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Suggest Treatment For Diabetic Neuropathy
Question: My dad has just been diagnosed with diabetic sensory and motor neuropathy. What can we do to help him Doctors say there are no treatments. I am sure something must be out there. What is the prognosis please? The Neurologist doesn't want to see my Dad again I feel we have been left on the shelf
Brief Answer:
Diabetic Neuropathy
Detailed Answer:
May I assume your father has type 2 diabetes?
Neuropathy is the medical term for nerve damage. Neuropathy is a common complication of type 1 and type 2 diabetes; up to 26 percent of people with type 2 diabetes have evidence of nerve damage at the time that diabetes is diagnosed.
Your father has probably had diabetes for a considerable duration. The likelihood and severity of neuropathy is also worse with longer duration and degree of diabetes control.
A generalized type of neuropathy, known as polyneuropathy, is the most common type of diabetic neuropathy. Other types of neuropathy can also affect people with diabetes, but are too complex to discuss here.
Signs and symptoms of diabetic neuropathy include loss of sensation and/or burning pain in the feet. Early detection of diabetes and tight control of blood sugar levels may reduce the risk of developing diabetic neuropathy. Since your dad has established diabetes, controlling it better should also help.
Treatments for diabetic neuropathy are available, and include several elements: control of blood glucose levels, prevention of injury, and control of painful symptoms.
DIABETIC NEUROPATHY RISK FACTORS — In people with type 1 or type 2 diabetes, the biggest risk factor for developing diabetic neuropathy is having high blood sugar levels over time.
Other factors can further increase the risk of developing diabetic neuropathy, including:
●Coronary artery disease
●Increased triglyceride levels
●Being overweight (a body mass index >24)
●Smoking
●High blood pressure
See which of the above applies to your father and work on addressing the relevant ones.
DIABETIC NEUROPATHY SYMPTOMS — The most common symptoms of diabetic neuropathy include pain, burning, tingling, or numbness in the toes or feet, and extreme sensitivity to light touch. The pain may be worst at rest and improve with activity, such as walking. Some people initially have intensely painful feet while others have few or no symptoms.
Diabetic neuropathy usually affects both sides of the body. Symptoms are usually noticed first in the toes. If the disease progresses, symptoms may gradually move up the legs; if the mid-calves are affected, symptoms may develop in the hands. Over time, the ability to sense pain may be lost, which greatly increases the risk of injury.
Potential complications — As the individual loses the ability to sense pain or hot and cold, the risk of injuring the feet increases. Injuries that would normally cause pain (eg, stepping on a splinter, wearing shoes that create a blister, developing an ingrown toenail) do not necessarily cause pain if one has neuropathy. Unless your dad inspects his feet on a daily basis, a small injury has the potential to develop into a large ulcer. One of the most serious complications of foot ulcers is the need for amputation of a toe, or in extreme cases, the foot itself.
DIABETIC NEUROPATHY TESTS — Diabetic neuropathy is diagnosed based upon a medical history and physical examination of the feet. During an examination, there may be signs of nerve injury, including:
●Loss of the ability to sense vibration and movement in the toes or feet (eg, when the toe is moved up or down)
●Loss of the ability to sense pain, light touch and temperature in the toes or feet
●Loss or reduction of the Achilles tendon reflex
More extensive testing, including nerve conduction studies, nerve biopsy, or imaging tests (eg, x-ray or CT scan), is not usually needed to diagnose diabetic neuropathy.
DIABETIC NEUROPATHY TREATMENT — There are three main components of diabetic neuropathy treatment:
●Tight control of blood sugar levels
●Care for the feet to prevent complications
●Control of pain caused by neuropathy
Although there is no cure for diabetic neuropathy, use of these treatments can improve painful symptoms and prevent complications.
Control blood sugar levels — One of the most important treatments for diabetic neuropathy is to control blood sugar levels. Symptoms of pain and burning may improve when blood glucose sugar improves.
If blood sugar levels are not adequately controlled with the current treatment regimen, a different regimen may be recommended.
●For people with type 2 diabetes like your dad , this may mean taking an additional oral medication or starting insulin injections.
