The relation between HbA1c variability and diabetic autonomic neuropathy among type-2 diabetic patients

Background: Diabetic autonomic neuropathy (DAN) is the most neglected major and widespread microvascular complication of type-2 diabetes mellitus, involving multiple body organs. DAN is a subtype of diabetic peripheral neuropathy.Objective: To investigate the relationship between the variability of HbA1c and diabetic autonomic neuropathy in type-2 diabetes patients.Materials and methods: This study recruited a total of 150 type-2 diabetic patients to screen for diabetic autonomic neuropathy and estimated quarterly levels of HbA1c were performed within the year before enrollment. With a noninvasive procedure, DAN was validated by careful history taking, anthropometric assessment, clinical manifestations and neurological assessment.Results: Out of 150 type- 2 diabetic patients, recruited randomly, where 81 were female and 69 were male. Among all patients 29 (19.33%) had been screened positive for DAN which showed higher HbA1c than non-DAN patients. Different autonomic neuropathic dysfunction among total diabetic patients were also studies and found that the highest prevalence of sexual dysfunction among all autonomic dysfunction prevalence which is 16.66% whereas the lowest prevalence was postural hypotension that is 6.66%. The second higher prevalence is urinary incontinence (10.66%). Abnormal sweating (9.33%) and nocturnal diarrheas (7.33%) are in third and fourth position respectively. No significant (p>0.05) differences were found in the case of BMI, sex, systolic, and diastolic blood pressure between DAN and non-DAN. Data shows a major (p<0.05) risk factor for DAN has also been the prolonged period of diabetes and older age.Conclusion: The study indicates that the increased level of HbA1c in type-2 diabetic patients is closely correlated with DAN and may be considered a potent predictor of DAN in the recruited patients.International Journal of Human and Health Sciences Vol. 06 No. 01 January’22 Page: 89-95

Evaluation of the Degree of Agreement of Four Methods for Diagnosing Diabetic Autonomic Neuropathy

Background: There are many methods to diagnose diabetic autonomic neuropathy (DAN); however, often, the various methods do not provide consistent results. Even the two methods recommended by the American Diabetes Association (ADA) guidelines, Ewing's test and heart rate variability (HRV), sometimes give conflicting results. The purpose of this study was to evaluate the degree of agreement of the results of the Composite Autonomic Symptom Score 31 (COMPASS-31), skin sympathetic reaction (SSR) test, Ewing's test, and HRV in diagnosing DAN.Methods: Patients with type 2 diabetes were recruited and each received the COMPASS-31, SSR, Ewing's test, and HRV for the diagnosis of DAN. Patients were categorized as DAN(+) and DAN(–) by each of the tests. Kappa consistency tests were used to evaluate the agreement of diagnosing DAN between any two methods. Spearman's correlation test was used to evaluate the correlations of the severity of DAN between any two methods. Receiver operating characteristic (ROC) analyses were used to evaluate the diagnostic value and the cutoff value of each method.Results: A total of 126 type 2 diabetic patients were included in the study. The percentages of DAN(+) results by HRV, Ewing's test, COMPASS-31, and SSR were 61, 40, 35, and 33%, respectively. COMPASS-31 and Ewing's test had the best agreement for diagnosing DAN (κ = 0.512, p &lt; 0.001). COMPASS-31 and Ewing's test also had the best correlation with respect to the severity of DAN (r = 0.587, p &lt; 0.001). Ewing's test and COMPASS-31 had relatively good diagnostic values (AUC = 0.703 and 0.630, respectively) in the ROC analyses.Conclusions: COMPASS-31 and Ewing's test exhibit good diagnostic consistency and severity correlation for the diagnosis of DAN. Either test is suitable for the diagnosis of DAN and treatment follow-up.

