Loose and frequent stools and PTH levels are positively correlated post-gastric bypass surgery due to less efficient intestinal calcium absorption.

BACKGROUND: After Roux-en-Y gastric bypass, calcium and vitamin D deficiencies are frequently reported. In the presence of adequate vitamin D levels, calcium deficiency is caused by a lower efficacy of the intestinal calcium transport. OBJECTIVE: To investigate whether the use of a simple clinical score quantifying bowel habits (fecal score [FS]) correlates with the degree of secondary hyperparathyroidism that arises to compensate for calcium deficiency postsurgery. SETTING: Large peripheral hospital. METHODS: Seventy-five patients supplemented with calcium and vitamin D were prospectively studied before and 6 and 12 months after Roux-en-Y gastric bypass. FS, calcium (mmol/L), phosphate (mmol/L), magnesium (mmol/L), vitamin D (nmol/L), and parathyroid hormone (PTH; pmol/L) were measured in each patient. RESULTS: Mean body mass index was 44.7±5.4 kg/m2 preoperatively and decreased to 34.3±5.0 kg/m2 at 6 months and 30.8±4.8 kg/m2 at 12 months, corresponding to a total weight loss of 23.2±5.9% and 30.9±8.3% respectively. There were no significant changes in serum calcium levels. Mean PTH levels rose from 3.5 pmol/L at baseline to 4.1 pmol/L at 6 months (P = .01) and to 4.9 pmol/L at 12 months (P<.001). Nine patients (12%) had increased PTH levels at 6 months, and 14 patients (19%) had increased PTH levels at 12 months. A significant positive correlation between FS and PTH at 12 months was found, which persisted after adjusting for vitamin D levels. CONCLUSION: FS is positively correlated with secondary hyperparathyroidism using vitamin D-adjusted PTH levels as a biochemical marker. The present study in humans confirms the relation reported in animal studies. These results emphasize that managing stool habits are important after bariatric surgery.

Penile anesthesia in Post SSRI Sexual Dysfunction (PSSD) responds to low-power laser irradiation: a case study and hypothesis about the role of transient receptor potential (TRP) ion channels.

Treatment of paroxetine-induced penile anesthesia in Post SSRI Sexual Dysfunction (PSSD) by Low-power Laser Irradiation (LPLI) is unknown in medical literature. The aim of the current article is to report partial efficacy of LPLI for paroxetine-induced persistent penile anesthesia. We report on a male patient who presented with a history of reversible loss of smell, taste and skin sensitivity occurring within a week after start of 20mg/day paroxetine-hemihydrate for a depressive period. Concurrently, patient suffered from penile anesthesia, scrotum hypesthesia, anejaculation and erectile difficulties with normal sexual desire. During 2.5 years of paroxetine treatment and throughout 2 years after paroxetine discontinuation, genital and sexual complaints persisted. Penile anesthesia was treated by LPLI with single and multi diode pulsed laser probes. After 20 LPLI-treatment sessions of 15min each, patient reported partial return of penile touch and temperature sensation. Clinical improvement of glans penis sensitivity was reported to 20% and 40%, compared to pre-paroxetine treatment penile sensitivity during erect and flaccid states, respectively. However, anejaculation and erectile difficulties remained unchanged. Briefly, in the current patient with early onset of PSSD, LPLI treatment reduced paroxetine-induced penile anesthesia. It is hypothesized that SSRI treatment induces disturbances of transient receptor potential (TRP) ion channels of mechano-, thermo- and chemosensitive nerve endings and receptors resulting in the penile anesthesia in PSSD. It is further hypothesized that there are two types of PSSD, one of which occurs soon after the start of SSRI treatment.

Foot orgasm syndrome: a case report in a woman.

INTRODUCTION: Spontaneous orgasm triggered from inside the foot has so far not been reported in medical literature. AIMS: The study aims to report orgasmic feelings in the left foot of a woman. METHODS: A woman presented with complaints of undesired orgasmic sensations originating in her left foot. In-depth interview, physical examination, sensory testing, magnetic resonance imaging (MRI-scan), electromyography (EMG), transcutaneous electrical nerve stimulation (TENS), and blockade of the left S1 dorsal root ganglion were performed. MAIN OUTCOME MEASURES: The main outcomes are description of this clinical syndrome, results of TENS application, and S1 dorsal root ganglion blockade. RESULTS: Subtle attenuation of sensory amplitudes of the left suralis, and the left medial and lateral plantar nerve tracts was found at EMG. MRI-scan disclosed no foot abnormalities. TENS at the left metatarso-phalangeal joint-III of the left foot elicited an instant orgasmic sensation that radiated from plantar toward the vagina. TENS applied to the left side of the vagina elicited an orgasm that radiated to the left foot. Diagnostic blockade of the left S1 dorsal root ganglion with 0.8 mL bupivacaine 0.25 mg attenuated the frequency and intensity of orgasmic sensation in the left foot with 50% and 80%, respectively. Additional therapeutic blockade of the same ganglion with 0.8 mL bupivacaine 0.50 mg combined with pulsed radiofrequency treatment resulted in a complete disappearance of the foot-induced orgasmic sensations. CONCLUSION: Foot orgasm syndrome (FOS) is descibed in a woman. Blockade of the left S1 dorsal root ganglion alleviated FOS. It is hypothesized that FOS, occurring 1.5 years after an intensive care emergency, was caused by partial nerve regeneration (axonotmesis), after which afferent (C-fiber) information from a small reinnervated skin area of the left foot and afferent somatic and autonomous (visceral) information from the vagina on at least S1 spinal level is misinterpreted by the brain as being solely information originating from the vagina.

