Long-term results of syndactyly correction by the trilobed flap technique focusing on hand function and quality of life

Syndactyly is usually corrected surgically during the first years of life. The trilobed flap, a surgical method that does not require skin grafting, was developed in the 1990s and the short-term results were comparable with previously reported techniques. Here we report on long-term outcomes, focusing on how children perceive their hand function and quality of life when they grow up. A total of 19 patients (29 web spaces) were operated on between 1990 and 2000, and followed-up 16 years later with questionnaires and clinical tests. The patients reported low QuickDASH scores, normal sensibility and dexterity, and minor cold intolerance. Only two reoperations, due to early web creep, were needed. The condition minimally affected the choice of occupations, leisure activities and perceptions of appearance. The trilobed flap technique for release of syndactyly provides a good long-term outcome with good hand function and minimal impact on the quality of life.

LEVEL OF EVIDENCE

IV.

Nerve regeneration in chitosan conduits and in autologous nerve grafts in healthy and in type 2 diabetic Goto-Kakizaki rats

Knowledge about nerve regeneration after nerve injury and reconstruction in appropriate diabetic animal models is incomplete. Short-term nerve regeneration after reconstruction of a 10-mm sciatic nerve defect with either a hollow chitosan conduit or an autologous nerve graft was investigated in healthy Wistar and diabetic Goto-Kakizaki (GK) rats. After 21 days, axonal outgrowth, the presence of activated and apoptotic Schwann cells and the thickness of the formed matrix in the conduits were measured. In general, nerve regeneration was superior in autologous nerve grafts. In chitosan conduits, a matrix, which was thicker in diabetic rats, was formed and was positively correlated with length of axonal outgrowth. Axonal outgrowth in conduits and in nerve grafts extended further in diabetic rats than in healthy rats. There was a higher percentage of activating transcription factor 3 (ATF3)-immunostained cells in nerve segments from healthy rats than in diabetic rats after autologous nerve graft reconstruction. In chitosan conduits, more cleaved caspase 3-stained Schwann cells were generally observed in the matrix from the diabetic rats than in healthy rats. However, there were fewer apoptotic cells in the distal segment in diabetic rats reconstructed with a chitosan conduit. Preoperative glucose levels were positively correlated with axonal outgrowth after both reconstruction methods. Axonal regeneration was better in autologous nerve grafts than in hollow chitosan conduits and was enhanced in diabetic GK rats compared to healthy rats after reconstruction. This study provides insights into the nerve regeneration process in a clinically relevant diabetic animal model.

Chitosan-film enhanced chitosan nerve guides for long-distance regeneration of peripheral nerves

Biosynthetic nerve grafts are developed in order to complement or replace autologous nerve grafts for peripheral nerve reconstruction. Artificial nerve guides currently approved for clinical use are not widely applied in reconstructive surgery as they still have limitations especially when it comes to critical distance repair. Here we report a comprehensive analysis of fine-tuned chitosan nerve guides (CNGs) enhanced by introduction of a longitudinal chitosan film to reconstruct critical length 15 mm sciatic nerve defects in adult healthy Wistar or diabetic Goto-Kakizaki rats. Short and long term investigations demonstrated that the CNGs enhanced by the guiding structure of the introduced chitosan film significantly improved functional and morphological results of nerve regeneration in comparison to simple hollow CNGs. Importantly, this was detectable both in healthy and in diabetic rats (short term) and the regeneration outcome almost reached the outcome after autologous nerve grafting (long term). Hollow CNGs provide properties likely leading to a wider clinical acceptance than other artificial nerve guides and their performance can be increased by simple introduction of a chitosan film with the same advantageous properties. Therefore, the chitosan film enhanced CNGs represent a new generation medical device for peripheral nerve reconstruction.

Normalized activation in the somatosensory cortex 30 years following nerve repair in children: an fMRI study

The clinical outcome following a peripheral nerve injury in the upper extremity is generally better in young children than in teenagers and in adults, but the mechanism behind this difference is unknown. In 28 patients with a complete median nerve injury sustained at the ages of 1-13 years (n = 13) and 14-20 years (n = 15), the cortical activation during tactile finger stimulation of the injured and healthy hands was monitored at a median time since injury of 28 years using functional magnetic resonance imaging (fMRI) at 3 Tesla. The results from the fMRI were compared with the clinical outcome and electroneurography. The cortical activation pattern following sensory stimulation of the median nerve-innervated fingers was dependent on the patient's age at injury. Those injured at a young age (1-13 years) had an activation pattern similar to that of healthy controls. Furthermore, they showed a clinical outcome significantly superior (P = 0.001) to the outcome in subjects injured at a later age; however, electroneurographical parameters did not differ between the groups. In subjects injured at age 14-20 years, a more extended activation of the contralateral hemisphere was seen in general. Interestingly, these patients also displayed changes in the ipsilateral hemisphere where a reduced inhibition of somatosensory areas was seen. This loss of ipsilateral inhibition correlated to increasing age at injury as well as to poor recovery of sensory functions in the hand. In conclusion, cerebral changes in both brain hemispheres may explain differences in clinical outcome following a median nerve injury in childhood or adolescence.

