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The best way to detect early onset of diabetic peripheral neuropathy

By Barry L. Jacobs D.O. 2 years ago 3660 Views No comments

In Diabetic Peripheral Neuropathy (DPN) cutaneous pinprick sensation deteriorates early and gradually over time. Therefore, as a testing modality, it can be exploited for both sensitivity and if the technique is correct, for subtle specificity.

Continuous Pinprick Comparison (CPC) is far better than conventional pinprick technique because the latter only utilizes a binary response. ‘All or nothing’ is bound to provide many false negative results because sensory loss is incremental. The patient is asked only IF they can feel the sensation and not to rate HOW MUCH they feel it.

If a comparative, analogue scale is introduced, the technique is able to demonstrate subtle loss of sensation by degree. This will enable the detection of sensation deficit by pinprick testing to precede other modalities and more accurately reflect progress of deficit.

The provision of an analogue scale then affords the facility to more reliably predict patients at risk of complication and facilitate cost effective management.

How To Do It

In the past pinprick sensation testing has been dismissed clinically because it is typically used only in a binary, "on or off" fashion which produces largely false negative results. Essentially, where pinprick perception has diminished, patients can still report a stimulus though there is no facility to express magnitude. In consequence pinprick appears insensitive to neuropathy by virtue of it being applied to the wrong question.

If the technique is modified to employ a continuous repetitive comparison with a control area of skin, effectively unaffected by pathology, whilst asking the patient to express their sensitivity in the affected area on a simple scale of 1-5 (where "normal" is 5) it is possible to establish a subtle analogue scale from verbal feedback.

When a different observer/operator repeats the procedure on the same subject it is a simple matter to re-establish the new ‘5’. Furthermore intra and inter-operator test reliability can be significantly facilitated by use of a rapid repetitive application technique to iron out random variations in application pressure and nociceptor distribution.

In short pinprick is often the first sensation to be lost (sensitivity) and the most easily assessed accurately (specificity) providing the correct technique is employed.

Below is a table of modalities and their strengths in detecting neuropathy.

Modality

Vibration

Temperature

Monofilament

Pinprick

Ease of application in primary care Setting

Easy

Difficult

Easy

Easy

Sensitivity

Very Sensitive in the young

(Goes Early)

Very Sensitive in the young

(Goes Early)

Very insensitive (Goes late)

Very Sensitive in all age groups (Goes early)

Specificity

Very Unspecific

absent in middle stages and physiologically less sensitive in the elderly

Very specific in the young

and physiologically less sensitive in the elderly

Very Specific but only to crude/late loss

Very Specific with CPC as caters to an analogue/

Predictive scale

Inter & Intra Observer /Operator Reliability

Not Very reliable due to inter-operator error in application

Not very reliable due to accuracy of equipment

Very reliable with new instrument

Very reliable with CPC

Proven by North West Study nearly 10,000 patient cohort and crude test

Abbott et al, 2002, The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort 2002 Diabetes UK. Diabetic Medicine, 19, 377–384

Medipin is an FDA listed, all-plastic precision instrument which was designed to avoid skin puncture whilst, simultaneously, significantly heightening stimulation at lower application pressures by exploiting the phenomenon of neural lateral inhibition. A specially faceted and blunted point is situated within a surrounding annular component that serves to both micro stretch the skin and create an artificial center surround field.

Find more about Medipin for Home Self-Care

Learn more about Medipin for Clinical Care

What happens when your blood sugar is out of control?

By Steve Freed, R.PH., CDE 2 years ago 838 Views No comments

According to the American Diabetes Association, if your HbA1c is above 7.0% your blood sugar is out of control and you need to make some changes quickly to prevent the complications from diabetes occurring. The American College of Endocrinologists recommend that your HbA1c should be below 6.5% and as close to normal as possible. But if you want to reduce your risk for complications to almost zero, then it needs to be as close to normal as possible. Normal is an A1c of below 5.6%

According to a study Diabetes in the UK 2010: Key Statistics on Diabetes, if you get diabetes at the age of 50, and your blood sugars are not in control, you will probably die 10 years early and be miserable for the last 12-15 years of your life.

