine of 3405 (1.4%) had inconsistent records. Agreement between observers for clinical examination was significant (p < 0.05) for aggregate neuropathy score and its individual components except the knee jerk: Kappa score for observer variation for neuropathy score 0.56 (95% confidence interval 0.36-0.76). There was good agreement between neuropathy defined as aggregate score > or = 4, and as combined vibration perception thresholds for both feet > 60 V: Kappa statistic 0.62 (95% confidence interval 0.44-0.80). The chance of developing a foot problem in 3 years increased from 3% for patients with a score of zero to 45% for people with a score of between 9 and 12. We conclude that the calculation of a clinical neuropathy score is a simple, valid and relevant method for diabetes care both in hospital and the community. When combined with palpation of peripheral pulses most patients at risk of foot ulceration can be identified allowing targeting of preventive chiropody and orthotic resources.     

Nomogram for prediction of diabetic retinopathy in patients with type 2 diabetes mellitus: A retrospective study

ObjectiveTo develop a nomogram for the risk of diabetic retinopathy (DR) among type 2 diabetes mellitus (T2DM).MethodsQuestionnaires, physical examinations and biochemical tests were performed on 5900 T2DM patients in the Second Hospital of Shijiazhuang. The least absolute shrinkage and selection operator regression was used to optimize feature selection, and the importance of selected features was analyzed by random forest. Logistic regression was performed with selected features, and the nomogram was established based on the results. The Harrell's C-statistic, bootstrap-corrected C-statistic, area under curve (AUC), calibration curve, decision curve analysis (DCA) and clinical impact curve (CIC) were used to validate the discrimination, calibration and clinical usefulness of the nomogram, and further assessment was running by external validation.ResultsPredictors included duration of diabetes, diabetic neuropathy, diabetic kidney disease, diabetic foot, hyperlipidemia, hypoglycemic drugs, glycated albumin, Lactate dehydrogenase. The model displayed medium predictive power with a Harrell's C-statistic of 0.820, bootstrap-corrected C-statistic of 0.813 and AUC of 0.820 in the training set, and which was respectively 0.842, 0.835 and 0.842 in the validation set. The calibration curve displayed good agreement (P > 0.05). The DCA and CIC showed that the nomogram could be applied clinically if the risk threshold is between 2 % and 75 % and 2 %–88 % in validation set.ConclusionsThis nomogram incorporating 8 features is useful to predict the risk of DR in T2DM patients.     

A simple plaster for screening for diabetic neuropathy: A diagnostic test accuracy systematic review and meta-analysis

ObjectiveNeuropad is an adhesive indicator test applied at the plantar surface of the foot that detects sweating through color change. We examined the diagnostic accuracy of this simple plaster as triage test for screening for clinically relevant diabetic sensorimotor polyneuropathy in adult outpatients with type 1 or type 2 diabetes.Materials/MethodsSystematic review and meta-analysis of diagnostic accuracy studies. We searched Medline, Embase, Cochrane Library, Biosis Previews, Web of Science, Scopus and gray literature without date or language restrictions. We pooled estimates of sensitivity and specificity, and fitted hierarchical models to produce summary receiver operating characteristic curves. We assessed methodological quality of included studies utilizing the Quality Assessment of Diagnostic Accuracy Studies 2 tool.ResultsEighteen studies with 3470 participants met the inclusion criteria. Average sensitivity and specificity were 86% (95% CI 79 to 91) and 65% (95% CI 51 to 76) respectively. Likelihood ratios (LRs) were LR + = 2.44 and LR − = 0.22. Subgroup analyses per reference standard utilized provided similar estimates. Most studies were at risk of bias for patient selection and use of index or reference test, and had concerns regarding applicability due to patient selection.ConclusionThe adhesive indicator test has reasonable sensitivity and could be used for triage of diabetic neuropathy to rule out foot at risk. Patients who tested positive should be referred to specialized care to establish a definite diagnosis. There is insufficient evidence for effectiveness on patient-important outcomes and cost-effectiveness of implementation in the diagnostic pathway compared with the standard clinical examination.     

