The epidemic of type 2 diabetes in the latter part of the 20th and in the early 21st century, and the recognition that achieving specific glycemic goals can substantially reduce morbidity, have made the effective treatment of hyperglycemia a top priority (1–3). While the management of hyperglycemia, the hallmark metabolic abnormality associated with type 2 diabetes, has historically had center stage in the treatment of diabetes, therapies directed at other coincident features, such as dyslipidemia, hypertension, hypercoagulability, obesity, and insulin resistance, have also been a major focus of research and therapy. Maintaining glycemic levels as close to the nondiabetic range as possible has been demonstrated to have a powerful beneficial impact on diabetes-specific complications, including retinopathy, nephropathy, and neuropathy in the setting of type 1 diabetes (4,5); in type 2 diabetes, more intensive treatment strategies have likewise been demonstrated to reduce complications (6–8). Intensive glycemic management resulting in lower HbA1c (A1C) levels has also been shown to have a beneficial effect on cardiovascular disease (CVD) complications in type 1 diabetes (9,10); however, the role of intensive diabetes therapy on CVD in type 2 diabetes remains under active investigation (11,12). Some therapies directed at lowering glucose levels have additional benefits with regard to CVD risk factors, while others lower glucose without additional benefits.

The development of new classes of blood glucose–lowering medications to supplement the older therapies, such as lifestyle-directed interventions, insulin, sulfonylureas, and metformin, has increased the treatment options for type 2 diabetes. Whether used alone or in combination with other blood glucose–lowering interventions, the availability of the newer agents has provided an increased number of choices for practitioners and patients and heightened uncertainty regarding the most appropriate means of treating this widespread disease. Although numerous reviews on the …

https://care.diabetesjournals.org/content/diacare/29/8/1963.full.pdf

Management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes.

ropathic pain (7–10), and this and other putative mechanisms will be discussed The clinical features, diagnosis, and management of the focal and multifocal neuropathies will be described A major portion of this review will discuss the clinical features, assessment, and management of the patient with the most common form of DN, diabetic distal sensory polyneuropathy (DPN) The late sequelae of DPN and their prevention will also be described Finally, practical guidelines for the screening of DPN in clinical practice will be provided For further details on this topic, please refer to recent reviews (11– 18)

https://care.diabetesjournals.org/content/diacare/27/6/1458.full.pdf

Diabetic Somatic Neuropathies

The epidemic of type 2 diabetes in the latter part of the 20th and in the early 21st century, and the recognition that achieving specific glycaemic goals can substantially reduce morbidity, have made the effective treatment of hyperglycaemia a top priority [1–3]. While the management of hyperglycaemia, the hallmark metabolic abnormality associated with type 2 diabetes, has historically had centre stage in the treatment of diabetes, therapies directed at other coincident features, such as dyslipidaemia, hypertension, hypercoagulability, obesity and insulin resistance, have also been a major focus of research and therapy. Maintaining glycaemic levels as close to the non-diabetic range as possible has been demonstrated to have a powerful beneficial impact on diabetes-specific complications, including retinopathy, nephropathy and neuropathy in the setting of type 1 diabetes [4, 5]; in type 2 diabetes, more intensive treatment strategies have likewise been demonstrated to reduce complications [6–8]. Intensive glycaemic management resulting in lower HbA1c levels has also been shown to have a beneficial effect on cardiovascular disease (CVD) complications in type 1 diabetes [9, 10]; however, the role of intensive diabetes therapy on CVD in type 2 diabetes remains under active investigation [11, 12]. Some therapies directed at lowering glucose levels have additional benefits with regard to CVD Diabetologia DOI 10.1007/s00125-006-0316-2

/pdf/management-of-hyperglycaemia-in-type-2-diabetes-a-consensus-3nntnh1dt8.pdf

Management of hyperglycaemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. A consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes.