The Epic-Norfolk study, included 9000 people and compared their A1c results. What they found is that for those people with an A1c of 6 percent compared to those with an A1c of 5%, there was a 28 percent increase in cardiovascular death, regardless whether they had diabetes or not.

There are nearly 30 million people in the United States that have diabetes and 25% are not even diagnosed. There are another 90 million people with prediabetes, which if they took the test would have an A1C level of 5.7-6.4%. If you want to have a good quality of life as you get older and don't want to be one of the statistics above, then find out what your A1c number is, TODAY!

Check out this convenient A1C Test that gives you results in 5 minutes!

Why pay attention to A1C levels?

By Steve Freed, R.PH., CDE 2 years ago 839 Views No comments

Do you know what your A1c number is? Do you know what that number means? It can tell you your risk for diabetes, heart disease, Alzheimer’s, loss of limbs, blindness, kidney disease, cancer and just about every disease known to man.

Your A1C number represents your average blood sugar over the last 90 days, every second of the day. So when you or your doctor uses a blood glucose meter and sticks your finger, that tells you what your blood sugar is for just that one second in time, not what it was 1, 2 or every 8 hours before, just for that one second in time. That number is important to inform you how your food is working or your medicine, for that moment in time.

But your A1c number provides you an idea of the BIG PICTURE and tells you how you are doing over 90 days. Not just a short moment in time.

We know that too much sugar is harmful to our organs, it is the fuel we need but too much or too little is not good for our health.

An A1c is a single digit number that is the percentage of glucose attached to your red blood cells. A normal A1C level for a healthy person, who is not overweight, eats properly and exercises is between 4 and 5.5%

A person with prediabetes who is often on their way to becoming diabetic has an A1c of 5.7 to 6.4%’

A person with diabetes where their blood sugars are causing serious damage to their heart, brain, kidneys, nerves and almost every other organ in their body is an A1c of 6.5% or higher.

If you don't already know your A1C number there is a convenient fingerstick blood test that gives you your results in just 5 minutes. It's called the A1CNOW.

Learn more about A1CNow

What you need to know to prevent diabetes

By Steve Freed, R.PH., CDE 2 years ago 872 Views No comments

The most important thing you need to know to prevent diabetes is how well your body is managing your blood sugar. In order to find this out just ask your doctor to do an A1c blood test. This test provides a 90 day average measurement of your blood sugars, every second of the day for the last 90 days of your life. Too much sugar in your blood acts like rust and attaches to every organ in your body and can cause serious damage.

Knowing your A1c number can help you prevent from getting diabetes and heart disease and all the other diseases diabetes can cause.

If you know your A1C number is high, you can change your eating habits or your physical activity to keep your blood sugars in the normal range. Even if you can’t do it with changing your diet or physical activity alone, don’t worry too much as there are 1000’s of possible medications that can help you control your blood sugars and even your weight.

In this day and age there is absolutely no reason why you should have elevated blood sugars. If you know your A1c number, then you can take action before you get diabetes or even prediabetes and improve your quality of life as you get older.

NOTE: An elevated A1c number can also increase your risk for heart disease, so find out what your A1c number is and write it down and discuss it with your medical team.

Check out this convenient test that gives you A1C results in just 5 minutes!

Blood Sugar Testing Basics

By Steve Freed, R.PH., CDE 2 years ago 922 Views No comments

Understanding your blood sugar
There are two ways to find out how you are doing with your diabetes: the first is to check your blood glucose at home with a meter, and the second is to get a blood test called a hemoglobin A1C, or A1C.

What is an A1C test?
An A1C blood test is one of the most important tests for people with diabetes. This test tells the average of all the glucose results over the last 2-3 months. This is different than your blood glucose reading on your monitor, which tells you how you are doing just for that moment in time. So if you check your blood sugar with your meter at 8AM, that only tells you how you are doing for that second in time.

What does the A1C measure?
The test measures the amount of glucose that attaches to hemoglobin, part of red blood cells. As the hemo­globin travels through the bloodstream, it picks up glucose; the more glucose in the blood, the more glucose attaches to the hemoglobin. For most people with diabetes, the A1C should be less than 6.5% or as close to the non-diabetes range as safely possible. An A1C of 6.5% means that your average blood glucose readings are 140mg/dL.

