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1 : ), *,, ** * **., 1-3 ). 4 ).,,, (Charcot joint) )., 9, 10 ). :, , , Tel: (02) , Fax: (02) ).,. Uematsu 1 2 ).

2 (45%) 11 (55%). 2. 1),,,,,,. 2),,.,,.,,,,. (Valsava method),. 2 (Clinical diabetic neuropathy) DCCT (Diabetes Control and Complications Trial) ( 1) (Confirmed clinical diabetic neuropathy) 1 3 ). 3),,,,, F-H- (latency). 34, 32. 4) %. 24,,,, ( 2). () IR ) SAS % , Kg cm, (BMI) mg/dl, mg/dl, HbA 1C 7.8 (Table 1).

3 1. DCCT ne urologic e nd point definitions. DCCT neurologic end point definitions. Confirmed clinical neuropathy-a finding of definite clinical neuropathy by physical examination and hisatory confirmed by unequivocal abnormality of nerve conduction or autonomic nervous system response as defined below Clinical neuropathy-a definite diagnosis of peripheral diabetic neuropathy by clinical examination based on the presence of at least two of following: Physical symptoms normalities on sensory examination sent or decreased tendon reflexes normal nerve conduction-at least one abnormal conduction attribute on each of at least two anatomically distinct peripheral nerves according to the following standards: Median nerve motor conduction Amplitude < 4.2 mv Conduction velocity < 49.0 m/s F-wave latency > 31.8 ms Median sensory nerve action potential Amplitude > 10.0 V Conduction velocity < 48.0 m/s Peroneal nerve motor conduction Amplitude < 2.5 mv Conduction velocity < 40.0 m/s F-wave latency > 56.0 ms Sural nerve sensory action potential Amplitude < 5.0 V Conduction velocity < 40.0 m/s normal autonomic response-any of the following indications of cardiac autonomic neuropathy: R-R variation (mean resultant) < 15.0 R-R variation < 20.0 in combination with valsava ratio < 1.5 Orthostatic hypotension caused by autonomic nuropathy as indicated by a decrease of at least 10 mm Hg in diastolic blood pressure in postural studies confirmed by blunted norepinephrine response in plasma catecholamine specimens Subclinical neuropathy-abnormal nerve conduction, autonomic nervous system response, or both without a definite diagnosis of peripheral neuropahty by clinical examination (30.0%) 14(70.0%) (Table 2) (60.0%) 8(40.0%) (Table 2) (50.0%) 10(50.0%) (Table 2).

4 2. Patie nt pre pa ration a nd s etting for the rmogra phy. Patient preparation and setting for thermography Patient preparation 1. Patient should not smoke for at least 4 hours prior to the study. 2. Any physical therapy should not be permitted. 3. Alcoholic beverages should not be consumed. 4. Procedures such as electromyelography, acupuncture, nerve block or myelography should be deferred after thermal graphic examination. Setting for thermography 1. Diagnostic tool : Medicore IR Air flow: uniform and constant 3. Room temperature : Humidity : below 50% 5. Examination distance : 1 m Ta ble 1. De mogra phic cha ra cte ristics of the study population. Characteristics Male Female Total Age(years) Total Age (meansd*) Height (cm) (meansd*) Weight (Kg) (meansd*) BMI (meansd*) Sugar (mg/dl) FBS (meansd*) PP2 (meansd*) HbA 1c** (meansd*) 1 ( 5.0) 4 (20.0) 3 (15.0) 1 ( 5.0) 0 ( 0.0) 9 (45.0) (10.0) 3 (15.0) 4 (20.0) 1 ( 5.0) 1 ( 5.0) 11 (55.0) (15.0) 7 (35.0) 7 (35.0) 2 (10.0) 1 ( 5.0) 20 (100 ) *SD, standard deviation BMI, body mass index FBS, fasting blood sugar PP2, postprandial 2hours blood sugar **HbA 1c, glycosylated hemoglobin 5. 6 (30.0%), 8(40.0%). 6 (30.0%)

5 . Kappa % (Table 3). 6. 6(30.0%), Ta ble 2. The re s ults of confirme d clinica l dia gnos is, EPS a nd the rmogra phy. Patient Duration(yrs) Confirmed clinical diagnosis EPS Thermography A B C D E F G H I J K L M O P Q R S T * *, normal, abnormal EPS, electrophysiologic study EPS* ormal normal Ta ble 3. Re lation betwe e n EPS* a nd confirme d clinica l dia gnos is. umber of cases (%) Confirmed clinical diagnosis ormal 8 (40.0) 6 (30.0) normal 0 ( 0.0) 6 (30.0) Total 8 ( 40.0) 12 ( 60.0) Total 14 (70.0) 6 (30.0) 20 (100.0) *EPS, electrophysiologic study Kappa coefficient=0.444 (95% CI= )