Impaired hypoxic ventilatory drive induced by diabetic autonomic neuropathy, a cause of misdiagnosed severe cardiac events: brief report of two cases

Background Sudden cardiac deaths are twice more frequent in diabetic patients with cardiac autonomic neuropathy. Sudden cardiac death etiologies remain unclear and no recommendations are made to identify factors associated with cardiorespiratory arrest in diabetic patients. We hypothesized, from two clinical cases, that impaired hypoxic ventilatory drive, induced by diabetic autonomic neuropathy, is a cause of misdiagnosed severe cardiac events. Case presentation We describe the cases of two patients with isolated low blood saturation on pulse oximeter during the systematic nurse check-up (77% and 85% respectively) contrasting with the absence of any complaint such as dyspnea, polypnea or other respiratory insufficiency signs observed during the clinical examination. Arterial blood gas measurements subsequently confirmed that blood oxygen saturation was low and both patients were indeed hypoxemic. Patient 1 suffered from vascular overload complicated by cardiac arrest caused by hypoxemia in light of the quick recovery observed after ventilation. Pulmonary edema was diagnosed in patient 2. The common denominator of these 2 cases described in this brief report is the absence of respiratory failure clinical signs contrasting with the presence of confirmed hypoxemia. Also, in both cases, such absence of precursory signs seems to be induced by an impaired ventilatory drive to hypoxemia. This appears to be related to the autonomic diabetic neuropathy encountered in those 2 patients. Conclusions Therefore, we describe, in this brief report, cardiac autonomic neuropathy as a cause of impaired hypoxic ventilatory drive involved in severe acute cardiorespiratory events in two type 1 diabetic patients. We assume that altered response to hypoxemia due to cardiac autonomic neuropathy and non-functional central neurological breathing command could play a key role in sudden deaths among diabetic patients. An important point is that hypoxemia can be easily missed since no clinical signs of respiratory failure are reported in these two clinical cases. Systematic screening of cardiac autonomic neuropathy in diabetic patients and proactive detection of impaired hypoxic ventilatory drive for early management (e.g. treatment of hypoxemia) should be systematically undertaken in diabetic patients to prevent its dramatic consequences such as cardiorespiratory arrest and death.

A STUDY ON THE PREVALENCE OF CARDIAC AUTONOMIC NEUROPATHY IN DIABETIC PATIENTS – A HOSPITAL BASED STUDY.

Background: Diabetic Autonomic Neuropathy (DAN) is a serious and common complication of diabetes. Despite its relationship to an increased risk of cardiovascular mortality and its association with the multiple symptoms and impairments, the signicance of diabetic autonomic neuropathy has not been fully appreciated. DAN can manifests in a spectrum of things, ranging from resting tachycardia and xed heart rate (HR) to development of “silent” myocardial infarction.The prevalence of CAN is variable based on published studies and ranges from 2% to 91% in type I diabetes mellitus (T1DM) and 25% to 75% in type 2 diabetes (T2DM). This signicant variability can likely be attributed to the lack of a uniform 2 diagnostic criteria as well as underdiagnosis in the typical hospital setting. Aim And Objectives :To study the prevalence of cardiac autonomic neuropathy in hospital admitted diabetic patients. Materials And Methods : 60 diabetic patients were taken for the study of which 48 were males and 12 were females.The study was carried out in tertiary care teaching hospital in North east India after clearance from institutional ethics committee. Subjects were divided according to duration of diabetes as Group I : 0 – 5 years(24 patients), Group II : 6 – 9 years(24patients), Group II I: 10 years or more(12 patients). Then special interest was taken to nd out cardiac autonomic neuropathy and all the 5 tests were carried out in each of the patients to detect cardiac autonomic neuropathy and were divided into 3 groups. Group I ( normal autonomic function test), group II ( early DAN), group III ( denitive DAN ). Results : In the present study it has been observed that out of 24 (40%) cases of diabetes mellitus in the 0 – 5 year duration group, 4 cases (16.7%) are having autonomic neuropathy, out of 24 cases in the duration group 6 – 9 years, 10 cases (41.7%) are having autonomic neuropathy and in the duration group ≥ 10 years, 8 cases out of 12 (66.7%) showing neuropathy. In the present study prevalence of diabetic autonomic neuropathy out of 60 number of patients taken it was seen as: 38 cases (63.3%) with normal autonomic function tests placed in group I, 12 cases (20%) with only cardiac parasympathetic damage or early DAN were placed in group II and 10 cases (16.7%) with both cardiac parasympathetic and sympathetic damage or denitive DAN were placed in group III. So out of 60 diabetic patients, 22 patients (36.7%) showed abnormal cardiovascular reex in the present study. Conclusion: It has been observed from the present study that duration of diabetes mellitus is directly proportional to development of cardiac autonomic neuropathy.