Care for the feet — People with neuropathy do not always feel pain when there is a wound or injury on the foot. As a result, daily foot care is necessary to monitor for changes in the skin (such as cracks or wounds), which can increase the risk of infection. The XXXXXXX Diabetes Association recommends that people with diabetes have a comprehensive foot examination once per year, and a visual examination of the feet at each visit (usually every three to four months).
Avoid activities that can injure the feet — Some activities increase the risk of foot injury and are not recommended, including walking barefoot, using a heating pad or hot water bottle on the feet, and stepping into the bathtub before testing the temperature with the hand.
Use care when trimming the nails — Trim the toe nails along the shape of the toe (rounded, not straight across) and file the nails to remove any sharp edges. Never cut (or allow a manicurist to cut) the cuticles. Do not pop blisters, try to free ingrown toenails, or otherwise break the skin on the feet. See a healthcare provider or podiatrist for even minor procedures.
Wash and check the feet daily — Use lukewarm water and mild soap to clean the feet. Gently XXXXXXX feet dry and apply a moisturizing cream or lotion.
Check the entire surface of both feet for skin breaks, blisters, swelling, or redness, including between and underneath the toes where damage may be hidden. Use a mirror or ask a family member or caregiver to help if it is difficult to see the entire foot.
Choose socks and shoes carefully — Select cotton socks that fit loosely, and change the socks every day. Wear shoes that are fit correctly and are not tight, and break new shoes in slowly to prevent blisters. Ask about customized shoes if your feet are misshapen or have ulcers; specialized shoes can reduce the chances of developing foot ulcers in the future. Shoe inserts may also help cushion the step and decrease pressure on the soles of the feet.
Ask for foot exams — Screening for foot complications should be a routine part of most medical visits, but is sometimes overlooked. At each visit, the shoes and socks should be removed and the clinician should visually examine the feet. Do not hesitate to ask the healthcare provider for a complete foot check at least once a year, and more frequently if there are problems.
Control pain — Neuropathic pain can be difficult to control and can seriously affect your quality of life. Neuropathic pain is often worse at night, seriously disrupting sleep.
Fortunately, only a small percentage of people with diabetic neuropathy experience pain. Pain resolves without treatment in some people over a period of weeks to months, especially if the episode of pain developed after a sudden change in health (eg, an episode of diabetic ketoacidosis, a significant weight loss, or a significant change in blood glucose control).
There are several medications that are useful for the treatment of diabetic neuropathy and have been approved by the US FDA, including duloxetine and pregabalin. Other medications are also useful, including tricyclic medications (eg, amitriptyline), gabapentin, tramadol, and alpha-lipoic acid.
Tricyclic antidepressants (TCAs)— There are several tricyclic antidepressants available for the treatment of chronic pain, including amitriptyline, nortriptyline, and desipramine. Clinical trials have shown than tricyclic antidepressant drugs are effective for patients with painful diabetic neuropathy. The dose of tricyclic antidepressants used to treat diabetic neuropathy is typically much lower than that used to treat depression.
These medications are usually taken at bedtime, starting with a low dose and gradually increasing over a period of several weeks. People with heart disease should not take amitriptyline or nortriptyline. Tricyclic medications can be taken with gabapentin and pregabalin, but should not be taken with duloxetine. Side effects can include dry mouth, sleepiness, dizziness, and constipation.
Duloxetine — Duloxetine is an antidepressant that is often effective in relieving pain caused by diabetic neuropathy. In short-term clinical trials, duloxetine was more effective than placebo. However, the long-term effectiveness and safety of duloxetine for diabetic neuropathy is uncertain. There are no trials comparing duloxetine with other drugs for the treatment of diabetic polyneuropathy.
Duloxetine is usually taken by mouth once per day on a full stomach, although in some cases it is taken twice per day. It should not be taken by people who take other antidepressant medications. Side effects can include nausea, sleepiness, dizziness, decreased appetite, and constipation.
Gabapentin — Gabapentin is an anti-seizure medication. It is usually taken by mouth three times per day. Side effects can include dizziness and confusion. Gabapentin can be taken with a tricyclic antidepressants or duloxetine. In some cases, gabapentin can be taken at night to prevent pain during sleep.
Pregabalin — Pregabalin is an anti-seizure medication, similar to gabapentin. Pregabalin is taken by mouth, starting at bedtime at a low dose, and then gradually increasing to three times per day over a period of several weeks.
