Symptoms of painful diabetic neuropathy (PDN) occur in 30-40% of patients with diabetic neuropath... more Symptoms of painful diabetic neuropathy (PDN) occur in 30-40% of patients with diabetic neuropathy. 1 It is most commonly associated with distal symmetrical neuropathy affecting the lower limbs (especially toes and feet), and patients present with burning, stabbing and tingling sensations. PDN is extremely distressing and significantly reduces the Hassan Fadavi is undertaking his PhD in the Cardiovascular Research Group at the University of Manchester. His main research interests include defining the basis of ethnic differences in the development of diabetic neuropathy and the diagnosis and treatment of diabetic foot ulceration.
To quantify corneal ultrastructure using laser scanning in vivo confocal microscopy (IVCM) in pat... more To quantify corneal ultrastructure using laser scanning in vivo confocal microscopy (IVCM) in patients with keratoconus and control subjects. Unscarred corneas of 78 keratoconic subjects without a history of contact lens use and 36 age-matched control subjects were evaluated with slit-lamp examination (SLE), corneal topography and laser scanning IVCM. One eye was randomly chosen for analysis. Anterior and posterior stromal keratocyte, endothelial cell and basal epithelial cell densities and sub-basal nerve structure were evaluated. IVCM qualitatively demonstrated enlarged basal epithelial cells, structural changes in sub-basal and stromal nerve fibers, abnormal stromal keratocytes and keratocyte nuclei, and pleomorphism and enlargement of endothelial cells. Compared with control subjects, significant reductions in basal epithelial cell density (5817±306 cells/mm(2) vs 4802±508 cells/mm(2), P<0.001), anterior stromal keratocyte density (800±111 cells/mm(2) vs 555±115 cells/mm(2), ...
Page 1. Management of Painful Diabetic Neuropathy Patrick G. Jensen and Jennifer R. Larson Univer... more Page 1. Management of Painful Diabetic Neuropathy Patrick G. Jensen and Jennifer R. Larson University of Iowa Hospital and Clinics, Department of Pharmaceutical Care, Iowa City, Iowa, USA Contents Abstract . . . . . ...
The aim of this systematic review and meta-analysis was to assess the effect of Ramadan focused e... more The aim of this systematic review and meta-analysis was to assess the effect of Ramadan focused education on clinical and metabolic parameters in patients with type 2 diabetes who fast during Ramadan. Methods: Literature search was done in PubMed, Embase (Ovid), and the Cochrane Library. Quality assessment was done using the ROBINS-I and Cochrane tools for risk of bias and analyses were performed using RevMan version 5.1. Results: From 770 records, 430 full text studies were assessed. After exclusions, the final quantitative analysis included 16 studies. Pre-Ramadan education was associated with a significant reduction in Hb A1c (SMD À0.46, 95% CI À0.65 to À0.27P < 0.05) and LDL (SMD À0.09, 95% CI À0.13 to À0.04P < 0.05), an increase in TG (SMD 0.07, 95% CI À0.23 to 0.93P < 0.05) and weight (SMD 0.44, 95% CI 0.06 to 0.81P < 0.05) and no change in hypoglycemic events, BMI, TC, HDL or blood pressure (P > 0.05) during Ramadan. Conclusions: This systematic review and meta-analysis shows that Ramadan-focused diabetes education leads to a decrease in Hb A1c and LDL, but an increase in TG and weight during Ramadan. It also identifies a lack of head to head studies and limited observational studies with adequately assessed end-points.
This Practice Point commentary discusses the results of a study that employed thermal threshold t... more This Practice Point commentary discusses the results of a study that employed thermal threshold testing and quantification of intraepidermal nerve fiber (IENF) density in patients with diabetes who had normal electrophysiology findings. The study showed that a significant proportion of these patients had abnormalities in small-fiber function, as quantified by thermal thresholds, and structure, as quantified by IENF density. Interestingly, patients who showed symptoms of diabetic neuropathy had reduced IENF densities but no difference in thermal thresholds compared with diabetic patients lacking these symptoms. This study highlights the importance of establishing which tests should be used to detect the earliest nerve damage in diabetic neuropathy, and which tests should be used as end points in clinical trials relating to this condition.
