Assessment of sensory neuropathy in diabetic patients without diabetic foot problems.

OBJECTIVES: To study the incidence and extent of peripheral sensory neuropathy in diabetic patients without diabetic foot problems (DFPs) with <5, 5-10 and >10 years duration of diabetes using three different modalities of testing: Pin-Prick Testing, 5.07 Semmes-Weinstein Monofilament Testing (SWMT) and Rapid-Current Perception Threshold (R-CPT) measurements using the Neurometer. METHODS: Our study population consisted of 60 patients (120 feet) treated for diabetes mellitus in the Division of Endocrinology at the National University Hospital. No patient had any DFPs. Twenty-two, 21 and 17 patients had duration of diabetes of <5, 5-10 and >10 years, respectively. All patients were tested for sensory neuropathy using Pin-Prick Testing using a standardized protocol, SWMT and the Neurometer. RESULTS: There was a significantly higher incidence of sensory neuropathy detected by both the Pin-Prick Test and the Neurometer as compared to the SWMT. Also, in all three modalities, there was a significant increase in incidence of sensory neuropathy detected in diabetics with >5 years duration of diabetes. In addition, the Pin-Prick Test showed an increase in extent of sensory neuropathy with a longer duration of diabetes. CONCLUSIONS: The Pin-Prick Test was found to be a simple, cheap and useful diagnostic tool for detection of sensory neuropathy in diabetics without DFPs. In addition, it could accurately delineate the extent of neuropathy in the lower limb - additional useful information not obtainable with SWMT or Neurometer. Even for patients with <5 years duration of diabetes, the incidence of sensory neuropathy detected was considerable. The incidence of neuropathy detected continued to increase with length of duration of diabetes. Hence, we recommend screening of patients for neuropathy as soon as they are diagnosed with diabetes.

Epidemiology of diabetic foot problems and predictive factors for limb loss.

OBJECTIVES: The aim of this study was to evaluate the epidemiology of diabetic foot problems (DFP) and predictive factors for major amputations (below- and above-knee). METHODS: This is a prospective study of 202 patients treated in National University Hospital (NUH) during the period of January 2005 to May 2006. A protocol was designed for documentation including patient profile, type of DFP, presence of risk factors, comorbidities and complications, clinical presentation, investigations, treatment given, and final outcome. The predictors for limb loss were determined using univariate and stepwise logistic regression analysis. RESULTS: One hundred ninety-two patients had Type 2 diabetes. Mean age of cohort was 60 years, with male to female ratio of 1:1. Incidence of DFP was significantly higher in Malays (P=.0015) and Indians (P=.036) and significantly lower in Chinese (P<.05). Of patients, 72.8% had poor endocrine control (GHb level >7%), and 42.1% of patients had sensory neuropathy based on 5.07 Semmes-Weinstein Monofilament test. Common DFP included gangrene (31.7%), infection (abscess, osteomyelitis) (28.7%), ulcer (27.7%), cellulitis (6.4%), necrotizing fasciitis (3.5%) and Charcot's osteoarthropathy (2.0%). Surgery was performed in 74.8% of patients and major amputation in 27.2% of patients (below-knee in 20.3% and above-knee in 6.9%). CONCLUSIONS: This is the first detailed prospective study evaluating predictive factors for major amputations in patients with DFP. Significant univariate predictive factors for limb loss were age above 60 years, stroke, ischaemic heart disease, nephropathy, peripheral vascular disease (PVD), sensory neuropathy, glycosylated haemoglobin level, Ankle Brachial Index (ABI) <0.8, gangrene, infection, and pathogens such as methicillin-resistant Streptococcus aureus (MRSA) and Staphylococcus aereus. Upon stepwise logistic regression analysis, only PVD and infection were significant.