Side effects can include dizziness, sleepiness, confusion, swelling in the feet and ankles, and weight gain. It may be possible to become addicted to pregabalin, and changes in dosing should be monitored carefully. Pregabalin can be taken with duloxetine or TCAs, but not with gabapentin.
Anesthetic drugs — Lidocaine is an anesthetic drug that may be recommended if other treatments have not improved pain. It is applied to the painful area in a patch, which slowly releases the medication over time. Up to four patches may be applied for up to 18 hours per day.
Alpha-lipoic acid — Alpha-lipoic acid (ALA) is an antioxidant medication. Several short-term trials showed that it was helpful in relieving pain caused by diabetic neuropathy. Thus, ALA may be recommended to people with diabetic neuropathy who do not improve with or who cannot tolerate other treatments. However, longer-term studies are still needed to confirm its safety and effectiveness. In the United States, ALA is available without a prescription as a dietary supplement. It is usually taken by mouth once per day.
Narcotics (opioids) — Tramadol is a pain medication that can be taken for breakthrough pain; in severe cases, it can be taken every six hours (four times per day). It can cause sedation, dizziness and confusion. It can be taken with pregabalin, duloxetine, gabapentin, and TCAs.
It is important to note that the long-term use of narcotic medications for non-cancer pain is associated with a number of problems, including the potential for abuse, addiction, and fatal overdose, particularly for patients treated with higher dose regimens. Because of these issues, some clinicians have stopped using narcotics altogether for the treatment of painful diabetic neuropathy.
Diabetic Neuropathy
Detailed Answer:
May I assume your father has type 2 diabetes?
Neuropathy is the medical term for nerve damage. Neuropathy is a common complication of type 1 and type 2 diabetes; up to 26 percent of people with type 2 diabetes have evidence of nerve damage at the time that diabetes is diagnosed.
Your father has probably had diabetes for a considerable duration. The likelihood and severity of neuropathy is also worse with longer duration and degree of diabetes control.
A generalized type of neuropathy, known as polyneuropathy, is the most common type of diabetic neuropathy. Other types of neuropathy can also affect people with diabetes, but are too complex to discuss here.
Signs and symptoms of diabetic neuropathy include loss of sensation and/or burning pain in the feet. Early detection of diabetes and tight control of blood sugar levels may reduce the risk of developing diabetic neuropathy. Since your dad has established diabetes, controlling it better should also help.
Treatments for diabetic neuropathy are available, and include several elements: control of blood glucose levels, prevention of injury, and control of painful symptoms.
DIABETIC NEUROPATHY RISK FACTORS — In people with type 1 or type 2 diabetes, the biggest risk factor for developing diabetic neuropathy is having high blood sugar levels over time.
Other factors can further increase the risk of developing diabetic neuropathy, including:
●Coronary artery disease
●Increased triglyceride levels
●Being overweight (a body mass index >24)
●Smoking
●High blood pressure
See which of the above applies to your father and work on addressing the relevant ones.
DIABETIC NEUROPATHY SYMPTOMS — The most common symptoms of diabetic neuropathy include pain, burning, tingling, or numbness in the toes or feet, and extreme sensitivity to light touch. The pain may be worst at rest and improve with activity, such as walking. Some people initially have intensely painful feet while others have few or no symptoms.
Diabetic neuropathy usually affects both sides of the body. Symptoms are usually noticed first in the toes. If the disease progresses, symptoms may gradually move up the legs; if the mid-calves are affected, symptoms may develop in the hands. Over time, the ability to sense pain may be lost, which greatly increases the risk of injury.
Potential complications — As the individual loses the ability to sense pain or hot and cold, the risk of injuring the feet increases. Injuries that would normally cause pain (eg, stepping on a splinter, wearing shoes that create a blister, developing an ingrown toenail) do not necessarily cause pain if one has neuropathy. Unless your dad inspects his feet on a daily basis, a small injury has the potential to develop into a large ulcer. One of the most serious complications of foot ulcers is the need for amputation of a toe, or in extreme cases, the foot itself.