6 Thermo* ormal normal Ta ble 4. Re lation betwe e n the rmogra phy a nd confirmed clinica l diagnos is. umber of cases (%) Confirmed clinical diagnosis ormal 10 (50.0) 4 (20.0) normal 0 ( 0.0) 6 (30.0) Total 9 ( 50.0) 11 ( 50.0) Total 11 (70.0) 6 (30.0) 20 (100.0) *Thermo, Thermography Kappa coefficient=0.60 (95% CI= ) Ta ble 5. Re lation betwee n the rmogra phy a nd EPS. ormal umber of cases (%) EPS normal Total Thermo* ormal normal 7 (35.0) 1 ( 5.0) 3 (15.0) 9 (45.0) 10 ( 50.0) 10 ( 50.0) Total 8 (40.0) 12 (60.0) 20 (100.0) Thermo, thermography. EPS, electrophysiologic study. Kappa coefficient=0.6 (95% CI= ) 10(50.0%). 4(20.0%). Kappa % (Table 4). 7. 9(45.0%), 7(35.0%) 3(15.0%) 1(5.0%). Kappa % (Table 5) Research System IDL (intera-ctive data lagnguage), x (width), y(height), z. IR2000, 3 (Fig. 1). 30

7 Fig. 1. The electrophys iologic studies a nd the rmogra phic findings % 10.1% 2.8%.,, 1-3 ).,

8 Fig. 2. Data ba se d the rmogra phic ima ging % 5-8 ). (,, ).., 9, 10 )... A-K-ATPase., ).

9 ..,..., 1 1, 1 7, 1 8 )...,,,, San Antonio Conference 19 ),,,, Dyck 2 0,2 1 ) 1997Rochester Diabetic europathy Study,,,,..,, ( ) 2 2 )., 2 3 ).,.,,,,,,,, 12,2 4 ). Uematsu 2 5 ) 0.5 (asymmetry).,,. Sangiorgio 2 6 ) Saint Antonio Conference 44.9%, 37.8%,, 3,, 30.0%, 60.0%, 50.0%

10 ., 45.0% 66.7%. Sangiorgio.,, 2 6 ) 20.,., 100.0%, 57.1% 100.0%, 71.3% Kappa ,, Kappa 0.600,. Kappa (matching)... Benbow 2 7 ) 3032 (curvature) Armstrong 2 8 ). 2 9 ) (Fig. 2). Fig. 2 (c), 82.9% (d)(surface-curvature) ( ),. (L 1 ( n) - L 2 ( n) ) 2 n = 0, Dyck 100%,., 20,..

11 . :... : : 2012(60%) 6 (30.0%) 8(40.0%) 100.0%, 57.1% (50.0%) 6(30.0%) 10(50.0%) 100.0%, 7 1.4%. 12(60.0%)9(45.0%) 8(40.0%) 7(35.0%). :. :,, = stract = U sefulness of Thermography in D iabetic europathy Lee Sang-Kyun, M.D., Kang Tae-Geun, M.D., Kim Jeong-A, M.D., Yoon Do-Kyoung, M.D., Kim Seon-Mee, M.D., Park Young-Kyu, M.D.*, Chang Jung-Ae, M.D., Kim Yong-Cheol, Ph.D., Choi Gi-Heung, Ph.D.**, Cho Kyung-Hwan, M.D. and Hong Myung-Ho, M.D. Department of Family Medicine, College of Medicine, Korea University, Department of Family Medicine, College of Medicine, Sungkyunkwan University *, Department of Electrical Eng., University of Seoul, Dept. of Industrial system Eng., Hansung University ** Background : Diabetic neuropathy is one of the serious complication of diabetes mellitus and it can cause serious foot problems. These foot problems could be preventable if early detection method of diabetic neuropathy is established. Therefore, essential diagnostic tool is needed. The changes on electrophysiologic studies (EPS) may not be necessarily correlated with clinical neuropathy. Theater has attempted to confirm the thermography as an useful tool for detecting diabetic peripheral neuropathy.

