Research – is it academic, challenging or applicable?

When reading research papers, I always try to focus upon two main issues, as I am sure many of our readers do. Firstly, can I apply and use the research findings in my everyday clinical practice and, secondly, does the research stimulate new ways of thinking or innovation? With this in mind, I want to examine a couple of papers that I think represent this approach. The first looks at a Cinderella complication that causes immense suffering – symptomatic/painful neuropathy – and the other has potential for risk screening for diabetes using a very simple clinical tool.

Painful diabetic neuropathy (PDN), although generally under-reported, is a frequent and clinically difficult complication to manage. Clinical guidelines are based on short-term trials (≤3 months’ duration), as there are limited trial data on long-term treatment outcomes. The study by Mai et al (summarised alongside) provides a useful assessment of the long-term clinical effectiveness of standard pharmacotherapies in the management of chronic PDN. In a prospective, multicentre, observational cohort study conducted in Canada, 60 people with PDN (other causes of pain excluded) were identified and recruited for analysis; however, there was a 22% dropout rate. Clinical outcome measures included pain scores and functional improvements (depression, mood and activity) using validated tools.

Pharmacological management mainly comprised opioids, antidepressants and/or anticonvulsants, with half of the participants using two and 25% using three of these drug classes. At 12 months, 37.2% of the cohort achieved a reduction in pain intensity of ≥30%, 51.2% achieved functional improvement and 30.2% achieved both of these outcomes, with no difference between those using two versus three analgesic classes. The study has many limitations but shows that two analgesics are as effective as three, and that long-term pain reduction can be modestly achieved, with better outcomes in terms of functional improvement.

The second paper (summarised on the facing page) reports on the potential use of ankle–brachial pressure index (ABPI) for identifying people who are at risk of developing diabetes! People with peripheral artery disease often have reduced physical activity, which may increase the future risk of diabetes. Hua and colleagues examined the association of ABPI with incident diabetes using Cox proportional hazards models in the ARIC (Atherosclerosis Risk In Communities) study. ABPI was measured in 12247 people of black or white ethnicity, aged 45–64 years, without diabetes at baseline. For each participant, ABPI measurements were obtained under strict conditions and were divided into seven ranges (≤0.90, 0.91–1.00, 1.01–1.10, 1.11–1.20, 1.21–1.30, 1.31–1.40 and >1.40). Incident diabetes cases were identified at subsequent visits by several methods.

Overall, 3305 participants developed diabetes over a median of 21 years of follow-up. Subjects with low (≤0.90) and borderline low (0.91–1.00) ABPI had a 30–40% higher risk of incident diabetes compared to those with an ABPI of 1.10–1.20. After adjusting for coronary heart disease and other potential confounders, the risk remained significant for ABPI 0.91–1.00 (hazard ratio [HR], 1.17; 95% confidence interval [CI], 1.04–1.31) and marginally significant for ABPI ≤0.90 (HR, 1.19; 95% CI, 0.99–1.43). There was a stronger association in people without hypertension, those with normal fasting glucose, and those with a history of stroke compared to their counterparts. This study suggests that a low ABPI may be a useful potential indicator for increased risk of developing diabetes.

To read the article summaries, please download the PDF