Methods:
The study includes all type 2 diabetics from OPD's and IPD s in the department of medicine
AIMS and AH &RC,BG NAGARA in the period Between DEC 2014 to JUNE2016
Results:
In the study group, mean age of study population is 58.27 11.52. The mean HbA1C level in
this study is 8.611.66. In this study, mean FBS is 161.7445.17 and mean PPBS is
240.7083.80. In a total of 50 study population, 36 patients had nerve conduction study positive
and 14 patients had normal nerve conduction study and with symptoms of peripheral neuropathy.
Conclusion:
Peripheral neuropathy is most common micro vascular complication of type 2 diabetes
mellitus. Severe forms of diabetic complications where noted in uncontrolled blood sugars and
high HbA1c.There is strong relation between peripheral neuropathy with uncontrolled blood
sugars and duration of diabetes
Key words: Diabetes Mellitus, Peripheral Neuropathy, HbA1C, Blood sugar levels, Nerve
Conduction Study.
TABLE OF CONTENTS
1. Introduction
2. Objectives
3. Review of Literature
4. Materials and methods
5. Results
6. Discussion
7. Conclusion
8. Summary
9. Bibliography
10. Annexures
LIST OF TABLES
SL.NO.
TABLES
1.
5
6
HbA1C LEVELS
10
11
12
LIST OF FIGURES
PAGE NO.
SL.NO.
FIGURES
POLYOL PATHWAY
5
6
LIST OF ABBREVIATIONS
PAGE
NO.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
A.N.
ALA
B.D.R
BMI
CN
CVS
D.N
DAN
DCCT
DSMN
DSN
DSPN
DSSN
ED
FBS
GLA
GlycoHb
HTN
IDDM
NIDDM
OHA
P.A
P.D.R
P.MN
PPBS
r-NGF
Autonomic Neuropathy
Alpha Lipoic Acid
Background Retinopathy
Body Mass Index
Cranial Nerve
Cardio Vascular System
Diabetic Neuropathy
Distal Autonomic Neuropathy
Diabetic Control and Complication Trial
Distal Sensory Motor Neuropathy
Distal Sensory Neuropathy
Distal Symmetrical Peripheral Neuropathy
Distal Symmetrical Sensory Neuropathy
Erectile Dysfunction
Fasting Blood Sugar
Gamma Linolenic Acid
Glycosylated Hemoglobin
Hypertension
Insulin Dependant Diabets Melilitus
Non Insulin Dependant Diabetis Mellitus
Oral Hypo Glycemic Agents
Perabdomen
Proliferative Diabetic Retinopathy
Proximal Neuropathy
Post Prandial Blood Sugar
Recombinant Nerve Growth Factor
INTRODUCTION
Diabetes mellitus is a syndrome characterised by chronic hyperglycemia and disturbances of
carbohydrate,fat and protein metabolism associated with absolute or relative deficiency in insulin
secretion and/or insulin action, which is modulated by genetic, HLA and environmental factors
resulting in micro and macroangiopathy.
It often runs in families.
Strict maintenance of glycemic state is most essential to prevent or slow the progression of
diabetic neuropathy in a patient of peripheral neuropathy, if autonomic system is also involved, it
Usually correlates with somatic neuropathy.
However it has been recognized that some patients with excellent glucose control were also
developed diabetic neuropathy,
Hence further studies are required to determine the possible risk factors.
REVIEW OF LITERATURE
Historical Review
Diabetes mellitus
Aretaus (AD 30-90 of Cappadocia in Secondary century coined the term "Diabetes"
derived from Greek word dia (through) and Bianeon (to go) meaning a Siphon. Because
fluid does not remain in body but uses man's body as a ladder where by to leave it as
patient was a Siphon "Which described the disease as melting down of flesh into the urine,thirst
unquenchable, kidneys never stop making water 4.5.6"
During 5th & 6th century BC, sweet taste of urine in polyuric patient was described in Sanskrit
(Indian) literature by Sushruta, Charaka. Vagbhata and the disease was named "Madhumeha"
They described that the urine of these Patients tasted like honey (madhu), sticky to touch and
ants were strongly attracted to it.
They differentiated two forms of the disease. One affecting thin people who do not survive long
and the other affecting older and obese. They also described relation of diabetes mellitus to
hereditary obesity sedentary life and diet.7
This description was parallel to the subdivision of Diabetes mellitus into the type l and type 2
Diabetes mellitus. Indian literature gets credit for the term Honey urine Referring to the clear
colorless nature of Diabetic Urine.
Diabetes Neuropathy is one of the commonest causes of Peripheral Neuropathy.
It accounts for hospitalization more frequently than complications of the Diabetes mellitus and is
the most frequent cause of non traumatic amputation diabetic autonomic neuropathy accounts for
silent myocardial infarction and Shortens the life span resulting in death in 25-50% of Patients
Within 5-10yrs of Autonomic diabetic Neuropathy.8
The diagnosis of subclinical Diabetic neuropathy requires Electro diagnostic testing and
quantitative sensory and autonomic testing.
Diabetic neuropathy has-been defined by the consensus conference of San Antonio as peripheral
neuropathy .Either clinically evident or sub clinically That occurs in the setting of diabetes
mellitus without other causes.31
The presence combination of the triad of neuropathy, retinopathy and nephropathy in the course
of the lifelong disease Regarded this "Triopathy" as consequences rather than complication,32
Diabetic neuropathy is one of the MOST common long term complication of diabetes mellitus
and is clinically present in 30- 50% of all diabetes Patients.33,34
The Responsibility of the patient and his physician in close monitoring control of diabetes and
Tailoring the various components in Their management Have Assumed greater significance.35
The present study has-been undertaken to monitor the levels of blood sugar and HbA1C, in
diabetic neuropathy.