12 Methods : Author has studied 20 patients with diabetes visiting to department of family medicine of Korea University Hospital between December 1, 1998 and June, 30, All cases were evaluated on clinical cirteria. Furthermore, the EPS and thermography have been taken. The author investigated the results of thermography and the relation of the clinical diagnosis and EPS. Results : Among 20 cases, 12 (60.0%) cases have shown abnormality on EPS and 6 (30.0%) cases of them were also abnormal on clinical criteria, the other 8 (40.0%) cases were normal on EPS. Results of EPS were moderately related to clinical diagnosis. 10 (50.0%) cases have shown abnormality on thermography and 6 (30.0%) cases of them were also abnormal on clinical criteria, the other 10 (50.0%) cases were normal on thermography. Results of thermography were related to clinical diagnosis. Among 12 (60.0%) cases were abnormal on EPS, 9 (45.5%) cases also have shown abnormality on thermography. Among 8 (40.0%) cases were normal on EPS, 7 (35.0%) cases were also normal on thermography. Results of thermography were highly related to EPS. Conclusion : Thermography is a useful diagnostic tool in diabetic peripheral neuropathy. Key Words : Diabetic neuropathy, Thermography, Diagnostic usefulness 1),,, :. 1:17-24, ),,, :. 26(3): , ),,,,, :. 20(2): , ) American Diabetes Association. Report of the Expert Committee on the Diagnosis and Classification of Diabetes. Diabetes Care 20(7): , ),,,,, :. 8(1): 55-65, ) Reiber GE, Lipsky BA, Gibbons GW: The burden of diabetic foot ulcers. Am J Surg 176(2A suppl):5s-10s, ) Edmonds ME: The Diabetic foot: pathophysiology and treatment. Clin Endocrinol Metab 15(4): , ) Reiber GE, Pecoraro RE, Koepsell TD: Risk factors for amputation in patients with diabetes mellitus. A case-control study. Ann Intern Med 117(2):97-105, ) Pecoraro RE, Reiber GE, Burgess EM: Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 13:513-21, ) Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patient with diabetes. Engl J Med 331(13):854-60, ),,,,, :.. 2: ; 1998(p ) 12) Fujimasa I: Pathophysiological expression and analysis of far infrared thermal images. IEEE Engineering in medicine and biology. 17(4): 34-42, ) Greene DA, Stevens MJ, Feldman EL: Glycemic control. In Dyck PJ, Thomas PK, Asbury AK. Daibetic neuropathy. 2nd ed. Philadelphia, WB Saunders, (p ) 14) orman E, Cameron, Mary A: Cotter. Metabolic and vascular factors in the pathogenesis of diabetic neuropathy. Diabetes 46(2):31-37, ) Winegrad Al, Simmons DA, Martin DB: Has one diabetic complication been explained. Engl J Med 308(3):152-4, ) Simmons DA: Pathogenensis of diabetic neuropathy. In Kahn CR, Weir CG: Joslin's diabetetes mellitus. 13th ed. Pensylvania, Lea & Febiger, 1994(p ). 17) Dyck PJ, O'Brien PC: Meaningful degrees of prevention or improvement of nerve conduction in controlled clinical trials of diabetic neuropathy. Diabetic Care 12:649-52, 1989

13 18) Daube JR: Electrophysiologic testing in diabetic neuropathy. In Dyck PJ, Thomas PK, Asbury AK. Daibetic neuropathy. 2nd ed. Philadelphia, WB Saunders, (p222-38) 19) San Antonio Conference. Proceedings of consensus development conference on standarized measures in diabetic neuropathy. eurology 42: , ) Dyck PJ, Melton LJ 3rd, O'Brien PC, Service FJ: Approaches to improve epidemiological studies of diabetic neuropathy: insights from the Rochester Diabetic europathy Study. Diabetes 46(2):S5-8, ) Dyck PJ, Litchy WJ, Karnes JL, Litchy WJ, Klein R, Patch JM, et al: Variablein fluencing neuropathic endpoints: the Rochester Diabetic europathy study. eurology 45(6): , ) Turner TA, Purohit RC, Fessler JF: Thermography: A review in equine medicine. Comp Cont Ed 8: , ) Uematsu S, Jankel WR, Edwin DH, Kozikowski J, Trattner M: Quantification of thermal asymmetry. Part 1: ormal values and reproducibility. J eurosurgery 69: , ) Anbar M: Clinical thermal imaging today. IEEE Engineering in medicine and biology 17(4):25-33, ) Uematsu S: Thermographic imaging of cutaneous sensory segment in patients with peripheral nerve injury. Skin-temperature stability between sides of the body. J eurosurg 62: , ) Sangiorgio L, Lemmolo R, Le Moli R, Grasso G, Lunetaa M: Diabetic neuropathy: prevalence, concordance between clinical and electrophysiological testing and impact of risk factors. Panminerva Med 39(1):1-5, ) Benbow SJ, Chan AW, Bowsher DR, Williams G, Macfarlane IA: The Prediction of diabetic neuropathic plantar foot ulceration by liqiudcrystal contact thermography. Diabetic Care 17(8):835-9, ) Armstrong DG, Lavery LA, Liswood PJ, Todd WF, Tredwell JA: Infrared dermal thermography for the high risk diabetic foot. Phys Ther 77(2):169-75, ) Park ES, Park CI, Jung KI, Chun S: Comparison of sympathetic skin response and digital infrared thermographic imaging in pheripheral neuropathy. Yonsei Med J 35(4): , ) Yang Xin: Hierarchical contour matching in medical images. Image and Vision Computing 14: , ) Klaus-Peter Pleiner. ew algorithmic approaches to protein spot detection and pattern matching in two-dimensional electrophoresis gel databases. Electrophoresis 20: , ) D. Clemens, D. Jacobs. Model group indexing for recognition. Proceedings of IEEE CVPR. 6:4-9, 1991

Pharmacotherapeutics Application of New Pathogenesis on the Drug Treatment of Diabetes Young Seol Kim, M.D. Department of Endocrinology Kyung Hee Univ

Pharmacotherapeutics Application of New Pathogenesis on the Drug Treatment of Diabetes Young Seol Kim, M.D. Department of Endocrinology Kyung Hee Univ Application of New Pathogenesis on the Drug Treatment of Diabetes Young Seol Kim, M.D. Department of Endocrinology Kyung Hee University College of Medicine & Hospital E mail : ycell2@yahoo.co.kr Abstract