The objective of this report was to develop a case definition of distal symmetric polyneuropathy to standardize and facilitate clinical research and epidemiologic studies. A formalized consensus process was employed to reach agreement after a systematic review and classification of evidence from the literature. The literature indicates that symptoms alone have relatively poor diagnostic accuracy in predicting the presence of polyneuropathy; signs are better predictors of polyneuropathy than symptoms; and single abnormalities on examination are less sensitive than multiple abnormalities in predicting the presence of polyneuropathy. The combination of neuropathic symptoms, signs, and electrodiagnostic findings provides the most accurate diagnosis of distal symmetric polyneuropathy. A set of case definitions was rank ordered by likelihood of disease. The highest likelihood of polyneuropathy (useful for clinical trials) occurs with a combination of multiple symptoms, multiple signs, and abnormal electrodiagnostic studies. A modest likelihood of polyneuropathy (useful for field or epidemiologic studies) occurs with a combination of multiple symptoms and multiple signs when the results of electrodiagnostic studies are not available. A lower likelihood of polyneuropathy occurs when electrodiagnostic studies and signs are discordant. For research purposes, the best approach to defining distal symmetric polyneuropathy is a set of case definitions rank ordered by estimated likelihood of disease. The inclusion of this formalized case definition in clinical and epidemiologic research studies will ensure greater consistency of case selection.

https://n.neurology.org/content/neurology/64/2/199.full.pdf

Distal symmetric polyneuropathy: A definition for clinical research Report of the American Academy of Neurology, the American Association of Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation

OBJECTIVE: To observe the relationship of fasting plasma glucose (FPG), postchallenge plasma glucose (PG) (30, 60, 90, and 120 min during an oral glucose tolerance test [OGTT], as well as maximal PG during an OGTT, postchallenge glucose spikes [PGS], and glucose under the OGTT curve), and HbA1c to intima-media thickness (IMT) as a marker of atherosclerosis. RESEARCH DESIGN AND METHODS: OGTT, ultrasound measurement of carotid IMT, and various atherosclerosis risk factors, such as family history of diabetes, obesity, and/or hyperlipoproteinemia, but without known diabetes, were analyzed in 582 individuals aged 40-70 years and at risk for type 2 diabetes. RESULTS: In univariate analysis, all examined glycemic parameters were significantly correlated to IMT. The 2-h postchallenge plasma glucose showed the strongest odds ratio (OR) of 1.88 (1.34-2.63) in relation to abnormal IMT. All PG variables, except for 30-min glucose in OGTT, showed a significant OR, whereas the OR for HbA1c and FPG was not significant. In logistic regression analysis, 2-h PG was identified as the strongest determinant of IMT from all glycemic parameters. The 2-h PG and PGS, but not FPG, were associated with a significant rise of IMT in tertiles of HbA1c. Glycemic parameters were strongly related to each other and to many atherosclerosis risk factors. In multivariate analysis including a variety of atherosclerosis risk factors, 2-h PG was a significant independent determinant of IMT. CONCLUSIONS: PG and PGS are more strongly associated with carotid IMT than FPG and HbA1c level and modify substantially the risk for atherosclerosis, estimated by HbA1c alone, in a cohort at risk for diabetes and in the early diabetes stage.

https://care.diabetesjournals.org/content/diacare/23/12/1830.full.pdf

Postchallenge plasma glucose and glycemic spikes are more strongly associated with atherosclerosis than fasting glucose or HbA1c level.

Aims To identify neuropathic sensory symptoms associated with a clinical neurological examination (CNE) and to investigate whether these symptoms could be used as a diagnostic or screening tool for diabetic polyneuropathy in general practice. Methods Five hundred and eighty-eight patients with Type 2 diabetes, recruited from 26 general practices in the Netherlands, underwent a CNE and completed a diabetes symptom checklist that included 10 items on neuropathic sensory symptoms. Linear regression analyses were performed to assess the association between neuropathic symptoms and CNE. Receiver operating characteristic (ROC) curves were created to assess the diagnostic properties of neuropathic symptoms. Results In this population, with a mean age of 66.8 years, 32% were identified with diabetic polyneuropathy according to the CNE. Variables that showed the strongest association with CNE score were age (beta = 0.41), symptoms of sensory alteration (beta = 0.27), and the item 'numbness of the feet' (beta = 0.35) in particular. ROC curves showed that prediction of diabetic polyneuropathy from these symptoms was unsatisfying. The sensitivity and specificity of daily symptoms of 'numbness of the feet' were 28% and 93%, respectively, in patients <68 years, and 22% and 92%, respectively, in patients greater than or equal to 68 years. Conclusions Identification of neuropathic sensory symptoms is not useful as a diagnostic or even a screening tool in the assessment of diabetic neuropathy in daily practice. Therefore, the results reported in this paper mandate an annual foot examination by the general practitioner.