The study of diabetic neuropathy has been Undertaken for the many reasons. The diabetes is a
frequent cause of peripheral neuropathy. Affects almost every part of nervous system and
produces various, type of neuropathy.
OTHER STUDIES
Study done by sumner. CJ et al. out of 73 diabetic patient They Studied, found Prevalence
of Neuropathy in 56%, and Patients With impaired glucose tolerance HAD
Predominantly small fiber neuropathy Compared to other Diabetic Patients Who Had
more Involvement of large fiber, and nerve conduction study velocity is Gradually
diminished in diabetic neuropathy with Estimated loss of about 0.5M / S year.16
Study done by S.Ashok et . Prevalence of diabetic neuropathy was 19.1% out of 1000
consecutive diabetic Patients Who Have visited there diabetic center They found
Prevalence of neuropathy Increases with Age of a patient and duration of diabetes. They
Also found age and duration, the major risk factor for neuropathy.17
Study done by Vishwanathan et al they studied 1319 type 2 diabetic Patients selected in
four different centers in India and found Prevalence of Diabetic Neuropathy in 15% of
Patients, mean age of development is 53 11 year, more in males than females ratio is
2:1, duration of diabetes in these study is 6.2 5.3 years, diabetic neuropathy patients
had mean PPBS of 278 91 mg%, hypertension in 34% subjects, mean systolic BP is
132 32 mmHg and Diastolic 85.1 11,5 mmHg, BMI of 25.41 2.99 kg/met2 in patient
with diabetic neuropathy, average cholesterol level is 194 48 and the incidence of
Neuropathy increased from 7.5% on diagnosis to 50% at 25years of follow up.21
Study done by Mitrabasu et.al found that out of 82 diabetic patients studied 42 patient
had peripheral neuropathy and 8 patients had autonomic dysfunction that shows 54.0%,
and Autonomic Involvement in 10.8%, average age of development of peripheral
neuropathy in these patients is 50.176.9 years. They also observed that age and duration
of diabetes play an important role in diabetic neuropathy and significantly associated with
higher age, male patients are predominant in developing diabetic neuropathy 75.8% than
females 24.2%, average years need to developing Diabetic Neuropathy is 6.737.21
fasting and post prandial Glucose levels and were associated with 2 times risk of
Developing peripheral Neuropathy. The mean fasting Glucose in there study is 149
48mg%, mean HbAIc for development of the diabetic neuropathy is 7.91.38, body mass
index,.hyper cholesterol and triglyceridemia levels were associated and higher incidence
of Diabetic neuropathy, systolic BP average in these study is 134 16mmhg. higher the
BMI higher the incidence of diabetic Neuropathy they found average BMI of 25.4 4,6
kg/met2 and average triglyceride levels of 133 44.20
Study done by Ch. Manes et al found That prevalence of diabetic Neuropathy is33.5%,
Among 821 diabetic Patients. they Studied found 275 patients HAD peripheral
neuropathy and it is more common in age group of 61.61 5.5years, there is no
significant difference Between male and female, in males 35.2% and females 32.6%, out
of 275 Patients theyStudied the average duration of diabetes is 10.68 07.8years to
Develop peripheral neuropathy, mean fasting glucose is 19550 mg%, 19
Study done by Kjerosti morkid et al out of 294 diabetic Patients They found the
prevalence of diabetic Neuropathy in 19.7%, and it Increases With Age 11.1% in 23-40
years age group. 32.3% in 60-80 years age group, prevalence is more in females (52.7%)
155 than males (47.3%), mean duration of diabetes to Develop neuropathy is 9-1 l years,
mean HbAlc of 8.752.20, hypertension was not significantly related to neuropathy,mean
BMI in neuropathy Patients is 24.43 3.35 kg /met2,,mean cholesterol level were 19031.
They found prevalence of Diabetic neuropathy is 13.7% in oral hypoglycemic agents
(CHA) Treated group and 29.2 in Insulin Treated group ,found more in insulin Treated
group.19
Study done by Arindam dutt and et al 'They Studied 100 diabetic Patients found That
neuropathy is more in the age group of 50. 44 10.35 years, found That 28% are male
31% are female, showing diabetic neuropathy effects females more than males, fasting
and post prandial Blood Glucose levels are higher in Neuropathic Patients Compared to
non neuropathic group. mean FBS 220 68mg%,. mean post prandial Blood sugar of
(33484 mg%), 18% of males and 12.82% of female Who Had Diabetic neuropathy Were
suffering from Hypertension. Both systolic and diastolic Blood pressure are higher in
Diabetic neuropathic Patients Compared to non- neuropathic group.
systolic12919.9mmHg and diastolie 82.2 9.32mmHg, nerve conduction study was
abnormal in 27% of patient, out of 27%, 15% of Patients HAD reduced nerve conduction
velocity, 23% of patient HAD BMI of 25 kg /met2
Study done by DCCT Diabetic control and complication trial, study Showed significant
Reduction in the development and progression of clinical neuropathy (64%). Motor
conduction velocity (44%) and Autonomic Dysfunctions (53%) in type-2 Diabetic With
optimal Glycemic control.1
Study done by UK Prospective Diabetes Study, Control of Blood Glucose was
Associated With improvement in vibration perception and reduction of odds ratio for the
development of Autonomic Neuropathy.27
Study done by Sultan et al found That mean fbs for development of peripheral
neuropathy in a diabetic Patients for 5-10 year duration is 18o30 mg%, for > 10 years
duration is 15030mg%, mean BMI of 25.41 2.99 kg / met2 Where as Patients Who are
diabetic for >10years HAD mean BMI of 23.21 2 97kg/ met2.28
Study done by Jyothi m et al. out of 65 Patients Studied They found That mean FBs in
neuropathy patient is 20668mg%, mean HbAlc is 7.74 1.48.29
Study done by Patel.H.s et al out of 838 diabetic They found 32.2% Patients of them had
a hypertension Among Diabetic neuropathy.30
Study done by Arezzo JC et al found They found maximum defect will be at sural nerve
They Also found 1% fall in HbAlc Improves the conduction velocity by about 1.3M/s.
