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LDL, low-density lipoprotein cholesterol 4 Clinical manifestations, screening and diagnosis of DPN 4.1 Clinical manifestations DPN usually manifests as a length-dependent, distal-symmetrical, sensorimotor polyneuropathy ( Alternatively, some patients may be completely asymptomatic, and signs may be only revealed by a detailed neurological examination ( In accordance with the higher vulnerability of lower-limb long axons to injury, DPN usually develops first in the feet and then progresses proximally involving the upper limbs (dying-back type of axonal degeneration), and patients typically present with a stocking-glove like distribution of neuronal dysfunction ( Overall, up to 50% of affected subjects do not report symptoms, and up to one fourth of patients develop painful DPN which is particularly associated with physical and psychosocial impairment, disability, and reduced health-related quality of life ( Most patients show a mixed neuropathy with both large and small nerve fiber damage and all patients with DPN are considered to be at increased risk of neuropathic complications such as foot ulceration and Charcots neuroarthropathy as well as the falls and fractures ( 4.2 Underdiagnosis insufficient awareness among physicians Despite its major impact on morbidity and mortality, DPN is frequently underdiagnosed and underestimated in clinical practice ( a) the insidious course of disease manifesting with non-specific symptoms and signs mimicking many other diseases, b) a lack of consensus on optimal screening and diagnostic procedures, c) the absence of a well-established diagnostic scrutiny, and d) the poor acceptance of guidelines and insufficient awareness of the disease among physicians ( DPN is a diagnosis by exclusion, and its recognition is mainly based on clinical suspicion and the effort put into finding it ( The current practice of DPN care is also considered inadequate in terms of patient journey which includes multiple visits to different clinicians having no specialist training to assess the level of risk, to provide advice, or to appropriately refer the patients for further investigation and appropriate interventions ( Accordingly, the participating experts consider the suspicion of the disease by clinicians as the key factor, emphasizing the awareness of the disease during the patient journey by the first-admission or referring physicians

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