'Numbness of the feet' is a poor indicator for polyneuropathy in Type 2 diabetic patients.

OBJECTIVE: To determine the prevalence and determinants of Chlamydia trachomatis (CT) infections among asymptomatic men and women in general practice. To determine participation rates in a systematic screening programme in general practice, using home obtained mailed urine samples. DESIGN: Cross-sectional study. METHODS: In 15 general practices in Amsterdam, the Netherlands, a sample of 11,005 persons (5541 women and 5464 men), aged 15-40 were invited to send in a urine sample and a completed questionnaire by mail. The urine samples were tested using the ligase chain reaction for DNA amplification. Patients diagnosed with CT were treated and partner notification was performed. RESULTS: 33% of invited males (1809/5464) and 50% of females (2751/5541) sent in the study material. Older patients participated more frequently than younger patients. Participation rates among persons with a Dutch background were higher than rates among persons from other ethnic groups. In 42 men and 79 women a CT infection was identified (2.3% and 2.9% respectively). Infections were more prevalent in patients from Surinam and the Dutch Antilles and in the age category 21-25 years. Type of health insurance as a proxy measure of socioeconomic status was not an indicator of infection. CONCLUSION: The participation in this systematic screening using mail-sent urine samples was 33% in men and 50% in women. The CT prevalences among asymptomatic men and women were 2.3% and 2.9% respectively

Systematische opsporing van infecties met chlamydia trachomatis bij mannen en vrouwen zonder klachten in de huisartspraktijk met behulp van per post verstuurde urinemonsters

Vaginal symptoms are frequently presented by women to general practitioners. In many cases, the aetiology of these symptoms remains unknown. This study focused on the factors associated with microbiologically unexplained vaginal symptoms, the course of symptoms and signs in these cases, and factors modifying this course. In a group of 610 women presenting to their general practitioner with vaginal symptoms (itching, irritation, abnormal but non-bloody discharge) the distribution of diagnoses was studied and factors associated with symptoms of unknown aetiology were identified using logistic regression analysis. During a three month follow up, the course of symptoms and signs was studied in 139 women with unexplained vaginal symptoms, using survival analysis methods. It was found that 25% of all the women had symptoms of unknown aetiology. A larger number of these women, compared with women with other diagnoses, were Caucasian, married, more highly educated, used oral contraceptives and reported psychological distress. During the follow-up period, a specific infection was diagnosed in less than 20% of the women with unexplained vaginal symptoms. Over half of the women (54%) recovered within three months. Short duration of symptoms before presentation was associated with a higher probability of recovery. From the study, it was found that many women visiting the general practitioner for vaginal symptoms had no demonstrable microbial disorder. Often these symptoms were transient and disappeared without intervention. Persistent symptoms may call for further examination where somatic, as well as psychosocial, factors should be taken into account.

Vaginal symptoms of unknown aetiology: a study in Dutch general practice.

OBJECTIVE: To assess the value of fasting blood glucose as a parameter for glycemic control in type 2 diabetic patients not using insulin. RESEARCH DESIGN AND METHODS: In 1,020 type 2 diabetic patients treated with diet or oral hypoglycemic agents (OHAs), measurements of fasting plasma glucose (FPG) and HbA1c were taken. In 617 patients, the measurement could be repeated after 3 months. Cross-sectional correlation coefficients were calculated for the association between HbA1c and FPG. Receiver-operating characteristic (ROC)-curve analyses were applied to examine the performance of FPG as a diagnostic test for HbA1c. Longitudinally, the change in FPG was compared with the change in HbA1c, with both correlation measures and ROC curve analyses. RESULTS: Correlation coefficients between HbA1c and FPG and between FPG change and HbA1c change were 0.77 and 0.65, respectively. ROC curve analysis showed that HbA1c is difficult to predict from FPG values: 66% of the patients with good HbA1c (

How valid is fasting plasma glucose as a parameter of glycemic control in non-insulin-using patients with type 2 diabetes?

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'Numbness of the feet' is a poor indicator for polyneuropathy in Type 2 diabetic patients.

Systematische opsporing van infecties met chlamydia trachomatis bij mannen en vrouwen zonder klachten in de huisartspraktijk met behulp van per post verstuurde urinemonsters

Vaginal symptoms of unknown aetiology: a study in Dutch general practice.

How valid is fasting plasma glucose as a parameter of glycemic control in non-insulin-using patients with type 2 diabetes?