Prediabetes is an A1c of 5.6 to 6.4% and the definition of diabetes is an A1c of 6.5% or higher.

How often should the A1C be checked?
Have your A1C checked between two to four times a year. You should check them more often if you are altering your treatment plan such as a changes to medications, diet or physical activity.

Make sure you know your results. So, Why should you lower your A1C?
Lowering your A1C level may greatly reduce your risk for developing diabetes complications. For every one point you lower your A1C, you lower your chances of getting diabetes complications by up to 35%!

Could your A1C level be the most important number in your life?

By Steve Freed, R.PH., CDE 2 years ago 636 Views No comments

If you have diabetes, or prediabetes or are overweight or even have a relative with diabetes, then YOU ARE AT RISK for kidney failure, heart attacks, strokes, blindness, loss of limbs, cancer, Alzheimer’s, and just about every disease known to man.

There is a blood test that can show you if you might be at risk. It is called the A1c test or HbA1c test or Hemoglobin A1c test. Now if you already have a risk factor for diabetes, then your doctor should have done this test when you went in to get a physical or a check up. So call your doctor's office and ask them what your last A1c result was and for your next appointment discuss the results with your doctor or nurse.

Diabetes and prediabetes can be diagnosed with the A1c test. What you need to know is that it takes years for you to possibly develop diabetes or prediabetes, but this A1c test can tell you exactly what your risk is depending upon how high the number is.

The definition of diabetes is an A1c of 6.5% or greater and every point it goes up it increases your risk for the medical issues mentioned above. The definition of prediabetes is an A1c of 5.7 to 6.4%.

The one thing we know is as we get older and our bodies slow down in metabolizing sugars. This means that as you age your A1C number will likely go up. Say you have an A1c of 5.9 (prediabetes) today, if your A1C level increases just a few more percentage points over the next few years to 6.5% then you will have diabetes.

Do you want to know your A1C number? Check out this convenient A1C Test that gives you results in 5 minutes!

ADA Recommends Pinprick Test for Asymptomatic Diabetic Neuropathy

By Barry L. Jacobs D.O. 2 years ago 613 Views No comments

With the release of the ADA’s new guidelines for 2017, there is much attention focused on early diagnosis of diabetic neuropathy or symmetrical neuropathy and that subtle signs of loss of pinprick or temperature sensation are important signals to implement appropriate management. But, there is still some confusion as to what might constitute Loss of Protective Sensation (LOPS).

In its annual position statements the American Diabetes Association often describes LOPS as if it were exclusively synonymous with failure to feel light touch. However, since the ADA's new 2017 guidelines acknowledge that pinprick is likely to be the first modality to be lost in diabetic neuropathic degeneration, due to the vulnerability of its small constituent fibers, then rather than light touch we primarily need to address the loss of the patients’ capacity to detect pain and other potentially harmful stimuli.

Essentially pain is a protective mechanism. That is precisely what it is for. This is the very implication of the term “The Gift of Pain” as forms the eponymous title in the well know volume (Brand P, Yancey P. Zondervan. Reprint edition September 1, 1997)
. In particular, this book was influenced much by the effect of Hansen’s disease (formerly known as leprosy) to cause neuropathy and loss of protective sensation leading to serious complications. If a patient fails to feel that they are treading on a shard of glass, which can penetrate their skin, then certainly they are vulnerable to damage. It is important to note that, unlike light touch, pain sensation is there to protect and does not permit habituation. We rapidly become used to the sensation of long hair or clothes on our skin but not to painful, noxious feelings that can be caused by encounters with objects that can harm or penetrate the skin. Light touch neither warns us against damage nor diminishes early on in the neuropathic process. Therefore, the Gift of pain is to protect us and pinprick is a remarkably valuable test for this. Loss of pain IS loss of protective sensation.