The Neuropad test: a visual indicator test for human diabetic neuropathy

Aims/hypothesis The commercially available Neuropad test was developed as a simple visual indicator test to evaluate diabetic neuropathy. It uses a colour change to define the integrity of skin sympathetic cholinergic innervation. We compared the results of Neuropad assessment in the foot with established measures of somatic and autonomic neuropathy. Methods Fifty-seven diabetic patients underwent Neuropad assessment, quantitative sensory and autonomic function testing, and evaluation of intra-epidermal nerve fibre density in foot skin biopsies. Results Neuropad responses correlated with the neuropathy disability score (r _s = 0.450, p < 0.001), neuropathic symptom score (r _s = 0.288, p = 0.03), cold detection threshold (r _s = 0.394, p = 0.003), heat-as-pain perception threshold visual analogue score 0.5 (r _s = 0.279, p = 0.043) and deep-breathing heart rate variability (r _s = −0.525, p < 0.001). Intra-epidermal nerve fibre density (fibres/mm) compared with age- and sex-matched control subjects (11.06 ± 0.82) was non-significantly reduced (7.37 ± 0.93) in diabetic patients with a normal Neuropad response and significantly reduced in patients with a patchy (5.01 ± 0.93) or absent (5.02 ± 0.77) response (p = 0.02). The sensitivity of an abnormal Neuropad response in detecting clinical neuropathy (neuropathy disability score ≥5) was 85% (negative predictive value 71%) and the specificity was 45% (positive predictive value 69%). Conclusions/interpretation The Neuropad test may be a simple indicator for screening patients with diabetic neuropathy.     

Quantitative vibration perception threshold in assessing diabetic neuropathy: Is the cut-off value lower for Indian Subjects? [Q-VADIS Study]

AimsThe aim was to compute a normative data of VPT [Vibration Perception Threshold], compare results of VPT among type 2 diabetes patients with and without neuropathy, validate VPT taking NDS [Neuropathy Disability Scores] as gold standard and suggest a cut off value for the Indian population.Materials and methodsA clinic based case-control study was conducted at Nightingale Hospital (NH) in Kolkata for 2 months duration. Fifty type 2 diabetes patients (who were detected with by fasting plasma glucose or on medication) reporting at OPD (Out Patent Department) were randomly selected and informed consent was obtained. The age range was 20–65 years and other common causes of neuropathy were excluded. Same number of control patients without diabetes and reporting at the same hospital during the study period in the similar age range were selected.ResultsThe normative data of VPT for mean of 4 sites (malleoli and great toe) was 11.3 ± 4.9 mV. The VPT value was significantly higher among diabetic patients with neuropathy compared to non-neuropathic and non-diabetic patients. Considering NDS score as gold standard lowering the cutoff value of VPT from 25 mV to 20 mV increased the sensitivity from 50% to 62.5% in detecting diabetic neuropathy compared to NDS taken as a gold standard.ConclusionsIt was found that lowering the cut off value of VPT in Indian population increased the sensitivity of the test to detect diabetic neuropathy without hampering the specificity. There is however no indication that a lower cut off VPT value is justified as of now.     

Glycemic control is related to the severity of impaired thermal sensations in type 2 diabetes

BACKGROUND: Small-fibre sensory neuropathy of diabetes presenting as impaired thermal sensations is associated with ominous consequences, such as foot ulcer and amputation, but there is a lack of systematic studies on its occurrence in large cohorts. We investigated (1) the impact of glycemic control on thermal thresholds, (2) the frequencies and patterns of sensory deficits, and (3) the contribution of sensory nerve abnormalities to neuropathic symptoms. METHODS: Quantitative sensory testing and nerve conduction studies were performed to measure warm and cold thresholds of extremities, and amplitudes of nerve action potentials on 498 type 2 diabetic patients and 434 control subjects with similar age and gender distributions, enrolled during the same period. RESULTS: The diabetic patients had higher thermal thresholds than control subjects (p < 0.0001). Thermal thresholds of the lower and upper extremities were linearly correlated with HbA1C on multiple linear regression analysis (p < 0.01). By the multivariate logistic regression analysis, HbA(1C) and age were the most important risk factors independently associated with elevated thermal thresholds (p < 0.01). Elevated warm threshold in the big toe was the most frequent abnormality (60.2%) compared to abnormal cold threshold in the big toe (39.6%) and abnormal sural nerves on nerve conduction studies (12.9%). Elevated thermal thresholds were risk factors for neuropathic symptoms independent of HbA(1C). CONCLUSION: Small-fibre neuropathy with the impairment of thermal sensations is the most frequent sensory deficit in diabetes, and HbA1C is significantly associated with the elevated thermal thresholds.     