Stronger evidence for small fiber sensory neuropathy in restless genital syndrome: two case reports in males.

INTRODUCTION: Restless genital syndrome (ReGS) is characterized by unwanted, unpleasant genital sensations, restless legs, and/or overactive bladder, as well as neuropathy of the dorsal nerve of the clitoris. So far, ReGS has only been reported in females. AIM: To report the occurrence of ReGS in two males. METHODS: Two males with unwanted genital sensations presented in our clinic. In-depth interview, routine and hormonal investigations, electro-encephalography, magnetic resonance imaging of brain and pelvis, manual examination of the pubic bone, and sensory testing of genital dermatomes were performed. In both males, conventional transcutaneous electrical nerve stimulation was applied bilaterally at the pudendal dermatome. MAIN OUTCOME MEASURES: Oral report, questionnaire on frequency and intensity of restless genital feelings, restless legs, overactive bladder, and satisfaction with the transcutaneous electrical nerve stimulation (TENS) treatment. RESULTS: ReGS in a 74-year-old male manifested as unpleasant genital sensations of being on the edge of an orgasm with overactive bladder, in the absence of erection and ejaculation. Genital sensory testing elicited bilateral points of static mechanical hyperesthesia in the pudendal dermatome. Manual examination of the dorsal nerve of the penis (DNP) elicited the genital sensations. TENS application resulted in a 90% reduction of genital sensations and complaints of overactive bladder syndrome (OAB). ReGS in a 38-year-old male manifested as unwanted and unpleasant spontaneous ejaculations and complaints of OAB. Genital sensory testing elicited bilateral points of static mechanical hyperesthesia in the pudendal dermatome. Manual examination of the DNP elicited the genital sensations. TENS application had no effect on genital complaints and complaints of OAB. CONCLUSIONS: ReGS is not a typical female disorder as it also affects males. This notion and the finding of typical sensory abnormalities of the genital end branches of the pudendal nerve in males and females--as previously reported--provides strong evidence for Small Fiber Sensory Neuropathy as a common cause of ReGS.

Successful transcutaneous electrical nerve stimulation in two women with restless genital syndrome: the role of adelta- and C-nerve fibers.

INTRODUCTION: Currently, efficacious treatment of restless genital syndrome (ReGS) is not available. AIM: This study aimed to report the results of transcutaneous electrical nerve stimulation (TENS) for ReGS, being a combination of genital dysesthesias, imminent and/or spontaneous orgasms, and/or restless legs, and/or overactive bladder. METHODS: Two women with ReGS were referred to our clinic. In-depth interview, routine and hormonal investigations, electroencephalography, magnetic resonance imaging (MRI) of the brain and pelvis, manual examination of the ramus inferior of the pubic bone, and sensory testing of genital dermatomes were performed. Conventional TENS (frequency: 110 Hz; pulse width: 80 milliseconds) was applied bilaterally at the region of the pudendal dermatome in which immediate reduction of genital sensations occurred. Patients were instructed for self-application of TENS each day for 2 months. MAIN OUTCOME MEASURES: Oral report, questionnaires on frequency of imminent and/or spontaneous orgasms, combined with questions on intensity of restless genital feelings, restless leg syndrome (RLS), overactive bladder syndrome (OAB), and satisfaction with TENS treatment. RESULTS: ReGS in a 56-year-old woman manifested as multiple spontaneous orgasms, RLS, and OAB. TENS applied to the sacral region resulted in immediate reduction of complaints and a 90% reduction of spontaneous orgasms, RLS, and OAB in 2 months. ReGS in a 61-year-old woman manifested as a continuous restless genital feeling, imminent orgasms, and OAB. TENS applied to the pubic bone resulted in a complete disappearance of restlessness in the genital area as well as OAB complaints in 2 months. Both women reported to be very satisfied and did not want to stop TENS treatment. CONCLUSIONS: Conventional TENS treatment is a promising therapy for ReGS, but further controlled research is warranted. Preorgasmic and orgasmic genital sensations in ReGS are transmitted by Adelta and C fibers and are inhibited by Abeta fibers. A neurological hypothesis on the pathophysiology of ReGS encompassing its clinical symptomatology, TENS, and drug treatment is put forward.