DIABETIC NEUROPATHY TESTS — Diabetic neuropathy is diagnosed based upon a medical history and physical examination of the feet. During an examination, there may be signs of nerve injury, including:
●Loss of the ability to sense vibration and movement in the toes or feet (eg, when the toe is moved up or down)
●Loss of the ability to sense pain, light touch and temperature in the toes or feet
●Loss or reduction of the Achilles tendon reflex
More extensive testing, including nerve conduction studies, nerve biopsy, or imaging tests (eg, x-ray or CT scan), is not usually needed to diagnose diabetic neuropathy.
DIABETIC NEUROPATHY TREATMENT — There are three main components of diabetic neuropathy treatment:
●Tight control of blood sugar levels
●Care for the feet to prevent complications
●Control of pain caused by neuropathy
Although there is no cure for diabetic neuropathy, use of these treatments can improve painful symptoms and prevent complications.
Control blood sugar levels — One of the most important treatments for diabetic neuropathy is to control blood sugar levels. Symptoms of pain and burning may improve when blood glucose sugar improves.
If blood sugar levels are not adequately controlled with the current treatment regimen, a different regimen may be recommended.
●For people with type 2 diabetes like your dad , this may mean taking an additional oral medication or starting insulin injections.
Care for the feet — People with neuropathy do not always feel pain when there is a wound or injury on the foot. As a result, daily foot care is necessary to monitor for changes in the skin (such as cracks or wounds), which can increase the risk of infection. The XXXXXXX Diabetes Association recommends that people with diabetes have a comprehensive foot examination once per year, and a visual examination of the feet at each visit (usually every three to four months).
Avoid activities that can injure the feet — Some activities increase the risk of foot injury and are not recommended, including walking barefoot, using a heating pad or hot water bottle on the feet, and stepping into the bathtub before testing the temperature with the hand.
Use care when trimming the nails — Trim the toe nails along the shape of the toe (rounded, not straight across) and file the nails to remove any sharp edges. Never cut (or allow a manicurist to cut) the cuticles. Do not pop blisters, try to free ingrown toenails, or otherwise break the skin on the feet. See a healthcare provider or podiatrist for even minor procedures.
Wash and check the feet daily — Use lukewarm water and mild soap to clean the feet. Gently XXXXXXX feet dry and apply a moisturizing cream or lotion.
Check the entire surface of both feet for skin breaks, blisters, swelling, or redness, including between and underneath the toes where damage may be hidden. Use a mirror or ask a family member or caregiver to help if it is difficult to see the entire foot.
Choose socks and shoes carefully — Select cotton socks that fit loosely, and change the socks every day. Wear shoes that are fit correctly and are not tight, and break new shoes in slowly to prevent blisters. Ask about customized shoes if your feet are misshapen or have ulcers; specialized shoes can reduce the chances of developing foot ulcers in the future. Shoe inserts may also help cushion the step and decrease pressure on the soles of the feet.
Ask for foot exams — Screening for foot complications should be a routine part of most medical visits, but is sometimes overlooked. At each visit, the shoes and socks should be removed and the clinician should visually examine the feet. Do not hesitate to ask the healthcare provider for a complete foot check at least once a year, and more frequently if there are problems.
Control pain — Neuropathic pain can be difficult to control and can seriously affect your quality of life. Neuropathic pain is often worse at night, seriously disrupting sleep.
Fortunately, only a small percentage of people with diabetic neuropathy experience pain. Pain resolves without treatment in some people over a period of weeks to months, especially if the episode of pain developed after a sudden change in health (eg, an episode of diabetic ketoacidosis, a significant weight loss, or a significant change in blood glucose control).
There are several medications that are useful for the treatment of diabetic neuropathy and have been approved by the US FDA, including duloxetine and pregabalin. Other medications are also useful, including tricyclic medications (eg, amitriptyline), gabapentin, tramadol, and alpha-lipoic acid.
Tricyclic antidepressants (TCAs)— There are several tricyclic antidepressants available for the treatment of chronic pain, including amitriptyline, nortriptyline, and desipramine. Clinical trials have shown than tricyclic antidepressant drugs are effective for patients with painful diabetic neuropathy. The dose of tricyclic antidepressants used to treat diabetic neuropathy is typically much lower than that used to treat depression.