found That motor nerves are Predominantly Involved early in Diabetic Neuropathy than
sensory.37
Study by Ewing et al They found out of 73 Patients They Studied 62 males and 11
females, out of 62 males 30 HAD erectile dysfunction followed by postural hypotension,
intermittent diarrhea, hypoglycemic unawareness and gustatory sweating, They found
autonomic function testing using a simple cardiovascular reflex Gives a good guide to
the diagnosis of autonomic neuropathy.92
Many of the Mechanisms: such as oxidative stress, glycosylation and activation of protein
kinase C (PKC) Have Been demonstrated in all tissues affected by microvascular complications.
Basement membrane is essential for maintaining tissue architecture, to modify cellular
proliferation and providing filtration barrier.
Various theories Have Been put forward, some accepted theories are:
Hyperglycemia causes an Increased flux through the enzyme aldose reductase Which gets
activated and use nicotinamide adenine dinucleotide phosphate hydrogenase (NADPH) to reduce
glucose to sorbitol.
This is then oxidized to fructose via sorbitol dehydrogenase. The decline in NADPH Caused by
Increased Aldose reductase flux decreases the generation of nitric oxide in endothelial cells.79
and cellular redox balance. Increased NADH /NAD ratio that May alter enzyme activity Also
Contribute to the complications.80 by Increased sorbitol accumulation Which is neurotoxic to
nerves.81
During the normal course of aging, proteins become irreversibly modified by sugar in a process
Known as Mailard reaction, leading to tissue "browning.hyperglycemia in diabetes accelerates
this process by covalent modification and cross linking proteins82.
The products of the nonenzymatic glycation of proteins are varied in chemical structure and as a
group, Have Been termed AGEs. Formation of AGE May damage cells by impairing function of
a wide range of proteins.83 including modifications of extracellular structural proteins: such as
collagen.84 and intracellular proteins.85,86 AGEs can Also cellular alter function by binding to
receptors called RAGE, a trans-membrane receptor.
This initiates a cascade of cellular signaling events, Such as activation of mitogen activated
protein (MAP) kinase Which can Lead to cellular dysfunction.87
The metabolism of glucose through glycolytic pathway and the tricarboxylic acid cycle produces
t Reducing equivalents that are used to drive ATP synthesis via oxidative phosphorylation in the
mitochondria.
Increased oxidant stress reduces nitric oxide levels damages cellular proteins and Promotes
leucocyte adhesion to the endothelium while inhibiting it barrier functions.
Protein kinase C and Diacylglycerol are critical intracellular signaling molecules that can
regulate many vascular functions Including permeability, vasodilator release, endothelial
activation and growth factor signaling.
FIG 1
FIG 2
FIG 3
Glucose is essentially used as a screening parameter. Values are highly diet dependent and drug
intake influences the results. Glucose can be Estimated chemical and enzymatically if the fasting
plasma glucose > 7.0 m (126 mg %) or the post prandial plasma glucose >11.1Immol l / L(200)
mg Then it is Considered to be a case of diabetes.
A glucose tolerance test in medical practice is the administration of glucose to determine how
quickly it is cleared from the blood.
The test is usually used to test for diabetes, insulin resistance and sometimes reactive
hypoglycemia.
The glucose is most often given orally so the common test is technically an oral glucose
tolerance test.(OGTT).
Glycosylated hemoglobin:
Of all the glycosylated form of hemoglobin, HbAle The most viable. More than 80% of the
glycosylated form is HbA1c. Hence its measurement is taken to be the perfect parameter
Understand the long term diabetic Control.
This is the Most Important tool for monitoring diabetes.This test Refers to the hemoglobin
component FORMED by interaction with glucose.
Since life span of RBCs is approx 120, a single HbAlc determination can give information about
glycemic control in the preceding 8- 12weeks. It is estimated by HPLC method, which is
considered to be the gold standard.
The advantage is this test does not require any dietary preparations and has low sensitivity and
high specificity Compared to oral glucose tolerance test
Microalbuminuria
FPG >126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.*
OR
2-h PG>200 mg/dL (11.1mmol/L) during an OGTT. The test should be performed as described
by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved
in water.*
OR
A1C >6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is
NGSP certified and standardized to the DCCT assay.*
OR
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma
glucose >200 mg/dL (11.1 mmol/L).
*In the absence of unequivocal hyperglycemia, results should be confirmed by repeat testing.
CHRONIC COMPLICATIONS oF DM
"Microvascular:
Eye disease
-Retinopathy (no proliferative proliferative)
-Macular edema
Neuropathy:
- Sensory and motor (mono- and polyneuropathy)
- Autonomic
Nephropathy
Macrovascular:
- Coronary heart disease
- Peripheral arterial disease
- Cerebrovascular disease
Others
- Gastrointestinal (gastroparesis, diarrhoea)
- Genitourinary ( uropathy/ sexual dysfunction)
- Dermatologic
- Infectious
- Cataract
-Periodontal disease
-glaucoma
-Hearing loss
The diagnosis of Diabetes Mellitus can be made on clinical examination but subsequently it
need to be confirmed by investigations (non-invasive/ invasive), The diagnosis of Diabetes
Mellitus in time is very important. Because effective intervention will only be possible only
during the subclinical or early phase of dysfunction.