Diabetic retinopathy is the major cause of premature blindness amongst adults in the western worl... more Diabetic retinopathy is the major cause of premature blindness amongst adults in the western world [1]. Characterised by microvascular occlusion and leakage due to endothelial and pericyte cell damage and basement membrane thickening, macular oedema, neovascularisation and vitreous haemorrhage can eventually result in blindness [1]. Sustained hyperglycaemia results in retinal under perfusion, hypoxia and retinal ischaemia. These changes induce the production of
Pitceathly, RDS and Tavakoli, M and Marshall, A and Roberts, ME and Gow, D and Efron, N and Malik... more Pitceathly, RDS and Tavakoli, M and Marshall, A and Roberts, ME and Gow, D and Efron, N and Malik, RA (2008) Corneal confocal microscopy to diagnose idiopathic small fibre neuropathy. In: JOURNAL OF NEUROLOGY NEUROSURGERY AND PSYCHIATRY.(pp. 342-342). BMJ PUBLISHING GROUP
In relatives of mutation positive FH patients we observed that LDL-C increases with age, but this... more In relatives of mutation positive FH patients we observed that LDL-C increases with age, but this is not taken into account within the criteria. In 250 relatives of mutation positive index patients we observed that genotype (p<0.001) and age (p<0.001), but not gender, significantly predicted LDL-C in relatives aged 18-70 years (LDL-C ¼ 2.004 + 3.620(genotype 0,1) + 0.035(age)). Applying this effect of age to index patients would suggest that older patients are more likely to have LDL-C high enough to meet the scoring criterion for LDL-C, but younger patients might not because their youth means that their LDL-C may be below the threshold, despite being high for their age. We conclude that the current criteria have proven utility for selecting patients for genetic testing. However there is scope for further refinement to take into account the variation in LDL-C with age.
As of March 2016, we continue to advocate the diagnosis of diabetic neuropathy using a simple foo... more As of March 2016, we continue to advocate the diagnosis of diabetic neuropathy using a simple foot examination or monofilament, which identifies only those with severe neuropathy and hence risk of foot ulceration. Given the fact that the 5-year mortality rate of diabetic patients with foot ulceration is worse than that of most common cancers, surely we should be identifying patients at an earlier stage of neuropathy to prevent its progression to a stage with such a high mortality? Of course, we lament that there is no licensed treatment for diabetic neuropathy. Who is to blame? As researchers and carers, we have a duty of care to our patients with diabetic neuropathy. So, we have to look forward not backwards, and move away from our firmly entrenched views on the design and conduct of clinical trials for diabetic neuropathy. Relevant organizations such as Neurodiab, the American Diabetes Association and the Peripheral Nerve Society have to acknowledge that they cannot continue to en...
Diabetic cardiomyopathy is a distinct primary disease process, independent of coronary artery dis... more Diabetic cardiomyopathy is a distinct primary disease process, independent of coronary artery disease, which leads to heart failure in diabetic patients. Epidemiological and clinical trial data have confirmed the greater incidence and prevalence of heart failure in diabetes. Novel echocardiographic and MR (magnetic resonance) techniques have enabled a more accurate means of phenotyping diabetic cardiomyopathy. Experimental models of diabetes have provided a range of novel molecular targets for this condition, but none have been substantiated in humans. Similarly, although ultrastructural pathology of the microvessels and cardiomyocytes is well described in animal models, studies in humans are small and limited to light microscopy. With regard to treatment, recent data with thiazoledinediones has generated much controversy in terms of the cardiac safety of both these and other drugs currently in use and under development. Clinical trials are urgently required to establish the efficacy of currently available agents for heart failure, as well as novel therapies in patients specifically with diabetic cardiomyopathy.
