***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: AIMS To test the accuracy of four measures of peripheral diabetic neuropathy in a primary care population . METHODS Type 2 diabetic ( n = 544 ) and 544 non-diabetic participants aged 45 - 76 years were r and omly selected from general practice registers . Neuropathy was assessed using  vibration threshold ( VT ) and scores for light touch , thermal sense and modified Michigan Neuropathy Screening Instrument question naire .  These measures were assessed for variation with diabetes status , age , diabetes duration , HbA1c , and presence of retinopathy and nephropathy .  Light touch , thermal sense and question naire scores were assessed against VT using ROC curve analysis . RESULTS Only VT and light touch were different between diabetic and non-diabetic groups ( P = 0.02 and < 0.0001 , respectively ) . All measures were significantly associated with diabetes duration and retinopathy , and all except question naire score ( P = 0.14 ) with age . None was associated with nephropathy and only question naire score was associated with HbA1c ( P = 0.033 ) . VT varied as expected across scores of light touch ( chi2 = 41.65 , P = 0.0001 ) , thermal sense ( chi2 = 15.86 , P = 0.015 ) and question naire ( chi2 = 21.22 , P = 0.047 ) . Area under the curve values for light touch , thermal and question naire scores were 0.72 ( 95 % confidence interval ( CI ) 0.63 , 0.82 ) , 0.63 ( 95 % CI 0.52 , 0.73 ) and 0.64 ( 95 % CI 0.53 , 0.74 ) , respectively . CONCLUSIONS All measures had associations with risk factors for neuropathy , but light touch score ( monofilament ) had the strongest association with vibration threshold ( the chosen gold st and ard ) and thus appeared the most appropriate tool for use in primary care , because of its validity and simplicity of use The Semmes-Weinstein pressure aesthesiometer , which measures cutaneous pressure sensation , was used for quantifying sensory loss in diabetic peripheral neuropathy . Eighty subjects comprising four groups were tested : nondiabetic controls ( Group C ) ; non-neuropathic , diabetic controls ( Group DC ) ; diabetic subjects with neuropathy and without a history of pedal ulcerations ( Group DN ) ; and , diabetic subjects with a history of or active pedal ulceration ( Group DU ) .  Cutaneous pressure sensation of 10 dorsal and plantar sites on the foot were tested , using a method of interval comparison modeled after the two-alternative forced choice algorithm . The sensitivity threshold level was defined as the lightest probe in which the subject accurately chose the correct interval in at least 2 out of 3 trials . The mean sensitivity threshold level for Group DC was not significantly increased ( p greater than .05 ) compared to Group C. In contrast , patients with neuropathy ( Group DN or DU ) showed a significantly higher mean sensitivity threshold ( p less than .001 ) than either Group C or DC . In addition , this technique demonstrated that patients in Group DU had a mean sensitivity threshold that was statistically higher ( p less than .001 ) than Group DN , although both groups of patients had symptomatic neuropathy . This study provides a direct demonstration that decreased sensation of pressure occurs in the feet of diabetic patients with a history of ulceration . The best discrimination between groups is obtained by requiring that three of the six plantar forefoot sites have a sensitivity threshold level of greater than 5.07 log ( 0.1 mg ) force as the risk discriminator level . Semmes-Weinstein aesthesiometry should now be tested in a prospect i ve study to demonstrate its effectiveness in determining those patients at great risk of developing foot ulcers OBJECTIVE Little prospect i ve research exists on risk factors for diabetic foot ulcer that considers the independent effects of multiple potential etiologic agents . We prospect ively studied the effects of diabetes characteristics , foot deformity , behavioral factors , and neurovascular function on foot ulcer risk among 749 diabetic veterans with 1,483 lower limbs . RESEARCH DESIGN AND METHODS Eligible subjects included all diabetic enrollees of a general internal medicine clinic without foot ulcer , of whom 83 % agreed to participate . Baseline assessment included history and lower-limb physical examination , tests for sensory and autonomic neuropathy , and measurements of macro- and microvascular perfusion in the foot .  