Laparoscopic sleeve gastrectomy improves renal transplant candidacy and posttransplant outcomes in morbidly obese patients.

Morbid obesity is a barrier to kidney transplantation due to inferior outcomes, including higher rates of new-onset diabetes after transplantation (NODAT), delayed graft function (DGF), and graft failure. Laparoscopic sleeve gastrectomy (LSG) increases transplant eligibility by reducing BMI in kidney transplant candidates, but the effect of surgical weight loss on posttransplantation outcomes is unknown. Reviewing single-center medical records, we identified all patients who underwent LSG before kidney transplantation from 2011-2016 (n = 20). Post-LSG kidney recipients were compared with similar-BMI recipients who did not undergo LSG, using 2:1 direct matching for patient factors. McNemar's test and signed-rank test were used to compare groups. Among post-LSG patients, mean BMI ± standard deviation (SD) was 41.5 ± 4.4 kg/m2 at initial encounter, which decreased to 32.3 ± 2.9 kg/m2 prior to transplantation (P < .01). No complications, readmissions, or mortality occurred following LSG. After transplantation, one patient (5%) experienced DGF, and no patients experienced NODAT. Allograft and patient survival at 1-year posttransplantation was 100%. Compared with non-LSG patients, post-LSG recipients had lower rates of DGF (5% vs 20%) and renal dysfunction-related readmissions (10% vs 27.5%) (P < .05 each). Perioperative complications, allograft survival, and patient survival were similar between groups. These data suggest that morbidly obese patients with end-stage renal disease who undergo LSG to improve transplant candidacy, achieve excellent posttransplantation outcomes.

Hyperinsulinemic hypoglycemia after gastric bypass surgery: what's up and what's down?

Obesity is a global public health problem and attempts to treat this condition using life style with and without pharmacological interventions have not been successful in majority of obese individuals. To date, the most effective treatment for obesity is weight loss surgery. One of the most widely used procedures to treat obesity worldwide, Roux-en-Y gastric bypass surgery (RYGB), has shown to induce diabetes remission in addition to significant and sustainable weight loss. As the number of this procedure performed over the last two decades increased, it has become clear that a subgroup of individuals develop postprandial hypoglycemia several years after surgery. This debilitating late complication of RYGB is often associated with loss of consciousness or seizures, and in severe cases, it is only partially responsive to diet modification or other available therapeutic options. The diagnosis is often a challenge resulting in delays in receiving care in the affected individuals. Although the underlying mechanisms are under current investigations, growing evidence suggest that a combination of exaggerated meal-derived nutrient appearance to systemic circulation and altered islet and gut hormone response after eating have a role in pathogenesis of this condition. The goal of this review is to highlight new perspectives regarding this life-threatening complication of RYGB. The etiology, diagnosis, recommendation on how to distinguish from classic dumping and current available treatment based on literature review will be discussed. In addition, physiologic changes after gastric bypass predisposing to hypoglycemia syndrome will be highlighted.International Journal of Obesity advance online publication, 31 October 2017; doi:10.1038/ijo.2017.257.

Spinal Cord Injury Pain Instrument and painDETECT questionnaire: Convergent construct validity in individuals with Spinal Cord Injury.

BACKGROUND: Neuropathic pain (NeuP) is a frequent sequel of spinal cord injury (SCI). The SCI Pain Instrument (SCIPI) was developed as a SCI-specific NeuP screening tool. A preliminary validation reported encouraging results requiring further evaluation in terms of psychometric properties. The painDETECT questionnaire (PDQ), a commonly applied NeuP assessment tool, was primarily validated in German, but not specifically developed for SCI and not yet validated according to current diagnostic guidelines. We aimed to provide convergent construct validity and to identify the optimal item combination for the SCIPI. The PDQ was re-evaluated according to current guidelines with respect to SCI-related NeuP. METHODS: Prospective monocentric study. Subjects received a neurological examination according to the International Standards for Neurological Classification of SCI. After linguistic validation of the SCIPI, the IASP-grading system served as reference to diagnose NeuP, accompanied by the PDQ after its re-evaluation as binary classifier. Statistics were evaluated through ROC-analysis, with the area under the ROC curve (AUROC) as optimality criterion. The SCIPI was refined by systematic item permutation. RESULTS: Eighty-eight individuals were assessed with the German SCIPI. Of 127 possible combinations, a 4-item-SCIPI (cut-off-score = 1.5/sensitivity = 0.864/specificity = 0.839) was identified as most reasonable. The SCIPI showed a strong correlation (rsp  = 0.76) with PDQ. ROC-analysis of SCIPI/PDQ (AUROC = 0.877) revealed comparable results to SCIPI/IASP (AUROC = 0.916). ROC-analysis of PDQ/IASP delivered a score threshold of 10.5 (sensitivity = 0.727/specificity = 0.903). CONCLUSION: The SCIPI is a valid easy-to-apply NeuP screening tool in SCI. The PDQ is recommended as complementary NeuP assessment tool in SCI, e.g. to monitor pain severity and/or its time-dependent course. SIGNIFICANCE: In SCI-related pain, both SCIPI and PainDETECT show strong convergent construct validity versus the current IASP-grading system. SCIPI is now optimized from a 7-item to an easy-to-apply 4-item screening tool in German and English. We provided evidence that the scope for PainDETECT can be expanded to individuals with SCI.