CLINICAL EXAMINATION
Sensory examination
NERVE TESTS
Skin punch biopsy
Autonomic neuropathy
ls sensory and often overlooked component of diabetic Neuropathy Any organ of the body
Which is supplied by autonomic nerves are Affect, it follows. "All or None phenomenon 12
symptoms range from minor to severe among autonomic neuropathic symptoms. , gustatory
sweating is common most followed by hypotension and diarrhea.
Proximal neuropathy
Typically Affects the elderly males >50 yrs suffering from type2 DM May be symmetrical or
asymmetrical With or Without sensory loss.13patient complaints of difficulty in squatting
position , climbing, marked weight loss. diabetic amyotrophic mainly nerve root involvement
due to occlusion of the vasa nervosum and infarction. mainly affected are anterior and lateral
adductor compartments of thigh , knee jerk absent, ankle jerk +.
FOCAL NEUROPATHIES
CRANIAL NEUROPATHY:3 rd,4th and 6th cranial nerves commonly involved .
TRUNCAL NUROPATHY:Most commonly affected groups are 5th and 6th decade of life. with
variable duration of diabetes, patients present with pain and dysasthesia in the lower ant chest or
upper abdomen with nocturnal intensification causing abdomen muscle weakness.
ENTRAPMENT NEUROPATHY
called pressure palsy
medial nerve most commonly involved
occasionally ulner or lat cutaneous nerve of thigh.
This is the test commonly used to Evaluate the function Especially the Ability of electrical
conduction of the Motor and sensory nerves of the Human body.
Nerve conduction studies are used mainly for the evaluation of paresthesis (tingling, numbness.
Burning) weakness of the arms and legs.
Performed by electrical stimulation of peripheral nerve and recording from muscle supplied by
this nerve.The Time It Takes for the electrical impulse to travel from the stimulation to recording
site is measured.
This value is the latency and is Measured in seconds (ms), The size of response is called
Amplitude. Motor amplitude are Measured in m volt (mv)
Sensory latencies are on the scale of milliseconds. Sensory amplitude are much smaller than the
amplitude motor Usually in microvolt (ultraviolet) range. The sensory NCV is Calculated based
upon the latency and the distance b/w the stimulating and recording electrode.
F "study
'F wave study use supramaximal stimulation of motor nerve and recording of action potentials
from a muscle supplied by the nerve.
This is not reflex per se in that the Action potentials travel from the site of the stimulating
electrode in the limb to the spinal cords central home and back to the limb in the same nerve That
was stimulated.
The F wave latency can be used to derive the conduction velocity of nerve b/w the limb and
spine.
H reflex study
H reflex study uses stimtilation of a nerve and recording the reflex electrical discharge from a
muscle in the limb
This also evaluates conduction b / n the limb the spinal cord but in this case The afferent
impulses (Those going towards the spinal cord) are in sensory nerves while the efferent impulse
(Those coming. from the spinal cord) are in motor nerves.
METHODOLOGY
STUDY GROUP
The study includes all type 2 diabetics from OPD's and IPD s in the department of medicine
AIMS and AH &RC,BG NAGARA in the period Between DEC 2014 to JUNE2016.
INCLUSION CRITERIA
Nutrition deficiency
Alcoholism
Leukemia
Chronic renal failure
Infectious diseases
Occupational diseases
Type l Diabetes mellitus
Unilateral reflex loss
Toxic neuropathy
chronic liver disease
critically illness polyneuropathy
heriditarry neuropathy
autoimmune diseases
GB syndrome
Drug induced neuropathy
Malignancy
A detailed history was taken and examination done as per the proforma. With detailed emphesis
on peripheral nervous system Including cranial autonomic Involvement-for target organ
Involvement due to diabetes. All Patients in Addition to hematological and routine work up.
All Patients underwent nerve conduction studies for assessment of peripheral nerve Involvement
reading of ENMG was done with the help of neurologists.
INVESTIGATIONS
-FBS
- PPBS
- HbAlc
-CBC
-ESR
- Routine urine
- ECG
- RFT, LFT
- Autonomic function test
- NERVE CONDUCTION STUDY
Two-hour plasma glucose of 11.1 mmol / L (200 mg / dl) During an oral glucose tolerance
test.subjects who are alrady on treatment for diabetes.
RESULTS
In this study, 50 patients with diabetic neuropathy are studied and results were tabulated
as follows
TABLE 1.
Sex
Male
Female
Size
25
25
Peripheral neuropathy
25
25
In the present study of 50 patients with type 2 diabetes, 25 are males and 25 are females. We
have found that prevalence of peripheral neuropathy was same in both females and male.
Male
Female
Total
Percentage
35-45years
10
20
46-55years
10
20
56-65years
11
12
23
46
66-90years
14
Total
25
25
50
100
Figure 4
25
20
15
FEMALES
MALES
10
0
35-45
46-55
55-65
66-90
In this study, we had 50 patients with type 2 diabetes with neuropathy, they were in age
group between 35 to 90 years. Out of this, 10 patients were in age group 35-45
years(20%), 10 patients were in age group 46-55 years(20%), 23 patients were in age
group 56-65 years(46%) and 7 patients were above the age of 65 years(14%)
Mean age of all 50 patients is 58.27 11.52years. Diabetic neuropathy was found
common in the age group of 56 to 65 years that is 23 patients 46%, males 11 Patients
(22%) and females 12 patients (24%)
No of pts
Percentage
5 10 years
11 15 years
16
32
16 20 years
30
60
Duration of diabetes in these patients varied from 5 20 years. Mean duration of diabetes is 9.54
3.65 years
Increased duration of diabetes had significant relation to neuropathy.