Subjects were followed for the occurrence of a full thickness skin defect on the foot that took > 14 days to heal , with a mean follow-up of 3.7 years . RESULTS Using stepwise Cox regression analysis , the following factors were independently related to foot ulcer risk : foot insensitivity to the 5.07 monofilament ( relative risk [ 95 % CI ] ) 2.2 ( 1.5 - 3.1 ) , past history of amputation 2.8 ( 1.8 - 4.3 ) or foot ulcer 1.6 ( 1.2 - 2.3 ) , insulin use 1.6 ( 1.1 - 2.2 ) , Charcot deformity 3.5 ( 1.2 - 9.9 ) , 15 mmHg higher dorsal foot transcutaneous PO2 0.8 ( 0.7 - 0.9 ) , 20 kg higher body weight 1.2 ( 1.1 - 1.4 ) , 0.3 higher ankle-arm index 0.8 ( 0.7 - 1.0 ) , poor vision 1.9 ( 1.4 - 2.6 ) , and 13 mmHg orthostatic blood pressure fall 1.2 ( 1.1 - 1.5 ) . Higher ulcer risk was associated with hammer/claw toe deformity and history of laser photocoagulation in certain subgroups . Unrelated to foot ulcer risk in multivariate models were diabetes duration and type , race , smoking status , diabetes education , joint mobility , hallux blood pressure , and other foot deformities . CONCLUSIONS Certain foot deformities , reduced skin oxygenation and foot perfusion , poor vision , greater body mass , and both sensory and autonomic neuropathy independently influence foot ulcer risk , thereby providing support for a multifactorial etiology for diabetic foot ulceration OBJECTIVE To evaluate the effectiveness of the Semmes-Weinstein monofilament examination ( SWME ) for diabetic peripheral neuropathy ( DPN ) screening at an outpatient clinic . METHODS Eighty-two type 2 diabetic out patients were question ed about 13 subjective symptoms and tested for deep reflexes . They were examined using two types of quantitative sensory testing : SWME ( using 4.31/2 g and 5.07/10 g monofilaments ) and vibration testing ( using the C-64 quantitative tuning fork ) . The patients were diagnosed with DPN when two of the following three criteria from both legs were met : ( 1 ) the presence of either pain , numbness , or paraesthesia ; ( 2 ) a diminished or absent ankle reflex ; or ( 3 ) a scale below 4 for their vibration perception thresholds ( VPT ) . RESULTS The most common subjective symptoms were muscle cramps and numbness in the extremities . SWME 4.31/2 g at the great toe or the plantar aspect of the fifth metatarsal was the most useful diagnostic test for DPN , providing 60.0 % sensitivity and 73.8 % specificity . SWME 4.31/2 g was correlated with lower limb VPT ( P=.029 ) and three subjective symptoms including fainting . SWME 5.07/10 g was correlated with lower limb VPT ( P=.011 ) , the ankle reflex ( P=.013 ) , the knee reflex ( P=.031 ) , and two subjective symptoms . However , the sensitivity to diagnose DPN was low ( 30.0 % ) . CONCLUSIONS The abnormalities indicated by SWME correlated well with those identified by lower limb VPT . Moreover , SWME 4.31/2 g correlated with fainting , suggesting that it could detect abnormalities in the small fibers . Considering the minimal time for this examination , SWME 4.31/2 g is a useful examination in an outpatient setting along with lower limb VPT and ankle reflex testing OBJECTIVE The purpose of this study was to evaluate the effects of different testing sites and buckling strengths on the sensitivity and specificity of using the Semmes-Weinstein monofilament to detect patients with insensate foot . The impact on workload required to educate and follow up these high-risk individuals was estimated by modeling in our patient population with a documented status of neuropathy . RESEARCH DESIGN AND METHODS Using the 5.07/10-g monofilament , one observer tested 132 r and omly selected subjects with diabetes at five sites on the right foot . The sensitivity and specificity of each site and combinations of sites in detecting vibration perception threshold > 40 was calculated . In addition , two monofilaments , one with a buckling force of 5 g and the other with a force of 15 g , were compared by testing 200 r and omly selected patients . An estimate of the prevalence of insensate foot and workload was made by modeling the findings to the 5,270 patients with neuropathy status registered on our computerized data base . RESULTS Specificity of the 5.07/10-g monofilament to detect insensate foot at each of the five sites is high , at