These medications are usually taken at bedtime, starting with a low dose and gradually increasing over a period of several weeks. People with heart disease should not take amitriptyline or nortriptyline. Tricyclic medications can be taken with gabapentin and pregabalin, but should not be taken with duloxetine. Side effects can include dry mouth, sleepiness, dizziness, and constipation.
Duloxetine — Duloxetine is an antidepressant that is often effective in relieving pain caused by diabetic neuropathy. In short-term clinical trials, duloxetine was more effective than placebo. However, the long-term effectiveness and safety of duloxetine for diabetic neuropathy is uncertain. There are no trials comparing duloxetine with other drugs for the treatment of diabetic polyneuropathy.
Duloxetine is usually taken by mouth once per day on a full stomach, although in some cases it is taken twice per day. It should not be taken by people who take other antidepressant medications. Side effects can include nausea, sleepiness, dizziness, decreased appetite, and constipation.
Gabapentin — Gabapentin is an anti-seizure medication. It is usually taken by mouth three times per day. Side effects can include dizziness and confusion. Gabapentin can be taken with a tricyclic antidepressants or duloxetine. In some cases, gabapentin can be taken at night to prevent pain during sleep.
Pregabalin — Pregabalin is an anti-seizure medication, similar to gabapentin. Pregabalin is taken by mouth, starting at bedtime at a low dose, and then gradually increasing to three times per day over a period of several weeks.
Side effects can include dizziness, sleepiness, confusion, swelling in the feet and ankles, and weight gain. It may be possible to become addicted to pregabalin, and changes in dosing should be monitored carefully. Pregabalin can be taken with duloxetine or TCAs, but not with gabapentin.
Anesthetic drugs — Lidocaine is an anesthetic drug that may be recommended if other treatments have not improved pain. It is applied to the painful area in a patch, which slowly releases the medication over time. Up to four patches may be applied for up to 18 hours per day.
Alpha-lipoic acid — Alpha-lipoic acid (ALA) is an antioxidant medication. Several short-term trials showed that it was helpful in relieving pain caused by diabetic neuropathy. Thus, ALA may be recommended to people with diabetic neuropathy who do not improve with or who cannot tolerate other treatments. However, longer-term studies are still needed to confirm its safety and effectiveness. In the United States, ALA is available without a prescription as a dietary supplement. It is usually taken by mouth once per day.
Narcotics (opioids) — Tramadol is a pain medication that can be taken for breakthrough pain; in severe cases, it can be taken every six hours (four times per day). It can cause sedation, dizziness and confusion. It can be taken with pregabalin, duloxetine, gabapentin, and TCAs.
It is important to note that the long-term use of narcotic medications for non-cancer pain is associated with a number of problems, including the potential for abuse, addiction, and fatal overdose, particularly for patients treated with higher dose regimens. Because of these issues, some clinicians have stopped using narcotics altogether for the treatment of painful diabetic neuropathy.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
My dad is insulin dependent type II diabetic and had it for 20 years.
Can dad get any mobility back and if so how? He has seen Neurologist but I think I am better getting in touch with Diabetes Team Dad was under as I think they may be able to help more do you agree?
Is a low carb diet any good? Dad needs to lose a bit of weight and blood sugar is now under control averaging around 6.2
This isn't classed as a terminal illness like motor neurone disease is it?
Can dad get any mobility back and if so how? He has seen Neurologist but I think I am better getting in touch with Diabetes Team Dad was under as I think they may be able to help more do you agree?
Is a low carb diet any good? Dad needs to lose a bit of weight and blood sugar is now under control averaging around 6.2
This isn't classed as a terminal illness like motor neurone disease is it?
Brief Answer:
Follow up
Detailed Answer:
1 Mobility improvement will require regular physiotherapy.
2 Seeing the Neurologist and Endocrinologist will serve him best.
Endocrinologists typically run Diabetes Care teams
3 Low carb diet is not the best. A balanced diet is preferred
4 Its not called terminal as such, but in many instances it is irreversible after progressing to a certain point.
Whether your dad has reached that stage, only a neurologist can comment after comprehensive physical examination and testing .
Follow up
Detailed Answer:
1 Mobility improvement will require regular physiotherapy.
2 Seeing the Neurologist and Endocrinologist will serve him best.
Endocrinologists typically run Diabetes Care teams
3 Low carb diet is not the best. A balanced diet is preferred
4 Its not called terminal as such, but in many instances it is irreversible after progressing to a certain point.
Whether your dad has reached that stage, only a neurologist can comment after comprehensive physical examination and testing .