Does measuring the median nerve at the carpal tunnel outlet improve ultrasound CTS diagnosis?

INTRODUCTION: Nerve conduction is often regarded as more sensitive than ultrasonography (US) for diagnosing carpal tunnel syndrome (CTS). The diagnostic value of US derives from median nerve enlargement occurring at both ends of the carpal tunnel resulting in a dumbbell-like swelling from carpal tunnel pressure. An important reason for the inferior sensitivity of US may be because measurements are restricted to the carpal tunnel inlet. We investigate the value of including median nerve enlargement at the carpal tunnel outlet for diagnosing CTS. METHODS: Retrospective cohort study of nerve conduction verified CTS, determining sensitivity, specificity, and positive and negative predictive values of carpal tunnel inlet and outlet median nerve cross sectional area as determined by US for the diagnosis of CTS. Nerve conduction graded CTS severity. RESULTS: 127 hands from 77 patients with CTS and 35 control healthy hands were assessed. US sensitivity for diagnosing CTS increased from 65% to 84% by including outlet enlargement of the median nerve. Specificity changed from 94% to 86%, positive predictive value from 98% to 96% and the negative predictive value from 43% to 60%. 25 hands out of the 127 from CTS patients showed enlargement restricted to the outlet and mainly occurred in moderate CTS. CONCLUSION: In our population, the use of carpal tunnel outlet median nerve enlargement in addition to inlet median nerve size increases sensitivity for diagnosing CTS by 19%.

Aquagenic wrinkling of the palms is due to vasoconstriction of palmar skin vasculature.

Aquagenic wrinkling of the palms is an unusual and rare dermatosis characterized by rapidly appearing edema, whitish papules, and strong wrinkling of the palms after brief immersion in water. Aquagenic wrinkling of the palms is postulated to be a result of abnormal electrolyte fluxes that result in sodium retention within epidermal keratinocytes and osmotically induced cell volume increases. A clear understanding is lacking. It is closely linked to Cystic Fibrosis and has been proposed as a test of Cystic Fibrosis but can also be induced by Cyclooxygenase (COX-2) inhibitors and Aminoglycosides. Since both aquagenic wrinkling of the palms and water immersion wrinkling occur with water immersion, are restricted to the glabrous skin, and show features of sympathetic stimulation, I hypothesize that aquagenic wrinkling of the palms is part of the spectrum of water immersion wrinkling which has recently been shown to be due to sympathetic nervous system induced vasoconstriction of the palms and digits. Furthermore I hypothesize that both conditions are restricted to the glabrous palmar skin because of unique anatomical characteristics. Palmar skin is highly porous to water and contains abundant specialized vasculature densely innervated by sympathetic nerves and has unique epidermal anchoring for gripping purposes. I postulate that in conditions with sweat electrolyte disturbances such as Cystic Fibrosis or drug induced; the normal water immersion wrinkling response is exaggerated, leading to the typical clinical features of aquagenic wrinkling of the palms.

Combined Doppler and B-mode sonography in carpal tunnel syndrome.