Study protocol for a multicentre, randomised, parallel group, sham-controlled clinical trial investigating the effect of transcutaneous vagal nerve stimulation on gastrointestinal symptoms in people with diabetes complicated with diabetic autonomic neuropathy: the DAN-VNS Study

IntroductionA high proportion of people with diabetes experience gastrointestinal (GI) symptoms, which may be manifestations of diabetic autonomic neuropathy (DAN). The current treatment regime is ineffective and associated with major side effects. Transcutaneous vagal nerve stimulation (tVNS) is a new therapeutic option, which has been shown to increase GI motility and reduce inflammatory responses. As vagus is the main neuronal pathway for extrinsic coordination of GI secretion and motility, we hypothesise that tVNS will improve DAN-induced GI symptoms in subjects with diabetes.Methods and analysisThe DAN-VNS study is a randomised multicentre clinical trial investigating the effect of short-term, high intensity as well as long-term, medium-intensity tVNS on GI symptom alleviation in 120 subjects with diabetes. The primary outcome consists of changes from baseline in subjective ratings of symptom severity. Secondary outcomes include changes in gastric motility and GI transit time measured by MRI and wireless motility capsule. Moreover, cardiovascular and sudomotor function, glycaemic control, brain sensory processing and presence of low-grade inflammation will be investigated as secondary outcome measures. Lastly, 15 responders of tVNS treatment will be included in an explorative, randomised, cross-over study, in which the acute endocrine and metabolic response to short-term tVNS will be investigated.Ethics and disseminationThe study has been approved by the North Denmark Region Committee on Health Research Ethics (N-20190020). Results will be published in relevant international peer-reviewed journals.Trial registration numberNCT04143269.

PECULIARITIES OF DETERMINING THE GASTRIC ACID SECRETION AND DIABETIC AUTONOMIC NEUROPATHY IN PATIENTS WITH CHRONIC PANCREATITIS AND TYPE 2 DIABETES

The aim: Is to determine the peculiarities of changes in the gastric acid secretion against the background of diabetic autonomic neuropathy and autonomic dysfunction in patients with chronic pancreatitis (CP) and type 2 diabetes (T2DM). Materials and methods: We investigated 64 patients with CP and T2DM, who were included in the first group of the patients examined; Group II consisted of 40 patients with T2DM; and Group III of the patients examined consisted of 34 patients with CP. Results: Differences were found in assessing the degree of autonomic nervous system (ANS) dysfunction in the examined patients, namely – the most pronounced ANS dysfunction according to the Wayne questionnaire was diagnosed in patients Group I, while patients of Group III. Analysis of gastric acid secretion indicates that no patients of Group III had normal acidity. Normal acidity is more often found in the second group of subjects. Both in patients with CP and T2DM, and in isolation with CP, moderate hyperacidity was more often determined. Conclusions: The predominance of the parasympathetic division of the ANS, as well as manifestations of severe ANS dysfunction, are observed in patients with CP and T2DM. The prevalence of gastric hyperacidity on the background of DAN was established in patients with CP and T2DM. In this case, the absence of clinical symptoms or their minimal severity is determined, which indicates the lesion of the digestive tract in these patients.