Validity of Self-rating Screening Scales for the Diagnosis of Depression and Anxiety in Adult Patients With Bronchiectasis

BackgroundThere are no previous studies aimed at assessing the validity of the screening scales for depression and anxiety in adult patients with bronchiectasis.AimsTo analyze the psychometric properties of Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory (BDI) and Hamilton Anxiety Scale and to evaluate the concordance for the diagnosis of depression and anxiety between these screening scales and the structured clinical interview in adult patients with bronchiectasis.MethodCross sectional study. 52 patients with bronchiectasis completed HADS, BDI and Hamilton Anxiety Scale; afterwards, were individually interviewed by a mental health care professional using the structured Mini International Neuropsychiatric Interview (MINI), which evaluates for depression and anxiety according to DSM-IV criteria.ResultsBased on MINI, 18 subjects (34.6%) had a diagnosis of depression and 25 (48.1%) had anxiety. Optimal cut-off values to detect depression were ≥9 for the HADS-D (sensitivity 0.833, specificity 0.971, AUC 0.962 [95% CI 0.918–1]), and 17 for BDI (sensitivity 0.889, specificity 0.912, AUC 0.978 [95% CI 0.945–1]). Optimal cut-off values to detect anxiety were ≥4 for the HADS-A (sensitivity 0.960, specificity 0.593, AUC 0.833 [95% CI 0.723–0.943]), and 17 for Hamilton Anxiety Scale (sensitivity 0.800, specificity 0.852, AUC 0.876 [95% CI 0.781–0.970]).ConclusionThe self-rating screening scales HADS, BDI and Hamilton Anxiety Scale are reliable tools to screen for depression and anxiety in adult patients with bronchiectasis. However, the use of specific cut-off values may improve the diagnostic accuracy of the previous scales in this specific group of patients.     

Comparison of diagnostic efficacy between CLE,tissue sampling,and CLE combined with tissue sampling for undetermined pancreaticobiliary strictures: a meta-analysis

Objective: The accurate diagnosis of undetermined pancreaticobiliary strictures remains challenging. Current ERCP-guided tissue sampling methods are of low sensitivity. Confocal laser endomicroscopy (CLE) is a new procedure and allows real optical biopsies that may improve the diagnosis of undetermined pancreaticobiliary strictures. The aim of this meta-analysis was to determine the diagnostic yield of CLE, tissue sampling, and CLE combined with tissue sampling for undetermined pancreaticobiliary strictures.

Method: Pubmed, Embase, and the Cochrane Library database were reviewed for relevant studies. Pooled estimates of sensitivity and specificity with 95% confidence intervals (CIs) were calculated using the random-effects meta-analysis model. The summary receiver-operating characteristic (SROC) curve was constructed, and the area under the receiver operating characteristic curve (AUC) was calculated.

Results: Twelve studies involving 591 patients were enrolled in our analysis. The overall sensitivity and the specificity estimate of CLE for discriminating benign and malignant pancreaticobiliary strictures were 87% (95%CI, 83–91%) and 76% (95%CI, 70–81%), respectively. The AUC to assess the diagnostic efficacy was 0.8705. For tissue sampling, the overall sensitivity and the specificity estimate were 64% (95%CI, 57–70%) and 94% (95%CI, 90–97%), respectively. The AUC to assess the diagnostic efficacy was 0.8040. A combination of both methods increased the sensitivity (93%; 95%CI, 88–96%) with a specificity of 82% (95%CI, 74–89%). The AUC to assess the diagnostic efficacy was 0.9377. There was no publication bias by Deeks’ Funnel Plot with p?=?.936.

Conclusions: Compared with tissue sampling, CLE may increase the sensitivity for the diagnosis of malignant pancreaticobiliary strictures. A combination of both can effectively diagnose malignant pancreaticobiliary strictures.     

