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Peripheral Neuropathy Underdiagnosed - from Medscape

By Charlene Laino

June 18, 2003 (New Orleans) — Both generalists and specialists are more

likely to miss a diagnosis of peripheral neuropathy than not to miss it,

a new analysis of data from a large cohort study suggests.

In the analysis of nearly 7,500 patients, both primary care physicians

and endocrinologists failed to diagnose nonsevere neuropathy in about

two thirds of cases, reported a team led by H. Herman, MD, MPH,

professor of internal medicine at the University of Michigan at Ann

Arbor. When it comes to severe neuropathy, about one in four

endocrinologists and one in three primary care physicians miss the boat,

the study suggested.

Dr. Herman presented the findings here on behalf of the Glycemic

Optimization with Algorithms and Labs At Po1nt of Care (GOAL A1C) study

group at the American Diabetic Association (ADA) 63rd Scientific

Sessions.

" Many patients with diabetes have evidence of peripheral neuropathy that

is not being picked up as early as it should be, " said coinvestigator

ce Kennedy, MD, FRCP, professor of medicine and chair of the

Division of Endocrinology at the University of Florida in Gainesville.

This is troubling because without early diagnosis and prompt

treatment, patients with peripheral neuropathy are at increased risk for

foot ulcers and even amputation, said ADA President Eugene Barrett, MD,

PhD.

Dr. Barrett, professor of internal medicine at the University of

Virginia in Charlottesville, echoed the researchers' call for routine

testing for neuropathy on a regular basis.

" Peripheral neuropathy is one of the most troubling complications of

diabetes, " he said. " It's an area where we all, primary care doctors and

specialists alike, can do a better job. "

If a diabetic patient comes in complaining of pain, diagnosis is a snap,

he said. " But when the nerves aren't functioning and the patient is numb

and doesn't complain, it's easily missed. "

Dr. Barrett's straightforward prescription: " Do a foot exam on all

diabetic patients when they come in for their annual exam. If there is

loss of sensation, you probably have your diagnosis. "

For their report, the researchers analyzed data from the ongoing GOAL

A1C study, the objective of which is to assess the impact of

point-of-care testing in a large population of patients predominantly

treated in a primary care setting. As part of the evaluations, patients

are screened for the presence of neuropathy using monofilament testing.

At the time of the ADA presentation, usable data were available for

7,378 patients, 88% of whom were seen by a primary care physician, and

the remainder were seen by an

endocrinologist.

Prior to monofilament testing on each patient, physicians completed a

short survey to assess their perception of the presence of neuropathy.

" These were patients already under the physicians' care, " Dr. Kennedy

explained in an interview. " So we asked them before they conducted the

foot exam, 'Do you, based on your knowledge of this patient, think he or

she has peripheral neuropathy?' "

During the foot exam to determine if neuropathy or insensate foot was in

fact present, small and large fiber monofilaments were applied to the

plantar surface of the patients' big toe. With their eyes closed,

patients were asked to indicate when and where a monofilament touch

occurred.

The testing showed that 63% of patients did not have neuropathy, 30% had

nonsevere neuropathy, and 7% had severe neuropathy.

Overall, 92.4% of patients without neuropathy were identified correctly

by their physicians, whereas 62.4% of those with neuropathy were not

identified, the study showed.

The study confirmed previous observations that patients with more severe

disease tend to be taller, older, male, and have a longer duration of

diabetes, Dr. Kennedy said.

As the severity of neuropathy increased, so too did feelings of pins and

needles at night, the likelihood of foot ulcers, and a need for custom

footwear, he said.

The GOAL A1C study, including the current analysis, is being funded by

Aventis Pharmaceuticals, which makes an insulin product used in the

trial.

ADA 63rd Scientific Session: Abstract 830-P. Presented June 14, 2003.

Reviewed by D. Vogin, MD