An intraoperatively enlarged engorged median nerve has been described as typical of patients with carpal tunnel syndrome (CTS). Although many studies of CTS have addressed median nerve enlargement, little is known about the usefulness of Doppler methods in detecting median nerve engorgement combined with nerve cross-sectional area (CSA). In a retrospective study of hands referred for evaluation of possible CTS, patients were clinically graded into Highly-likely or Indeterminate CTS. Nerve conduction studies (NCS), CSA, and Doppler analysis were compared. Median nerve blood flow was detected in 29 of 30 Highly-likely CTS hands (mean 13.3m/s (8.2) SD) and in 25 of 30 with Indeterminate CTS (mean 8.5m/s (4.5) SD). These were significantly higher than our laboratory normal values (mean 1.9 m/s (2.8) SD). Raised intraneural blood flow showed the highest test sensitivity in diagnosing Highly-likely carpal tunnel syndrome (83%) and combined with CSA reached 90%. NCS sensitivity was 83%. In the group of Indeterminate CTS, combined blood flow and CSA showed abnormality in 77% and NCS 47%. All nerve conduction parameters and median nerve cross sectional area showed linear correlation to intraneural blood flow velocity (P<0.05; Spearman's r=0.362 to 0.264). This study suggests that adding measures of intraneural blood flow to CSA further improves the sonographic evaluation of CTS and may be of particular use in patients with negative NCS.

Morphological development of larval cobia Rachycentron canadum and the influence of dietary taurine supplementation.

The morphological development of larval cobia Rachycentron canadum from 3 days post hatch (dph) until weaning (27 dph) was examined using S.E.M. Two groups of fish were studied: a control group (CF), reared under standard feeding protocol, and a group in which prey items were enriched with supplemental taurine (4 g l(-1) day(-1) ; TF). TF fish grew faster (P < 0·001), attained greater size (mean ±s.e. 55·1 ± 1·5 v. 33·9 ± 1·0 mm total length) and had better survival (mean ±s.e. 29·3 ± 0·4 v. 7·1 ± 1·2 %) than CF fish. Canonical variance analysis confirmed findings with respect to differences in growth between the treatment groups with separation being explained by two cranial measurements. S.E.M. revealed that 3 dph larvae of R. canadum (in both groups) possess preopercular spines, superficial neuromasts on the head and body, taste buds in the mouth, an olfactory epithelium which takes the form of simple concave depressions, and primordial gill arches. Gill filaments start to form as early as 6 dph and lamellae buds are visible at 8 dph in both groups. In CF fish, the cephalic lateral line system continues its development at 12-14 dph with invagination of both supra- and infraorbital canals. At the same time, a thorn-like or acanthoid crest forms above the eye. At 14 dph, invaginations of the mandibular and preopercular canals are visible and around 22 dph enclosure of all cranial canals nears completion. In CF larvae, however, completely enclosed cranial canals were not observed within the course of the trial, i.e. 27 dph. In TF larvae, grooves of the cephalic lateral line system form 4 days earlier than observed in CF larvae of R. canadum (i.e. at 8 dph), with enclosure commencing at 16 dph, and completed by 27 dph. Along the flanks of 6 dph larvae of either treatment, four to five equally spaced neuromasts delineate the future position of the trunk lateral line. As myomeres are added to the growing larvae, new neuromasts appear such that at 16 dph a neuromast is associated with each myomere. By 27 dph, the trunk lateral line starts to invaginate in CF larvae, while it initiates closure in TF larvae. These findings elucidate important features of the larval development of R. canadum and show that dietary taurine supplementation benefits larval development, growth and survival in this species. Moreover, they suggest a conditional requirement for taurine in larval R. canadum.

Sonography as an aid to neurophysiological studies in diagnosing tarsal tunnel syndrome.

Diagnosing tarsal tunnel syndrome can be difficult because of varying clinical diagnostic criteria and equivocal physical signs. We present a case of tarsal tunnel syndrome where nerve conduction identified distal tibial neuropathy and high-resolution sonography was able to show nerve swelling within the tarsal tunnel.

Sonography versus nerve conduction studies in patients referred with a clinical diagnosis of carpal tunnel syndrome.