Diagnostic accuracy of various forms of geriatric depression scale for screening of depression among older adults: Systematic review and meta-analysis

ObjectivesDepression is under-reported and under-identified by the healthcare professionals. Geriatric depression scale (GDS) is one of the most commonly used instruments for screening the older adults for depression. The current review was done to determine the diagnostic accuracy of various forms of GDS for screening of depression among older adults.MethodsWe conducted systematic search in various databases like Medline, Cochrane library, Sciencedirect and Google Scholar from inception till May 2019. Quality of trials was assessed by Quality Assessment of Diagnostic Accuracy Studies-2 tool. We performed bivariate meta-analysis to obtain the pooled sensitivity, specificity, positive, negative likelihood ratio and diagnostic odds ratio for each of the GDS forms.ResultsTotally 53 studies with 17,018 participants were included in the review. We found the pooled sensitivity and specificity of GDS 30 to be 82 % and 76 % with near higher diagnostic accuracy (AUC = 0.85). GDS 15 had pooled sensitivity and specificity of 86 % and 79 % with higher diagnostic accuracy (AUC = 0.90). GDS 10 had pooled sensitivity and specificity of 87 % and 75 % with AUC = 0.83. Our study found GDS 4 to have sensitivity of 74 % with specificity of 71 %. All the four forms of GDS belonged to right lower quadrant of LR scatter-gram indicating neither confirmation nor exclusion.ConclusionCurrent study found that all the forms of GDS are highly useful for detecting depression among elderly with higher sensitivity and specificity. The diagnostic performance was much better for shorter forms of GDS such as GDS 15 and GDS 10 when compared to GDS 30.     

Establishment of a scoring model for early diagnosis of infection associated with liver failure

Introduction and ObjectivesInfection is a common complication of liver failure. Serum inflammatory markers used to diagnose infection have sufficient diagnostic sensitivity but low specificity. This study aimed to improve the early diagnosis of infections in liver failure patients by developing a diagnostic model and evaluating its predictive ability.Patients and MethodsA retrospective analysis of clinical data from liver failure patients. Cases were divided into infected and non-infected groups according to their clinical diagnosis. Nine infection-related predictors (age, body temperature, neutrophil ratio (NE%), procalcitonin (PCT), C-reactive protein (CRP), lactic acid (Lac), serum albumin (Alb), model of end-stage liver disease (MELD) score, and sequential organ failure assessment (SOFA) score) were included in multivariate logistic regression analysis. The diagnostic model was validated, and the receiver operating characteristic (ROC) curve was used to analyze its predictive accuracy.ResultsIn the model group, multivariate logistic regression analysis showed that age, body temperature, PCT, CRP, Lac, and SOFA score were independent predictors of infection associated with liver failure (P < 0.05). The area under the ROC curve (AUC) of the model was 0.899 (95% confidence interval [CI] 0.846–0.939), and the sensitivity and specificity were 86.2% and 80.4%, respectively. The AUC for the validation group was 0.953 (95% CI 0.899–0.983), and the sensitivity and specificity were 91.7% and 84.2%, respectively.ConclusionsThis study reports a model for early diagnosis of infection in liver failure patients. The model had high overall accuracy and showed good reproducibility and reliability in patients from different centers in the same region.     

Effect of foot-ankle flexibility and resistance exercise in the secondary prevention of plantar foot diabetic ulcer

AimsThe study aimed to evaluate the effects of foot-ankle flexibility and resistance exercises on the recurrence rate of plantar foot diabetic ulcers, HbA1c levels, diabetic neuropathy examination (DNE) scores, ankle brachial index (ABI), and walking speed within 12 and 24 weeks.MethodsWe conducted a double-blind randomized clinical trial. Fifty patients with recently healed plantar foot diabetic ulcers were randomized to an intervention group that performed foot-ankle flexibility and resistance exercise three times a week in their home (n = 25) or a control group (n = 25). Both groups were given foot care education. Outcomes were assessed at plantar foot diabetic ulcer recurrence or at 12 and 24 weeks whichever came first. Outcome measures included plantar foot diabetic ulcer recurrence, changes of HbA1c levels, DNE scores, ankle brachial index ABI, and walking speed.ResultsThere were significant difference between groups in ulcer recurrence at either 12 weeks (intervention 8%, control 68%, RR 0.288; 95% CI 0.156–0.534, P = 0.000) within 12 weeks.or 24 weeks (intervention 16%, control 72%, RR 0.222; 95% CI 0.088–0.564, P = 0.000).). There were significant differences in the DNE score delta (P = 0.000) and walking speed delta (P = 0.000), but there were no significant differences in the HbA1c delta and ABI delta between groups at either 12 or 24 weeks.ConclusionsFoot-ankle flexibility and resistance exercises can reduce the recurrence of plantar foot diabetic ulcer incidence and improve diabetic neuropathy and walking speed.Clinical trial number: NCT04624516