Medipin is a precision device that provides consistent pinprick sensation testing while shielding and inhibiting penetration of the point

Learn more about Medipin for Clinical Care

Test for Diabetic Neuropathy

By Samuel Kolodney 2 years ago 838 Views No comments

Diabetic neuropathy when gone unchecked can have devastating consequences including ulcerative wounds and even limb amputation. Improvement in the rates of self-care and home testing for diabetic neuropathy can have a dramatic impact on individual health outcomes.

Pinprick sensation testing using the technique recommended in the ADA's guidelines to detect diabetic neuropathy and when performed with a Medipin, it is probably the easiest test for patients to do in the home.

Why Use Medipin?

The optimal pinprick test generates as acute a sense of sharpness as possible without increasing the risk of skin penetration. For decades, since the work of the likes of De Castillo, Katz, Miledi and others, we have understood the neurophysiology of these stimuli. Pinprick is not truly about physical sharpness at all. A hypodermic needle is very sharp – a blade really – and as such and in the right hands can be almost painless. On the other hand, sharp stimulation acuity is all about skin stretch and contact demarcation of the point and its surfaces of contact.

Medipin is an FDA listed, dedicated device which has been in regular use by US Doctors for many years, as well has having been employed successfully in quite a number of international medical studies. It utilizes a well demarcated but blunted pyramidal point in order to exploit the stretching phenomenon. As well as being intended to reduce the risk of skin penetration this stretching actually heightens the sense of pinprick. This heightened sensation is then augmented by the surrounding annulus in which the point is situated that creates a perimeter of duller sensation to exploit the cortical phenomenon of lateral neural inhibition.

Lateral inhibition, is the phenomenon that suppresses information form areas of perception bordering those that more vividly garner cortical stimulation to evoke discrete boundaries and delineations. This is the same phenomenon that fools us in optical illusions and is leveraged here by positioning Medipin’s well demarcated point at the center of an area of duller stimulation created by the annulus. Effectively the Medipin device generates the perception a localized center surround field effect which further enhances the sharp element at its’ center whilst surrounding neurons are inhibited to further augment perception of the point. This tricks the brain in to perceiving greater pain than the stimulus would otherwise warrant.

This means more acute stimulation at lesser contact pressure. Or, in layman’s terms more pain sensation with no actual harm.

Learn more about Medipin for home self-care testing

The resurgence of pinprick testing

By Samuel Kolodney 2 years ago 1166 Views No comments

Pinprick is a medically useful modality by which to assess sensation, especially with an instrument designed to lend itself to an easy testing scenario and utilising the very straight forward technique described by key source material cited by ADA literature

(Boulton et al, 2008, Comprehensive Foot Examination and Risk Assessment): A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists, Diabetes Care August vol. 31 no. 8 1679- 1685:

Pinprick sensation. Similarly, the inability of a subject to perceive pinprick sensation has been associated with an increased risk of ulceration. A disposable pin should be applied just proximal to the toenail on the dorsal surface of the hallux, with just enough pressure to deform the skin. Inability to perceive pinprick over either hallux would be regarded as an abnormal test result.”1

Pinprick sensory testing, whether in the doctors’ office or at the patient’s home, is a very simple procedure. By contrast the technique required for monofilament testing consistent with instructions published by the ADA is more complicated and whilst easy enough in the clinical setting, remains challenging to perform accurately in a self-care situation.

Testing sensation with a Medipin clearly represents the simplest and easily executed technique to perform in the home and empowers patients to participate in an important aspect of their own diabetic healthcare. As a testing modality for the prediction of serious diabetic complications, like the development of lower extremity ulceration, pinprick has actually been reputably demonstrated to be rather more sensitive than conventionally used techniques.

The study Abbott et al, 2002, The North-West Diabetes Foot Care Study: Incidence Of, And Risk Factors For New Diabetic Foot Ulceration In A Community Based Patient Cohort. Diabet Med 19: 377–384) utilised a population of almost 10,000 patients. This significant study undertaken at one of the most prolific neuropathy centres in the world, Withington, Central Manchester University Hospitals, UK, showed that pinprick was even more useful for predicting the development of foot ulceration than more conventional techniques including monofilament.

Rather than be dismissed for its relative obscurity, pinprick should be embraced as a clinically useful tool in helping patients with diabetes to monitor themselves for loss of protective sensation. Virtually all health care professionals working and studying in this area similarly express the view that anything that alters foot self-care behavior in diabetes has got to be a good thing. We believe that Medipin will massively encourage education and better self-care practice and all the undoubted benefits that come with it.

Medipin is an FDA listed, dedicated device which has been in regular use by US Doctors for many years, as well has having been employed successfully in quite a number of international medical studies. It is an all-plastic precision instrument which was designed to avoid skin puncture whilst, simultaneously, significantly heightening stimulation at lower application pressures by exploiting neural lateral inhibition. A specially faceted and blunted point is situated within a surrounding annular component that serves to both micro stretch the skin and create an artificial center surround field.

To summarise;

  1. Home testing for diabetic neuropathy has excellent potential to transform self-management strategy of the diabetic foot in the USA and elsewhere.
  2. Whilst pinprick has not been the historic primary choice of testing modality for diabetic neuropathy, as much though fashion and neglect rather than appropriate scrutiny it remains, nonetheless, acknowledged as a potent, justifiably efficacious and ADA recommended test.
  3. Pinprick sensation testing using the technique recommended in the ADA's guidelines and performed with a Medipin, is probably the easiest test for patients to do in the home.
  4. If the spirit of ADA assessment were to be taken to the fullest degree the optimum scenario for home testing would be to offer the patient an option to perform a pinprick test with Medipin with the addition of a simple disposable monofilament test or instructions for the ‘Ipswich Touch Test’ which has been shown to be as efficacious as the monofilament and requires no extra equipment at all: (Rayman G, Vas PR, Baker N, et al. The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration. Diabetes Care. 2011;34:1517-1518)

Find more about Medipin for Home Self-Care

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References

1 http://care.diabetesjournals.org/content/31/8/1679.full.pdf+html

The gift nobody wants but everybody needs?

By Samuel Kolodney 2 years ago 770 Views No comments

The Gift of Pain.

The gift of pain is what keeps our bodies healthy. Without it we can unknowingly harm ourselves. People with Diabetes are susceptible to losing the gift of pain through a condition called Diabetic Peripheral Neuropathy (DPN), which is a form of nerve damage.

Diabetes is a leading cause of peripheral neuropathy in the United States. The National Institute of Health estimates between 60 to 70 percent of people with diabetes have mild to severe forms of nerve damage that can affect sensory, motor, and autonomic nerves and present with varied symptoms.1

One of these symptoms is the Loss of Pain Sensation, which may lead to foot ulceration due to even minor trauma. As many as 25% of people with diabetes develop at least one foot ulcer during their lifetime. Studies also suggest that between 4 and 10 per 1000 people with diabetes will have a lower limb amputation.2

According to the American Diabetes association in 2010, about 73,000 non-traumatic lower-limb amputations were performed in adults aged 20 years or older with diagnosed diabetes.3

Data collected by Southern California Kaiser Permanente between 2008 and 2011 shows that the rate of lower limb amputations drop as the number of foot exams increase. The difference was significant, which improved from a country wide average of 2.2 amputations per 1000 people to 0.79 amputations per 1000 people for those undergoing regular foot exams.4

What can be done to reduce the incidents of diabetic foot ulcer and amputation?
Medipin diabetic toes test makes it easier, safer, and more convenient than ever to perform monthly self-testing for loss of pain sensation.

Learn more about Medipin:
https://www.doctorsoption.com/medipin-the-diabetic...


References:

1 Peripheral Neuropathy Fact Sheet

http://www.ninds.nih.gov/disorders/peripheralneuro...

2. Singh N, Armstrong DG, Lipsky BA. “Preventing foot ulcers in patients with diabetes.” JAMA.2005;293:217–28.
http://www.ncbi.nlm.nih.gov/pubmed/15644549

3. American Diabetes Association. “Statistics About Diabetes”
http://www.diabetes.org/diabetes-basics/statistics...

4. Lee- Reducing Amputation Rates - HealthConnect Strategies
https://www.signup4.net/Upload/KAIS13A/PHYE362E/Le...

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