No of cases
Percentage
Good control
14
17
34
26
52
FBS>180mg, PPBS
>235mg
Out of 50 diabetic neuropathy patients, 7 patients had good control (14%), 17 patients had fair
control(34%) and 26 patients had poor control(52%)
No of patients
Percentage
36
72
Motor symptoms
11
22
Autonomic symptoms
Figure 5
Sensory symptoms
2%4%
Motor symptoms
22%
Cranial nerve
symptoms
Autonomic symptoms
72%
Symptoms pertaining to the involvement of nervous system due to diabetes mellitus were further
analysed in 50 cases as follows.
Out of 50 diabetic patients, symptoms of neuropathy were present in 50 patients. The symptoms
with which patients presented are burning feet in 20 patients(40%), tingling sensation of limbs in
11 patients(22%), numbness of limbs in 5 patients (10%), weakness of limbs in 11
patients(22%), the commonest symptom was burning pain at night hours in 20 patients (40%).
Neurological examination
Sensory system:
The following observation were made in 36 patients.
1. Impairment of temp, touch, and pain, sensation.
9 (25%)
9 (25%)
8 (22%)
5 (14%)
5 (14%)
Figure 6
Impairment of temp,
touch, and pain,
sensation
14%
25%
Impairment of vibration
sensation
14%
Impairment of joint/
position 'sensation
22%
25%
Absent
Total
Ankle jerk
15
20
Knee jerk
10
13
Diminished or absence of reflexes were mainly found in patients with uncontrolled blood sugars
and higher values of HbA1c levels.
Gait:
Gait was normal in all patients except 5 patients who had sensory ataxia and all of these patients
showed romberg's test positive
Types of neuropathy
No of cases
Percentage
36
72
11
22
Autonomic neuropathy
Cranial neuropathy
Distal symmetrical sensory neuropathy was most commonest type found in 36 patients
(72%).
No of Cases
Percentage
Good control(5.5-6.8%)
14
17
34
26
52
Mean HbA1c level is found to be 8.611.66 and 40 Patients (80%) had higher HbAlc values of
more than 7
and it is found that 26 patients (52%) had poor control.
Percentage
33
66
No complications
17
34
Total no of pts.
Retinopathy
33
Nephropathy
17
In this study, out of 50 patients with type 2 diabetes, 33 patients (66%) had complications
of diabetes in the form of retinopathy, nephropathy and peripheral vascular disorder
based on clinical and laboratory evidences. 12 out of 33 patients had retinopathy changes
(24%), nephropathy in 17 patients(34%).
No of pts
OHA`S
39
INSULIN
11
In this study of 50 patients with type 2 diabetes with peripheral neuropathy, 39 patients
(78%) were on only OHAs and 11 patients (22%) were on both insulin and OHAs, none
of them were on only insulin.
To conclude among those with peripheral neuropathy, we have found that glycemic
control was poor, this could be due to the effect of hyperglycemia on peripheral nerves.
Nerve
Conduction
Study - Positive
Nerve
Conduction
Study - Normal
No of patients with
peripheral neuropathy
Velocity
Reduced
Amplitude
Reduced
27
36
9
14
14
50
Total
Nerve conduction study was done for all patients with signs and symptoms of
neuropathy. Nerve conduction study was positive in 36 patients (72%), among them 30
patients (60%) had uncontrolled blood sugars and HbAlc levels, 6 patients( 12%) with
normal blood sugars and HbAlc. 14 patients (34%) who had symptoms of neuropathy
and uncontrolled blood sugars found normal nerve conduction study
DISCUSSION
Among the endocrinal metabolic diseases diabetes occupies the major share. India has the
dubious distinction of being home to the largest number of people suffering from diabetes in any
country. The disease is responsible for significant mortality and morbidity due to the
complications.15
This study was conducted at AIMS, AH&RC during 2015 and 2016. Peripheral neuropathy was
studied in type 2 Diabetes Mellitus patients attending the OPD and IPD of AIMS Medical
College and Research Hospital.
A total of 50 type 2 diabetics were studied. All were confirmed diabetics who previously had
blood glucose levels of > 126 mg / dl or RBs of >199 on more than one occasion and were
receiving treatment such as Insulin, OHA's or physical exercise therapy.
Study done by Sumner. CJ et al16 ,out of 73 diabetic patients they have found prevalence of
Neuropathy in 56% of Patients.
Study done by S.Ashok et al17 Prevalence of diabetic neuropathy was 19.1% out of 1,000
consecutive diabetic patients who have visited there diabetic center.
Study done by Ch. manes et al18 they found incidence of that diabetic neuropathy was 33.5%,
among 821 diabetic patients they found 275 patients had peripheral neuropathy.
Study done by Kjerosti morkid et al19 , they studied 294 diabetic patients they found Prevalence
of Diabetic neuropathy in 19.7% patients.
Study done by Mitrabasu et al20 , found that out of 82 diabetic patients studied 42 patient had
peripheral neuropathy and 8 patients had autonomic dysfunction that shows 54.0% patients had
peripheral neuropathy and that Autonomic Involvement in 10.8%.
Study done by Vishwanathan et al21,3,they studied 1319 type 2 diabetic subject patients in
selected four different centers in India and found prevalence of Diabetic neuropathy in 15% of
patients .
In this study it was found prevalence of diabetic neuropathy is 52% in patient with uncontrolled
blood sugars which is similar to study done by sumner c J et al. mitrabasu et al
Study done by S. Ashok et al17 they studied 1000 consecutive diabetic patients who have
visited there diabetic center they found prevalence of neuropathy Increases with Increases in Age
of a patient and duration of Diabetes.
Study done by Ch manes et al18 in there study they found Diabetic neuropathy is more
common in age group of 61.615.5 years, out of 821 diabetic patients 275 patients had diabetic
neuropathy which falls in above age group.