Symptoms of painful diabetic neuropathy (PDN) occur in 30-40% of patients with diabetic neuropath... more Symptoms of painful diabetic neuropathy (PDN) occur in 30-40% of patients with diabetic neuropathy. 1 It is most commonly associated with distal symmetrical neuropathy affecting the lower limbs (especially toes and feet), and patients present with burning, stabbing and tingling sensations. PDN is extremely distressing and significantly reduces the Hassan Fadavi is undertaking his PhD in the Cardiovascular Research Group at the University of Manchester. His main research interests include defining the basis of ethnic differences in the development of diabetic neuropathy and the diagnosis and treatment of diabetic foot ulceration.
To quantify corneal ultrastructure using laser scanning in vivo confocal microscopy (IVCM) in pat... more To quantify corneal ultrastructure using laser scanning in vivo confocal microscopy (IVCM) in patients with keratoconus and control subjects. Unscarred corneas of 78 keratoconic subjects without a history of contact lens use and 36 age-matched control subjects were evaluated with slit-lamp examination (SLE), corneal topography and laser scanning IVCM. One eye was randomly chosen for analysis. Anterior and posterior stromal keratocyte, endothelial cell and basal epithelial cell densities and sub-basal nerve structure were evaluated. IVCM qualitatively demonstrated enlarged basal epithelial cells, structural changes in sub-basal and stromal nerve fibers, abnormal stromal keratocytes and keratocyte nuclei, and pleomorphism and enlargement of endothelial cells. Compared with control subjects, significant reductions in basal epithelial cell density (5817±306 cells/mm(2) vs 4802±508 cells/mm(2), P<0.001), anterior stromal keratocyte density (800±111 cells/mm(2) vs 555±115 cells/mm(2), ...
Page 1. Management of Painful Diabetic Neuropathy Patrick G. Jensen and Jennifer R. Larson Univer... more Page 1. Management of Painful Diabetic Neuropathy Patrick G. Jensen and Jennifer R. Larson University of Iowa Hospital and Clinics, Department of Pharmaceutical Care, Iowa City, Iowa, USA Contents Abstract . . . . . ...
The aim of this systematic review and meta-analysis was to assess the effect of Ramadan focused e... more The aim of this systematic review and meta-analysis was to assess the effect of Ramadan focused education on clinical and metabolic parameters in patients with type 2 diabetes who fast during Ramadan. Methods: Literature search was done in PubMed, Embase (Ovid), and the Cochrane Library. Quality assessment was done using the ROBINS-I and Cochrane tools for risk of bias and analyses were performed using RevMan version 5.1. Results: From 770 records, 430 full text studies were assessed. After exclusions, the final quantitative analysis included 16 studies. Pre-Ramadan education was associated with a significant reduction in Hb A1c (SMD À0.46, 95% CI À0.65 to À0.27P < 0.05) and LDL (SMD À0.09, 95% CI À0.13 to À0.04P < 0.05), an increase in TG (SMD 0.07, 95% CI À0.23 to 0.93P < 0.05) and weight (SMD 0.44, 95% CI 0.06 to 0.81P < 0.05) and no change in hypoglycemic events, BMI, TC, HDL or blood pressure (P > 0.05) during Ramadan. Conclusions: This systematic review and meta-analysis shows that Ramadan-focused diabetes education leads to a decrease in Hb A1c and LDL, but an increase in TG and weight during Ramadan. It also identifies a lack of head to head studies and limited observational studies with adequately assessed end-points.
This Practice Point commentary discusses the results of a study that employed thermal threshold t... more This Practice Point commentary discusses the results of a study that employed thermal threshold testing and quantification of intraepidermal nerve fiber (IENF) density in patients with diabetes who had normal electrophysiology findings. The study showed that a significant proportion of these patients had abnormalities in small-fiber function, as quantified by thermal thresholds, and structure, as quantified by IENF density. Interestingly, patients who showed symptoms of diabetic neuropathy had reduced IENF densities but no difference in thermal thresholds compared with diabetic patients lacking these symptoms. This study highlights the importance of establishing which tests should be used to detect the earliest nerve damage in diabetic neuropathy, and which tests should be used as end points in clinical trials relating to this condition.