approximately 90 % , but there is considerably more variation and lower sensitivity , ranging from 44 - 71 % . Data derived from the use of different combinations of sites showed that more stringent criteria are associated with lower sensitivity but higher specificity . If the foot is considered insensate when either of sites 3 and 4 ( plantar aspect of the first and fifth metatarsal heads , respectively ) can not feel the monofilament , there is reasonable sensitivity and specificity ( 80 - 86 % , respectively ) . By modeling on our diabetes center population , it can be demonstrated that the choice of different method ologies leads to different conclusions about the prevalence of severe neuropathy , ranging from 3.4 to 29.3 % . CONCLUSIONS Using a combination of sites 3 and 4 for monofilament testing gives a reasonable compromise for time , sensitivity , and specificity . Minor changes in sensitivity and specificity can lead to major changes in the prevalence of neuropathy , with implication s for workload OBJECTIVE Diabetic foot ulceration is a preventable long-term complication of diabetes . A multicenter prospect i ve follow-up study was conducted to determine which risk factors in foot screening have a high association with the development of foot ulceration . RESEARCH DESIGN AND METHODS A total of 248 patients from 3 large diabetic foot centers were enrolled in a prospect i ve study .  Neuropathy symptom score , neuropathy disability score ( NDS ) , vibration perception threshold ( VPT ) , Semmes-Weinstein monofilaments ( SWFs ) , joint mobility , peak plantar foot pressures , and vascular status  were evaluated in all patients at the beginning of the study . Patients were followed-up every 6 months for a mean period of 30 months ( range 6 - 40 ) , and all new foot ulcers were recorded . The sensitivity , specificity , and positive predictive value of each risk factor were evaluated . RESULTS Foot ulcers developed in 95 feet ( 19 % ) or 73 patients ( 29 % ) during the study . Patients who developed foot ulcers were more frequently men , had diabetes for a longer duration , had nonpalpable pedal pulses , had reduced joint mobility , had a high NDS , had a high VPT , and had an inability to feel a 5.07 SWE NDS alone had the best sensitivity , whereas the combination of the NDS and the inability to feel a 5.07 SWF reached a sensitivity of 99 % . On the other h and , the best specificity for a single factor was offered by foot pressures , and the best combination was that of NDS and foot pressures . Univariate logistical regression analysis yielded a statistically significant odds ratio ( OR ) for sex , race , duration of diabetes , palpable pulses , history of foot ulceration , high NDSs , high VPTs , high SWFs , and high foot pressures . In addition , 94 ( 99 % ) of the 95 ulcerated feet had a high NDS and /or SWF which result ed in the highest OR of 26.2 ( 95 % CI 3.6 - 190 ) . Furthermore , in multivariate logistical regression analysis , the only significant factors were high NDSs , VPTs , SWFs , and foot pressures . CONCLUSIONS Clinical examination and a 5.07 SWF test are the two most sensitive tests in identifying patients at risk for foot ulceration , especially when the tests are used in conjunction with each other . VPT measurements are also helpful and can be used as an alternative . Finally , foot pressure measurements offer a substantially higher specificity and can be used as a postscreening test in conjunction with providing appropriate footwear Current recommendations for the prevention of foot ulceration and amputation include screening at-risk individuals by testing for loss of protective sensation at eight sites using 10-g ( 5.07 ) nylon monofilaments . Yet measurement of the cutaneous pressure threshold to differentiate one-point from two-point static touch stimuli may allow identification of these at-risk individuals earlier in the clinical course of diabetic neuropathy . The present study tested this hypothesis using a prospect i ve , cross-sectional , multicenter design that included sensibility testing of 496 patients with diabetic neurop 
    Output:
    
However , current literature suggests that nerve conduction study ( NCS ) is the gold st and ard for diagnosing DPN .
There is great variation in the current literature regarding the diagnostic value of SWME as a result of different method ologies .