backgroundOther than glycemic control, there are no treatments for diabetic neuropathy. Thus, identifying potentially modifiable risk factors for neuropathy is crucial. We studied risk factors for the development of distal symmetric neuropathy in 1172 patients with type 1 diabetes mellitus from 31 centers participating in the European Diabetes (EURODIAB) Prospective Complications Study. methodsNeuropathy was assessed at baseline (1989 to 1991) and at follow-up (1997 to 1999), with a mean (±SD) follow-up of 7.3±0.6 years. A standardized protocol included clinical evaluation, quantitative sensory testing, and autonomic-function tests. Serum lipids and lipoproteins, glycosylated hemoglobin, and the urinary albumin excretion rate were measured in a central laboratory. resultsAt follow-up, neuropathy had developed in 276 of 1172 patients without neuropathy at baseline (23.5 percent). The cumulative incidence of neuropathy was related to the glycosylated hemoglobin value and the duration of diabetes. After adjustment for these factors, we found that higher levels of total and low-density lipoprotein cholesterol and triglycerides, a higher body-mass index, higher von Willebrand factor levels and urinary albumin excretion rate, hypertension, and smoking were all significantly associated with the cumulative incidence of neuropathy. After adjustment for other risk factors and diabetic complications, we found that duration of diabetes, current glycosylated hemoglobin value, change in glycosylated hemoglobin value during the follow-up period, body-mass index, and smoking remained independently associated with the incidence of neuropathy. Cardiovascular disease at baseline was associated with double the risk of neuropathy, independent of cardiovascular risk factors. conclusionsThis prospective study indicates that, apart from glycemic control, the incidence of neuropathy is associated with potentially modifiable cardiovascular risk factors, including a raised triglyceride level, body-mass index, smoking, and hypertension.
OBJECTIVE -The goal of the study was to examine risk factors in the prediction of coronary heart disease (CHD) and differences in men and women in the EURODIAB Prospective Complications Study. RESEARCH DESIGN AND METHODS -Baseline risk factors and CHD at follow-upwere assessed in 2,329 type 1 diabetic patients without prior CHD. CHD was defined as physician-diagnosed myocardial infarction, angina pectoris, coronary artery bypass graft surgery, and/or Minnesota-coded ischemic electrocardiograms or fatal CHD.RESULTS -There were 151 patients who developed CHD, and the 7-year incidence rate was 8.0 (per 1,000 person-years) in men and 10.2 in women. After adjustment for age and/or duration of diabetes, the following risk factors were related to CHD in men: age, GHb, waistto-hip ratio (WHR), HDL cholesterol, smoking, albumin excretion rate (AER), and autonomic neuropathy. The following risk factors were related to CHD in women: age, systolic blood pressure (BP), fasting triglycerides, AER, and retinopathy. Multivariate standardized Cox proportional hazards models showed that age (hazard ratio 1.5), AER (1.3 in men and 1.6 in women), WHR (1.3 in men), smoking (1.5 in men), fasting triglycerides (1.3 in women) or HDL cholesterol (0.74 in women), and systolic BP (1.3 in women) were predictors of CHD.CONCLUSIONS -This study supports the evidence for a strong predictive role of baseline albuminuria in the pathogenesis of CHD in type 1 diabetes. Furthermore, sex-specific risk factors such as systolic BP, fasting triglycerides (or HDL cholesterol), and WHR were found to be important in the development of CHD. Diabetes Care 27:530 -537, 2004T ype 1 diabetes is associated with a four-(in men) to eightfold (in women) excess risk of coronary heart disease (CHD) (1,2). This substantially elevated risk in women with diabetes effectively obliterates the sex difference in CHD observed in the general population (3,4).Established risk factors do not appear to account for the excess risk of CHD in type 1 diabetes, and reasons for the greater impact in women are not clear. But there is a lack of large prospective studies in type 1 diabetic patients. Much of the research into CHD risk in diabetes has focused on type 2 diabetes and insulin resistance. Type 1 diabetes has a different pathogenesis from type 2 diabetes, and although there are similarities between the diseases such as hyperglycemia, inferences cannot be made from one type to the other for all risk factors, such as lipids and obesity. For example, type 1 diabetes is associated with a favorable lipid pattern compared with the general population, which is clearly not true for type 2 diabetes (5).Previous studies of type 1 diabetic patients suggest that albuminuria (4,6 -9) and raised blood pressure (BP) (4,6 -9) are important risk factors for CHD, but these studies had insufficient power to stratify analyses by sex. The case for an independent relationship between obesity measures and CHD is unclear, the role of the other complications of diabetes uncertain, and findings for lip...
We conclude that painful symptoms are frequent in diabetic neuropathy, irrespective of the presence or absence of foot ulceration and that these symptoms can occur at any stage of the disease. These results suggest that there is a spectrum of neuropathic syndromes from the painful to the patients with foot ulceration, and that much overlap exists.
This study aimed to examine the rates and risk factors for ipsilateral re-amputation in 121 patients with diabetic foot and prior amputation. Twenty-six (21.5%) patients required re-amputation during a mean follow-up of 18 months. Most re-amputations were performed within the first 6 months of the initial amputation. Re-amputation was more common among patients in whom the initial amputation had only affected one or two toes. Age (hazard ratio: 1.06) and heel lesions (hazard ratio: 2.69) were significantly associated with re-amputation. There is a high risk of re-amputation in the diabetic foot, especially within the first 6 months of the initial amputation, mainly due to poor selection of the original amputation level in an effort to save a greater part of the lower extremity. Patients 70 years and those with heel lesions are at greatest risk of re-amputation.
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.
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