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Neurologist just says nothing can be done
Brief Answer:
Second follow up
Detailed Answer:
I dont believe 'nothing' at all can be done. You may wish to get a second opinion from another neurologist
Second follow up
Detailed Answer:
I dont believe 'nothing' at all can be done. You may wish to get a second opinion from another neurologist
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Have you ever heard of the natural tablet nerve renew? Just wonder if it worth buying
Brief Answer:
Third follow up
Detailed Answer:
No I have not. To my knowledge no such natural remedies have been proven to help diabetic neuropathy
Third follow up
Detailed Answer:
No I have not. To my knowledge no such natural remedies have been proven to help diabetic neuropathy
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Please find below the letter received from hospital. Is there really nothing we can do I would like your opinion please as I feel my Dad has been written off;
Diagnosis: likely diabetic motor sensory neuropathy
Thank you for referring this 68 year old right handed gentleman to the Neurology clinic. He has had diabetes since 2000. His control was previosuly poor though has improved in the last 9 months. Mr Bridge has a previous history of osteomyelitis for which he was treated long term antibiotics. He now describes a 3 month history of progressive weakness of both legs. Although he can stand he feels unsteady and his legs quite often give way. He also described numbness in the legs. His arms bowel bladder speech and swallowing is unaffected.
On examination today his cranial nerves were unremarkable. Examination of limbs revealed normal tone. Power was normal in both arms and legs. Hip flexion was reduced to 3/5 bilaterally. Reflexes were absent in the legs but present in the arms. Sensation to pinprick was reduced distally in the legs but was present in the arms. Vibration sense was absent up to the hips. There were no fasiculations visible.
I suspect this gentleman has quite a severe axonal motor sensory neuropathy secondary to his diabetes. I have explained that this is not a treatable condition but we need to do some further investigations to exclude any more treatable causes. I am areanging MRI scan of lumbar spine to make sure there is no cord pathology or nerve root compression and some nerve conduction studies to quantify the extent of his nerve damage. I will write with the results once they are available.
Please help me there must be something I can do to help my dad I am really upset
Diagnosis: likely diabetic motor sensory neuropathy
Thank you for referring this 68 year old right handed gentleman to the Neurology clinic. He has had diabetes since 2000. His control was previosuly poor though has improved in the last 9 months. Mr Bridge has a previous history of osteomyelitis for which he was treated long term antibiotics. He now describes a 3 month history of progressive weakness of both legs. Although he can stand he feels unsteady and his legs quite often give way. He also described numbness in the legs. His arms bowel bladder speech and swallowing is unaffected.
On examination today his cranial nerves were unremarkable. Examination of limbs revealed normal tone. Power was normal in both arms and legs. Hip flexion was reduced to 3/5 bilaterally. Reflexes were absent in the legs but present in the arms. Sensation to pinprick was reduced distally in the legs but was present in the arms. Vibration sense was absent up to the hips. There were no fasiculations visible.
I suspect this gentleman has quite a severe axonal motor sensory neuropathy secondary to his diabetes. I have explained that this is not a treatable condition but we need to do some further investigations to exclude any more treatable causes. I am areanging MRI scan of lumbar spine to make sure there is no cord pathology or nerve root compression and some nerve conduction studies to quantify the extent of his nerve damage. I will write with the results once they are available.
Please help me there must be something I can do to help my dad I am really upset
Brief Answer:
Fourth follow up
Detailed Answer:
It is a good assessment. The doctors have recommended further testing. I fully concur with their advice. Kindly proceed to get them done in order to determine treatable causes
Fourth follow up
Detailed Answer:
It is a good assessment. The doctors have recommended further testing. I fully concur with their advice. Kindly proceed to get them done in order to determine treatable causes
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
If there is nothing underlying is there nothing we can do for my dad?
Brief Answer:
Fifth follow up
Detailed Answer:
I explained in my first response above, in detail about medical options
Fifth follow up
Detailed Answer:
I explained in my first response above, in detail about medical options
Note: For further follow-up, discuss your blood glucose reports with our diabetologist. Click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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