Study done by Kjerosti They morkid et al19 they studied 294 diabetic patients they
found prevalence of Diabetic neuropathy Increases With age 11.1% in 23- 40 years. 32.3% in age
group 60-80 years. age
Study done by Sase et al22 in there study they found mean age of development of
diabetic neuropathy is 50 years.
Study done by Mitrabasu et al20 found that out of 82 diabetic patients studied 42 patient
had peripheral neuropathy, Average age of development of peripheral neuropathy In these
patients is 50.17 is 6.9 years. They also observed hat age and duration of diabetes play an
Important role in diabetic neuropathy and significantly associated with higher age.
Vishwanathan et al3 they studied 1319 type 2 diabetic subject patients in selected four
different centers in India found mean age of development of diabetic neuropathy was 53 11
years.
Study done by Arindam dutt et al23 they studied 100 diabetic patients found that
neuropathy is more in the age group of 50.44 10.35 years
In this study incidence of neuropathy is more in age group of 58.2711.52 years, similar
to other study by ozgur boyraj et al vishwanath et al, ch mane et al
Study done by Sase et al22 in their study they found among diabetic patients who had
peripheral neuropathy, 62% are male and 38% female, showing males predominant than females
Study done by Mitrabasu et al 20 found that out of 82 diabetic patients studied 42 patient
had peripheral neuropathy, and male patients are predominant in developing diabetic neuropathy
75.8% than females 24.2%.
Study done by the Kjerosti morkid et al19 they studied 294 diabetic patients they found
prevalence is more in female (52.7%) 155 than males (47.3%) 139
Study done by Vishwanathan et al3 they studied 1319 type 2 diabetic subject patients in
selected four different centers in India found diabetic neuropathy more in males than females
ratio was 2: 1.
Study done by Arindam dutt et al23 they studied 100 diabetic patients found That 28% are
male diabetics 31% are female, showing diabetic neuropathy effects females >males
In this study females are equal to males which is similsr to kjerosti mokrid et al, a study by
sase et al shows slight male predominant, and study by arindam dutt et al shows female
predominant.
Study done by Mitrabasu et al20 found that out of 82 diabetic patients studied 42 patients
had peripheral neuropathy, they found average years need to develop Diabetic Neuropathy
is6.737.21 years.
Study done by by Ch manes et al18 the average duration of diabetes is 10.687.8 years to
develop in to peripheral neuropathy they Studied 821 diabetic patients among which 275 had
diabetic neuropathy.
Study done by Kjerosti morkid et al19 they studied 294 diabetic patients they They found
average duration of diabetes to develop was 9-11 years.
Study done by s Ashok et al17 out of 1000 consecutive diabetic patients who have visited
their diabetic center they found age and duration the major risk factor for neuropathy.
Study done by Vishwanathan et al3 l they studied 1319 type 2 diabetic patients in selected
four different centers in India found duration of diabetes in these study is 6.255.3years to
develop diabetic neuropathy.
Study done by Pirarat et al25 the incidence of Neuropathy Increased from 7.5% on
diagnosis to 50% at 25 years of follow up.
Study done by Rathmann w et al diabetic autonomic neuropathy accounts for silent
myocardial infarction and shortens the life-span, resulting in death in 25-50% of patients with in
5 - 10 years of autonomic neuropathy.
The average time of developing diabetic neuropathy being 9.54 6.5years in this study
is similar to the other studies by ch manes et al, kjerosti mokrid et al, Vishwanath et al, pirarat et
al ashok et al, Ozgur boyraj et al
In this study, it is found out of 50 patients mean fasting blood sugar is 161.74 45.17mg
%, mean post prandial blood sugar 240.70 83.80mg%, 26 patients 52% who have poor control
of blood sugars were more prone to develop neuropathy
Study done by Arindam dutt et al23 they studied 100 diabetic patients found that both
fasting and postprandial Blood Glucose levels are higher in Neuropathic patients compared to
non-Neuropathic group. Average FBS (22068 mg%), average post prandial blood sugar of (333
84 mg%).
Study done by Mitrabasu et al 20 found that out of 82 diabetic patients studied 42 patient
had peripheral neuropathy in theier study they found fasting and post prandial Glucose levels and
Were associated and 2 times risk of Developing Peripheral Neuropathy in diabetic patients. The
mean fasting Glucosein their study is 149 +/- 48 mg%
Study done by Vishwanathan et al3 'Profile of diabetic foot complication and Its associated
complications a multi center study from India they studied 1319 type 2 diabetic patients in
selected four different centers in India found diabetic neuropathy patients have mean PPBS IS
27891 mg%.
Study done by Ch manes et al18 they found mean fasting glucose was fo 19550mg% in
a patient who had developed Diabetic Neuropathy it was very significant finding. They studied
among 821 diabetic patients among which 275 had diabetic neuropathy.
Study done by Sultan and et al28 found that fasting Blood Glucose average for development
of peripheral neuropathy in a diabetic Patients for 5-10 year is 180 30mg%. for > 10 years
duration is 150 30mg%.
Study done by Jyothi.m Sarvant et al29 out of 65 patients they studied found that average
FBS in neuropathy patient is 20668.mg%.
The mean fasting and postprandial levels in present study was similar to the other studies
reported by Viswanath et al, mitrabasu et al, sultan at al and jyothi et al.
Study done by Mitrabasu et al20 found that out of 82 diabetic patients 42 patients had
peripheral neuropathy, and they found mean glycosylated Hb% for development of the diabetic
neuropathy is 7.9 1.38
Study done by Jyothi. M sawant et al29 out of 65 patients they studied found average
HbA1c of 7.74 1.48 in a diabetic neuropathy patient.