Diabetic retinopathy is the major cause of premature blindness amongst adults in the western worl... more Diabetic retinopathy is the major cause of premature blindness amongst adults in the western world [1]. Characterised by microvascular occlusion and leakage due to endothelial and pericyte cell damage and basement membrane thickening, macular oedema, neovascularisation and vitreous haemorrhage can eventually result in blindness [1]. Sustained hyperglycaemia results in retinal under perfusion, hypoxia and retinal ischaemia. These changes induce the production of
Pitceathly, RDS and Tavakoli, M and Marshall, A and Roberts, ME and Gow, D and Efron, N and Malik... more Pitceathly, RDS and Tavakoli, M and Marshall, A and Roberts, ME and Gow, D and Efron, N and Malik, RA (2008) Corneal confocal microscopy to diagnose idiopathic small fibre neuropathy. In: JOURNAL OF NEUROLOGY NEUROSURGERY AND PSYCHIATRY.(pp. 342-342). BMJ PUBLISHING GROUP
In relatives of mutation positive FH patients we observed that LDL-C increases with age, but this... more In relatives of mutation positive FH patients we observed that LDL-C increases with age, but this is not taken into account within the criteria. In 250 relatives of mutation positive index patients we observed that genotype (p<0.001) and age (p<0.001), but not gender, significantly predicted LDL-C in relatives aged 18-70 years (LDL-C ¼ 2.004 + 3.620(genotype 0,1) + 0.035(age)). Applying this effect of age to index patients would suggest that older patients are more likely to have LDL-C high enough to meet the scoring criterion for LDL-C, but younger patients might not because their youth means that their LDL-C may be below the threshold, despite being high for their age. We conclude that the current criteria have proven utility for selecting patients for genetic testing. However there is scope for further refinement to take into account the variation in LDL-C with age.
As of March 2016, we continue to advocate the diagnosis of diabetic neuropathy using a simple foo... more As of March 2016, we continue to advocate the diagnosis of diabetic neuropathy using a simple foot examination or monofilament, which identifies only those with severe neuropathy and hence risk of foot ulceration. Given the fact that the 5-year mortality rate of diabetic patients with foot ulceration is worse than that of most common cancers, surely we should be identifying patients at an earlier stage of neuropathy to prevent its progression to a stage with such a high mortality? Of course, we lament that there is no licensed treatment for diabetic neuropathy. Who is to blame? As researchers and carers, we have a duty of care to our patients with diabetic neuropathy. So, we have to look forward not backwards, and move away from our firmly entrenched views on the design and conduct of clinical trials for diabetic neuropathy. Relevant organizations such as Neurodiab, the American Diabetes Association and the Peripheral Nerve Society have to acknowledge that they cannot continue to en...
Diabetic cardiomyopathy is a distinct primary disease process, independent of coronary artery dis... more Diabetic cardiomyopathy is a distinct primary disease process, independent of coronary artery disease, which leads to heart failure in diabetic patients. Epidemiological and clinical trial data have confirmed the greater incidence and prevalence of heart failure in diabetes. Novel echocardiographic and MR (magnetic resonance) techniques have enabled a more accurate means of phenotyping diabetic cardiomyopathy. Experimental models of diabetes have provided a range of novel molecular targets for this condition, but none have been substantiated in humans. Similarly, although ultrastructural pathology of the microvessels and cardiomyocytes is well described in animal models, studies in humans are small and limited to light microscopy. With regard to treatment, recent data with thiazoledinediones has generated much controversy in terms of the cardiac safety of both these and other drugs currently in use and under development. Clinical trials are urgently required to establish the efficacy of currently available agents for heart failure, as well as novel therapies in patients specifically with diabetic cardiomyopathy.
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