Diabetic Neuropathy. Friedrich A. Gries

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Diabetic Neuropathy - Friedrich A. Gries

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Definition

       Assessment as Part of the Annual Review of the Patient

       Management

       Appendix 1: International Guide on the Outpatient Management of Diabetic Peripheral Neuropathy

       Introduction

       Peripheral Neuropathy in Diabetes

       Definitions

       Stages of Neuropathy

       Assessment

       Patient History

       Examination of the Patient

       Other Investigations

       The “At Risk” Foot

       Management

       No Clinical Neuropathy (Stage 0/1)

       Clinical Neuropathy (Stage 2)

       Late Complications of Clinical Neuropathy (Stage 3)

       Patient Education

       Who Should Provide Patient Education?

       What methods should be used?

       What elements should the education programme contain?

       Summary of the Management of Neuropathy

       Acknowledgement

       Appendix 2 List of Participants

       Pilot Working Party, Brussels, Belgium 13 April 1995

       Full Working Party, London, UK, 20-22 October 1995

       Index

      1 Diabetes Mellitus: An Introduction

      F.A. Gries, J. Eckel, P. Rösen, and D. Ziegler

      The aim of this introduction is to provide a general understanding of diabetes mellitus and its impact on the diabetic individual. It will focus on aspects of epidemiology, pathobiochemistry, prevention, and therapy. Given the scope covered, selectivity and bias of topics and citations have been accepted as unavoidable.

Definition

      The term “diabetes mellitus” comprises a number of chronic diseases characterized by hyperglycemia due to absolute or relative insulin deficiency. Hyperglycemia is only the most obvious biochemical marker of complex metabolic disorders that affect carbohydrate, lipid, protein, and electrolyte metabolism and may impair numerous organs and functions of the organism.

Diagnosis

      The diagnosis of diabetes mellitus is based on classical symptoms (weight loss, polyuria, thirst, muscular weakness and fatigue) and persistent hyperglycemia. Glucosuria and elevated glycosylated hemoglobin (HbAlc) levels should not be used for diagnosis. The criteria for diagnosis of hyperglycemia and the classification of diabetes mellitus are not uniformly accepted. Some physicians use the criteria of the United States National Diabetes Data Group of 1979 [1], which was endorsed by the World Health Organization Study Group on Diabetes Mellitus in 1985 [2], while others prefer the criteria of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus of the American Diabetes Association 1998 [3] (Table 1.1).

      The criteria published in 1998 tend to diagnose diabetes in younger and more obese subjects than the WHO 1985 criteria, while subjects with postprandial hyperglycemia, microalbuminuria, and those with other predictors of cardiovascular disease are less likely to receive this diagnosis despite the fact that they are at similar risk of premature death [48].

Classification

      The diabetes mellitus classification of 1979 [1] was based “in large part on the pharmacological treatment used in its management.” This was reflected in the terms “insulin-dependent diabetes mellitus” (IDDM) and “non-insulin-dependent diabetes mellitus” (NIDDM) and the further subdivision of patients with the latter into obese and nonobese. The typing of 1998 is based on etiology and pathogenetic mechanisms (Table 1.2). About 50 different types of diabetes mellitus have been identified, the majority of cases being type 1, type 2, or gestational diabetes mellitus.

      Table 1.1 Criteria for the diagnosis of diabetes according to the World Health Organization [2] and the American Diabetes Association [3]

World Health OrganizationAmerican Diabetes Association
Clinical:
Increased thirst and urine volume, unexplained weight loss, established by casual blood glucosePolyuria, polydipsia and unexplained weight loss plus casual plasma or capillary blood glucose ≥ 200 mg/dl (11.1 mmol/l)
oror
Biochemical:
Casual venous plasma glucosea > 200mg/dl (11.1 mmol/l), fasting venous or capillary plasma glucose b ≥ 140 mg/dl (7.8 mmol/l) and 2 h venous or capillary plasma or capillary whole blood glucose c ≥ 200 mg/dl (11.1 mmol/l) after glucose loaddFasting plasma glucose ≥ 126 mg/dl (7.0 mmol/l) or capillary blood glucose ≥ 110 mg/dl or 2 h plasma or capillary blood glucose ≥ 200 mg/dl (11.1 mmol/l) during an oral glucose tolerance test

      a Values for capillary plasma > 220 mg/dl, for venous whole blood >180 mg/dl. for capillary whole blood > 200 mg/dl

      b Value for venous and capillary whole blood ≥ 120 mg/dl

      c Value for venous whole blood ≥ 180 mg/dl

      d Performed as described by WH01985 [2] using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water

      There is a great similarity between type 1 diabetes and IDDM and between type 2 diabetes and NIDDM. However, these pairs of terms should not be used indiscriminately as being respectively synonymous. Type 1 diabetes mellitus may for a limited time after manifestation remain non-insulin-dependent, particularly when it begins in an adult (latent autoimmune diabetes in adults. LADA; see page

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