Study done by the Kjerosti morkid et al19 they studied 294 diabetic patients they found mean
HbA1c of 8.752.20 for the development of peripheral neuropathy.
Study done by Ozgur boyraj et al24 average HbA1c to develop peripheral neuropathy
6.91.7 in normal diabetic and in Obese patient 7.91.4 .
The mean HbA1c level in this study was 8.61 1.66 and is similar to other studies by
mitrabasu et al, jyothi m sawant et al, kjerosti mokrid et al and Ozgur boyraj et al.
Study done by Vishwanathan et al3 hypertension was found in 34% subjects who also had
diabetic peripheral neuropathy.
Study done by Patel.H. S et al30 they S studied 838 diabetic patients they found 32.2% of
patients had a hypertension with Diabetic neuropathy.
Study done by the Kjerosti morkid et al19 they studied 294 diabetic patients they found
hypertension not related to neuropathy.
Study done by Mitrabasu et al20 found that out of 82 diabetic patients studied 42 patient had
peripheral neuropathy in their study Body mass index, hypercholesterol and hyper
triglyceridemia levels were associated and higher incident of Diabetic neuropathy systolic BP
average in their study is 134 16.0 mmHg in peripheral neuropathy patients.
Study done by Vishwanathan et al3 they studied 1319 type 2 diabetic patients in selected
four different centers in India found that mean systolic BP of 132 32 mmHg and Diastolic BP
of 8511.5 mmHg in a patient of diabetic neuropathy.
Study done by Arindam dutt and et al23 they studied 100 diabetic patients found that 18%
of males and 12.82% of female patients who had Diabetic neuropathy were suffering from
Hypertension. Both systolic and Diastolic Blood pressure is higher in Diabetic neuropathy
patients compared to non-neuropathic group. Systolic 12919.9mmHg and diastolic of
82.29.32 mmHg.
In our study result were similar to Vishwanathan et al, and arindam Dutt et al.
In our study 36 patient 72% had abnormal nerve conduction study and 14 patients(34%)
had normal nerve conduction study.
Study done by Sase et al22 in their study found 76% of diabetic neuropathy patients had
predominantly demyelinating plus axonal type of neuropathy
Study done by Sumner C J. et al16 patients with impaired glucose tolerance had
predominantly small fiber neuropathy compared to other patients and in Diabetes Patient more
involvement of large fiber, According to nerve conduction study, velocity is gradually reduced in
diabetic neuropathy with estimated loss of about 0.5M / S / year.
Study done by Arezzo J C. et al37 they found maximum defect will be at sural nerve they
also found 1% fall in HbA1c mproves the conduction velocity by about 1.3M / S .
Study done by Arindam Dutt et al23 they studied 100 diabetic patients and found the nerve
conduction study was abnormal in 27% of patient of diabetic neuropathy out of 27%, 15% of
patients had reduced nerve conduction velocity.
Result of nerve conduction study was done at this center was in conformation with the
results of study done by sase et al and arindam et al.
In this study, it is found that average BMI is 25.143.41 kg / m2. Study revealed that 23
patients(46%) were obese with BMI>23.
Study done by Mitrabasu. et al20 found that of of 82 diabetic patients studied 42 patients
had peripheral neuropathy, and also they found that higher the BMI higher the incidence of
Diabetic Neuropathy, they found mean BMI of 25.4 4.6 kg / met2 in neuropathy patients.
Study done by Kjerosti morkid et al19 they studied 294 diabetic patients they found mean
BMI of 24.43 3.35 kg / met2 in neuropathy patients.
Study done by Ch manes et al18 in their study Body weight not positively correlated with
Neuropathy, in their study of 821 diabetic patients 275 had diabetic neuropathy.
Study done by Sultan. et al28 found that patients who are 5-10 years to develop Neuropathy
had mean BMI of 25.412.99kg/met2 where as patient who are diabetic for >10 years had
average BMI of 23.21 2.97 kg / met2
Study done by Vishwanathan et al21 they studied 1319 type 2 diabetic subject patients in
selected four different centers in India found BMI of 25.41 2.99 kg / met2 in a diabetic
neuropathy patient .
Study done by Arindam dutt et al23 they studied 100 diabetic patients found that 23% of
patient with diabetic neuropathy had BMI of 25 g / met2, according to them there is significant
difference in BMI of neuropathic and non neuropathic groups 22.5 3 kg /met2 and 22.953.15
kg / met2.
Study done by Ozgur boyraj et al24 BMI to develop neuropathy in diabetic patient is 25.5
2.4 kg / met2 in obese diabetics it is 27.9 1.4.kg/met2.
Result in this study is 25.24 3.41kg / met2 'which is similar to mitrabasu et al, sultan et al
and vishwanathan et al.
In this study we found mean cholesterol levels of 208.08 43.24 in diabetic neuropathy
patients, mean triglycerides levels 202.70 57.22, and 30% of patients who had diabetic
neuropathy also had deranged cholesterol levels.
Deranged Triglyceride level was found to be risk factor for development of Diabetic
neuropathy.
Study by Mitrabasu et al20 found that 82 diabetic patients studied 42 patients had peripheral
neuropathy and found mean triglyceride levels are 133 44, In neuropathy patients.
Study done by Kjerosti morkid et al19 they studied 294 diabetic patients they found average
cholesterol level of 19031 in Diabetic Neuropathy Patients.
Study done by Vishwanathan et al21 they studied 1319 type 2 diabetic subject patients in
selected four different centers in India found average cholesterol level of 19448 in a patient
with Diabetic Neuropathy.
Mean cholesterol level found in this study was similar to that of Vishwanathan et al and
kjerosti mokrid et al.