Premature ejaculation and pharmaceutical company-based medicine: the dapoxetine case.

INTRODUCTION: The manufacturer of dapoxetine funded randomized clinical trials to study its effect in premature ejaculation (PE). Financial support by pharmaceutical companies, however, may jeopardize the neutrality of clinical research. AIM: To investigate the scientific process that has been followed in dapoxetine treatment trials and reviews as compared to daily drug treatment trials and reviews with selective serotonin reuptake inhibitors (SSRIs) in men with PE. METHODS: A search of Medline and Embase was conducted using the search terms "dapoxetine" or "SSRI." References of retrieved articles were searched. Only studies describing the use of these drugs in men with PE were included. Main Outcome Measures. Compared fold-increase intravaginal ejaculation latency time (IELT), geometric mean IELT, and adverse effect profiles between dapoxetine and SSRIs in PE. RESULTS: Preclinical studies on dapoxetine, including a multicenter study (category A) and reviews (category B), were compared with clinical studies with daily conventional SSRIs in PE (category C). Categories A/B focused on patient-reported outcomes with less attention for the IELT. The ejaculation-delaying effect of dapoxetine was expressed as natural mean IELT rather than as geometrical mean IELT. Dapoxetine side effects were monthly scored. In contrast, a significant part of category C articles focused on IELT data, used geometric mean IELT outcomes, and one study reported the side effects measured 24-48 hours after drug intake using a validated questionnaire. Without the Food and Drug Administration approval, dapoxetine, as well as other SSRIs in PE, is an off-label drug for PE. However, the off-label use of dapoxetine has never been criticized by clinical investigators in contrast to commentaries against the off-label use of daily SSRI treatment in PE. CONCLUSIONS: Manufacturer-funded drug treatment research (categories A and B) is advantageously treated by some authors as compared with nonfunded trials with daily conventional SSRIs (category C). PE drug treatment research is a young and dynamic field, and its development deserves transparency to its development.

Mineral metabolism and bone disease after bariatric surgery and ways to optimize bone health.

There is no consensus on how to protect the skeleton with adequate supplements in patients who have undergone bariatric operations. The main problem in mineral metabolism is usually related to secondary hyperparathyroidism (2 degrees HPT), often caused by a lack of dietary calcium, magnesium or vitamin D, together with changes in intestinal fermentation, transit time, and resorption surfaces left behind after bariatric operations. After primarily restrictive bariatric surgery, adequate mineral metabolism depends mainly on the active metabolite of vitamin D, whereas after primarily malabsorptive surgery, it depends largely on passive resorption by means of the calcium sensitizing receptor (CaSR). Notably, CaSR-activated calcium transport is coupled to the presence of sufficient magnesium. The current review discusses clinically relevant mechanisms of mineral metabolism and provides recommendations for adequate calcium, magnesium, and vitamin D supplementation. Nevertheless, formal supplementation guidelines are needed in the near future.

Skeletal effects and functional outcome with olpadronate in children with osteogenesis imperfecta: a 2-year randomised placebo-controlled study.

BACKGROUND: Non-randomised studies have suggested beneficial effects of bisphosphonates in osteogenesis imperfecta. We assessed the effects of oral olpadronate in children with this disorder in a randomised double-blind placebo-controlled trial. METHODS: 34 children recruited from the Dutch national centre for osteogenesis imperfecta were randomly assigned olpadronate (10 mg/m2 daily; n=16) or placebo (n=18) for 2 years. All children also received calcium and vitamin D supplements. Primary endpoints were incident fractures of long bones and changes in bone mineral content (BMC), bone mineral density (BMD), and functional outcome. Anthropometry, vertebral height, and urinary markers of bone resorption were also studied. Analyses were by intention to treat. FINDINGS: Fracture follow-up was complete for all the children, including two who withdrew from the study (one from each group). Olpadronate treatment was associated with a 31% reduction in relative risk of fracture of long bones (hazard ratio 0.69 [95% CI 0.52-0.91], p=0.01). The olpadronate group showed significantly greater increases than the placebo group in spinal BMC (difference between groups 2.24 g/year [0.20-4.29], p=0.03) and spinal BMD (difference between groups 0.054 g/cm2 per year [0.012-0.096], p=0.01). There were no detectable effects on functional outcome, anthropometrics, or vertebral height and no differences between the groups in changes in urinary markers of bone resorption. INTERPRETATION: Oral treatment with olpadronate at a daily dose of 10 mg/m2 results in a reduction of fracture risk of long bones in children with osteogenesis imperfecta. However, the issue of whether bisphosphonates will alter the natural course of osteogenesis imperfecta remains unresolved, and further studies are needed.