PURPOSE: To compare the diagnostic value of high-resolution ultrasound (US) with nerve conduction studies (NCS) in patients with clinically defined carpal tunnel syndrome (CTS). METHODS: A prospective study was conducted on 66 consecutive patients investigated for sensory hand symptoms. The gold standard was the clinical diagnosis of CTS. RESULTS: NCS showed greater diagnostic sensitivity (82%) than US (62%) in supporting a diagnosis of CTS. With increasing neurophysiologic severity of median neuropathy, there was increasing convergence of the two test methods. Abnormal US as the only diagnostic supportive evidence of CTS was rare. However, the positive predictive value of US for CTS was 100%. CONCLUSION: NCS show better sensitivity than US in supporting a diagnosis of CTS. However, because of its high positive predictive value, one may consider using US as a screening test, eliminating the need for NCS in the majority of clinical suspicion of CTS and reserving NCS for cases in which US is negative.

Sensory distribution indicates severity of median nerve damage in carpal tunnel syndrome.

OBJECTIVE: Sensory symptoms within the median nerve distribution are a primary clinical diagnostic criterion for the diagnosis of carpal tunnel syndrome (CTS). However, the distribution of the sensory symptoms in CTS varies from patient to patient. This study identifies the clinical and electrophysiological findings that correlate with the distribution of sensory symptoms in an Asian population with CTS. METHODS: In a prospective study of 105 patients with electrophysiologically confirmed CTS, clinical and educational data were correlated with sensory symptom distribution. RESULTS: Median nerve distribution was strongly associated with more severe nerve conduction abnormality, male gender, and relief by movement. Patients with a complete median sensory distribution had more electrophysiological abnormality than those with an incomplete median distribution. Extra-median distribution was associated with the least nerve conduction abnormality. Educational qualification, age, symptom duration and body mass index were not associated with the pattern of sensory symptoms. CONCLUSIONS: In carpal tunnel syndrome, sensory symptom distribution is strongly dependant on the degree of electrophysiological median nerve damage. Median nerve sensory distribution is associated with severe nerve damage. SIGNIFICANCE: This study provides clinicians with a simple clinical rule for assigning the degree of median nerve damage in patients with CTS based on sensory distribution patterns.

Skin wrinkling for diagnosing small fibre neuropathy: comparison with epidermal nerve density and sympathetic skin response.

OBJECTIVE: To compare simple tests of small nerve fibre function with intraepidermal nerve fibre density (IENFD) in the evaluation of small fibre neuropathy (SFN). METHODS: Patients with idiopathic SFN of the hands were prospectively studied. Evaluation involved clinical examination, nerve conduction studies, sympathetic skin response (SSR) and skin wrinkling stimulated by water and EMLA (eutectic mixture of local anaesthetics). RESULTS: Of 21 patients, 16 (76%) had low IENFD, 15 (71%) impaired water-induced wrinkling, 14 (67%) impaired EMLA-induced wrinkling, and nine (43%) abnormal SSR. CONCLUSIONS: Stimulated skin wrinkling was nearly as sensitive as IENFD in diagnosing SFN, whereas SSR was of less use. Stimulated skin wrinkling is a useful supportive test when IENFD or other tests of small nerve fibre function are not available.

Epidermal transient receptor potential vanilloid 1 in idiopathic small nerve fibre disease, diabetic neuropathy and healthy human subjects.

AIMS: The transient receptor potential vanilloid 1 (TRPV1) plays an important role in mediating pain and heat. In painful neuropathies, intraepidermal TRPV1 nerve fibre expression is low or absent, suggesting that pain generated is not directly related to sensory nerve fibres. Recent evidence suggests that keratinocytes may act as thermal receptors via TRPV1. The aim was to investigate epidermal TRPV1 expression in patients with neuropathic conditions associated with pain. METHODS AND RESULTS: In a prospective study of distal small nerve fibre neuropathy (DISN; n = 13) and diabetic neuropathy (DN; n = 12) intraepidermal nerve fibre density was assessed using the pan axonal marker PGP 9.5 and epidermal TPVR1 immunoreactivity compared with controls (n = 9). Intraepidermal nerve fibres failed to show TRPV1 immunoreactivity across all groups. There was moderate and strong TRPV1 reactivity of epidermal keratinocytes in 41.8% and 6% for DISN, 32.9% and 2.9% for DN and 25.4% and 5.1% for controls, respectively. Moderate keratinocyte TRPV1 expression was significantly increased in DISN compared with controls (P = 0.01). CONCLUSION: Our study suggests that in human painful neuropathies, epidermal TRPV1 expression is mainly in keratinocytes.