Study done by Sase. et al in their study they found 72% of patients had Bi-lateral
Symmetrical mixed (sensory and motor) symptoms Predominant distal Involvement in 94% and
16% patient presented and pure sensory symptoms., 12% had pure motor symptoms.
Study done by Sultan et al28 found that motor nerves is predominantly Involved in early
Diabetic Neuropathy than sensory.
Study done by V.Bamal38 distal symmetrical Neuropathy is the commonest form of the
peripheral neuropathy in diabetic patients constitute 75%.
Study done by Arindam dutt et al23 they studied 100 diabetic patients found that 32% of
patients had Neuropathy symptoms, Tingling was the most common symptom (43.75%)
followed by Tingling and Numbness (21.87%), Tingling and Burning feet in (12.5% ), Buming
feet alone (12.5%), weakness of limbs (6.25%) combination of tingling, Numbness and Burning
feet (3.13%)
In this study results are similar to sase et al, sultan et al and arindam dutt et al.
In this study we found that 78% of patients were on only OHAs and 22% of patients are on
both OHA and insulin therapy
Study done by the Kjerosti morkid et al19 they studied 294 diabetic patients found
prevalence of Diabetic neuropathy in 13.7% who are on oral hypoglycemic agents (OHA) and
29.2% in insulin treated group , found prevalence more in Insulin treated group.
In this study, among those with peripheral neuropathy we found that glycemic control was
poor.
CONCLUSION
SUMMARY
50 patients of diabetic neuropathy studied clinically and nerve conduction study.
Symptoms of sensory system involvement were the most common, seen in 36 (72%)
patients, followed by motor symptoms seen in 11 (22%) cases. Autonomic symptoms 2
(4%) cases and cranial nerve symptoms one case (2%).
Examination of the cranial nerve revealed Ill cranial nerve palsy in one patient.
Symmetrical sensory loss was confined to the lower limbs and upper limbs in all
patients.
Distal symmetric sensory neuropathy was the most common type of clinical neuropathy
found.
Blood sugar estimation revealed evidence of poor control on 26 Patients (52%).
Estimation of glycosylated hemoglobin showed poor control in 26 Patients (52%).
Patients With hypertension (24%), BMI (46%) and age (56-65) 46% were predisposed
to neuropathy.
The efficacy of glycosylated hemoglobin estimation in assessing diabetic control is not
influenced by Age, Sex, duration, or diabetes and a mode of therapy.
Longer the duration and poorer the control of diabetes, more are the chance of
development of the complications of diabetic neuropathy.
14% of patient with diabetic neuropathy had good glycemic control.
This study is done in rural patients, the incidence of neuropathy in type 2 diabetes and
its relation to glycemic control were found to be similar to that of urban patients reported
from other studies.
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Income:
Diagnosis:
D.O.A.:
D.O.D:
I.P.No:
Diagnosis of DM type and duration :
Treatment - Diet / exercise / OHA'S / Insulin
Insulin: Type/Dose/Duration/Irregular or regular
Oral Hypogycemic agents: Type / dose duration regular or irregular.
Control of DM : Good /Fair/Uncontrolled .
General Symptoms:
Polyphagia/ Polyuria/ polydipsia/ Loss of Weight /Tiredness
C.N.S
a. Tingling and numbness (paraesthesia) of feet and hand /duration/ Pain in lower limbs/
Burning sensation in the feet or palm
b. Sensory loss/unsteadiness of gait/
c. Motor Weakness of limb
d. Symptoms suggestive of Cranial Nerve
, visual disturbances
Diplopia
Blurring of vision with headache
. Unilateral facial weakness
AUTONOMICSYMPTOMS
CVS
H / O Painless Myocardial infarction, Postural Giddiness ,gustatory sweating,Absence
of sweating
Genito Urinary
bladder dysfunction
Sensation of incomplete emptying with straining
overflow incontinence / recurrent urinary tract infection
Sexual Dysfunction
Male: Impotence/ Retrograde ejaculation
Genitourinary
Female: Dysuria / Pruritis / Vulva/White discharge per vagina
Hypoglycemic unawareness
sweating disturbance / Blurring of vision / Palpitation
CVS
Chest Pain / Palpitation / Breathlessness/syncope/swelling of feet
Personal History
Diet: mixed/ veg
Sleep:
Bowel / Bladder movements
Smoking Duration No. of beedi; Cigarette perday
Alcohol in take; Type/ Duration/ frequency/frequency
Drug Addiction. Tobacco chewing
GENERAL PHYSICALEXAMINATION
Level of consciousness
Decubitus
State of Nutrition
Build
Trophic Changes
Skin Changes
Lymphadenopathy
Oral hygiene
Pedal edema
ENT
Eye
Gangrene / Ulcer
Peripheral felt pulses / not felt
Wt. Kgs
Height in cm
Waist circumference
BMI
PULSE: rate / rhythm / volume /charecter condition of vessel wall/ change of pulse to Valsalva
maneuver
B.P. Supine / standing / postural drop
Respiratory Rate :Rate/ Rhythm
Temp: Normal/increased/ Decreased
Systemic Examination:
A. Central Nervous System
Higher Mental Functions
Cranial nerves
Sensory System
Touch
Pain
Temparature
Joint Sensation
Position Sensation
Vibration Sensation
Cortical Sensation
Romberg's Sign
Motor System
a. Nutrition .wasting+/-, type
b. Tone
c. Power
d. Coordination
e. involuntary movement.
Reflexes
a. Superficial reflexes
b. Deep reflexes
Cerebellar System
Signs of meningeal Irritation
Examination of spine/skull
B. Cardiovascular system
. Inspection/ Palpation/ Percussion/ Auscultation/ Heart sounds ,added sounds. Murmurs
C.Respiratory system.
Inspection/ Palpation/ Percussion/ Auscultation: