The 2017 Banting Memorial Lecture The diabetic lower limb – a forty year journey: from clinical observation to clinical science

Abstract

A series of clinical research projects conducted over the past 40 years, all of which were informed by clinical observation or discussions with people with diabetes and staff colleagues are described in this review. A study of necrobiosis lipoidica diabeticorum confirmed that this rare skin complication occurs predominantly in young women with Type 1 diabetes and other microvascular complications. Biopsies of necrobiotic lesions showed destruction of superficial nerve fibres by inflammatory tissue, which likely causes the sensory loss in lesions that is pathognomonic of the condition. The development of corneal confocal microscopy as a new non‐invasive surrogate marker of peripheral neuropathy in diabetes is described next and several small studies of the use of this new technique in clinical research are reported. The influence of blood glucose instability on the genesis of neuropathic pain is then explained, with results suggesting that the stability of glycaemic control may be more important than the level of control achieved. Lastly, in neuropathy, studies of gustatory sweating are discussed, including the observation that sweating in the head and neck region is more common in people with end‐stage diabetic nephropathy than in those with neuropathy. The disappearance of gustatory sweating after renal transplantation suggests a metabolic cause and for those with troublesome sweating, use of the anticholinergic, anti‐muscarinic, topical cream glycopyrrolate is confirmed in a randomized control trial. In the area of diabetic foot research, distended dorsal foot veins were observed to be a clinical sign of sympathetic autonomic neuropathy: raised venous Po2 and Doppler abnormalities of blood flow are highly suggestive of arteriovenous shunting. A series of studies of the abnormalities of pressures and loads under the neuropathic diabetic foot are described: high dynamic plantar pressures are highly predictive of subsequent ulceration in the neuropathic foot. Lastly, a number of recent studies on unsteadiness and gait abnormalities when climbing and descending stairs are described. It is hoped that the art of clinical observation survives in the highly technological 21st century.

Saving the Diabetic Foot During the COVID-19 Pandemic: A Tale of Two Cities

“…According to the 2011 Census, 84% of the population was white, 10% Asian (predominantly Indian subcontinent Asia), 3% black, and 3% other. One of the main university teaching hospitals in Manchester is the Royal Infirmary; the multidisciplinary diabetic foot clinic has been operational for more than 30 years ( 9 ) and includes a number of different specialties: diabetologists, vascular surgeon, podiatric surgeon, podiatrists, diabetes specialist nurses, and an orthotist.…”

Skin AGEs and diabetic neuropathy

“…One may be tempted to even extend these thoughts to the complications of DN, primarily diabetic foot ulcers (DFUs) [1,2,48]. Treatment of the latter is still based on revascularisation (if needed), debridement, infection control and off-loading, while other measures are used secondarily [50]. This therapeutic approach has not changed, because no other intervention has demonstrated superiority [50].…”

“…Treatment of the latter is still based on revascularisation (if needed), debridement, infection control and off-loading, while other measures are used secondarily [50]. This therapeutic approach has not changed, because no other intervention has demonstrated superiority [50]. There is also some progress in utilisation of screening tools to predict future development of DFUs, and, very recently, the indicator test for sudomotor function Neuropad has emerged as useful in this prediction [51].…”

“…There is also some progress in utilisation of screening tools to predict future development of DFUs, and, very recently, the indicator test for sudomotor function Neuropad has emerged as useful in this prediction [51]. One step earlier, timely identification of subjects at high risk of developing DN would also contribute to the identification of subjects at high risk of DFUs [50,51]. Accordingly, skin AGEs measurement might prove useful as a surrogate marker of DFUs risk and, thus, contribute to meticulous treatment and education of subjects with this risk.…”

Gustatory sweating in people with type 1 and type 2 diabetes mellitus: Prevalence and risk factors

“… 4 , 5 , 8 Others discuss evidence of separate aetiologies like compensatory thermoregulation, anti‐sympathetic ganglia antibodies, neuropathic loss of suppression of nerval tonus that controls sweating and the role of reversible molecular changes due to nephropathy. 9 , 10 , 11 The distribution of sweating is equivalent to the territory of the superior cervical ganglion 5 and can be objectified, by applying quinizarin powder to the face, head and upper torso/extremities (turning blue when getting wet) 5 or by weighing absorbent dressings worn during meals. 3 Both methods are impractical in larger cohorts.…”