Vibrotactile perception in finger pulps and in the sole of the foot in healthy subjects among children or adolescents

Aims

To evaluate vibrotactile perception at different frequencies in fingers and in foot in healthy girls and boys.

Methods

Vibration perception thresholds (VPTs) were measured in 283 healthy (8–20 years), consecutively included, girls (n=146) and boys (n=137); i.e., 269 children after excluding those with diseases or disorders possibly affecting the nervous system. Thresholds were measured in finger pulps of index and little fingers (seven frequencies; 8–500 Hz) and at first and fifth metatarsal head and at heel in the sole of the foot (six frequencies; 8–250 Hz;) using Multi Frequency Tactilometry.

Results

VPTs, divided in six groups by age and gender (i.e., 8–10 years, 11–15 years and 16–20 years), at all three sites in the sole increased with higher frequencies, but without gender differences. Thresholds at 64 and 125 Hz were generally higher at heel compared to metatarsal heads. VPTs in finger pulps of index and little fingers, with no finger differences, had a different pattern with increasing thresholds with frequency, but with lower thresholds at 64 and 125 Hz. Thresholds at lower frequencies were higher in finger pulps, while at higher frequencies VPTs were lower in finger pulps than in the sole of the foot; thus, vibration perception in the sole was better than perception in finger pulps at lower frequencies and opposite at higher frequencies. VPTs were higher among adolescents than in younger children in the foot, while thresholds were lower in the finger pulps among adolescents, particularly in index finger. Thresholds in finger pulps of index and little fingers, particularly at higher frequencies, correlated with each other, which the three sites in the sole also did.

Conclusions

VPTs in fingers and in feet are different as related to frequency in healthy girls and boys. Multi Frequency Tactilometry is a future valuable method to detect neuropathy in children and adolescents.

[Dupuytren's disease treatment]

Dupuytren's disease is a hereditary fibroproliferative disease commonly affecting the palmar fascia of the hand, which results in progressive and irreversibly fixed flexion contractures of the hand. It may occur in the sole of the foot or in the penis. Generally, treatment has been up against a high frequency of complications and recurrence, but promising results are reported from less invasive treatment options, e.g. needle fasciotomy and enzymatic fasciotomy with collagenase. This is a detailed, comparative review of available non-operative and surgical treatments with focus on the enzymatic fasciotomy.

Bullosis diabeticorum in median nerve innervated fingers shortly after carpal tunnel release: case report

Bullosis diabeticorum is a cutaneous manifestation of diabetes mellitus, mainly observed in the lower extremities in patients with longstanding disease. The etiology is unknown, but an association with neurologic or vascular disturbances has been suggested. We have reviewed a case of a 70-year-old man with rapid development of bullae in median nerve innervated fingertips following carpal tunnel release.

Autophagy in the posterior interosseous nerve of patients with type 1 and type 2 diabetes mellitus: an ultrastructural study

AIMS/HYPOTHESIS

We addressed the question of whether the autophagy pathway occurs in human peripheral nerves and whether this pathway is associated with peripheral neuropathy in diabetes mellitus.

METHODS

By using electron microscopy, we evaluated the presence of autophagy-related structures and neuropathy in the posterior interosseous nerve of patients who had undergone carpal tunnel release and had type 1 or type 2 diabetes mellitus, and in patients with no diabetes (controls).

RESULTS

Autophagy-related ultrastructures were observed in the samples taken from all patients of the three groups. The number of autophagy-associated structures was significantly higher (p < 0.05) in the nerves of patients with type 1 than type 2 diabetes. Qualitative and quantitative evaluations of fascicle area, diameter of myelinated and unmyelinated nerve fibres, the density of myelinated and unmyelinated fibres and the g-ratio of myelinated fibres were performed. We found degeneration and regeneration of a few myelinated axons in controls, and a well-developed neuropathy with the loss of large myelinated axons and the presence of many small ones in patients with diabetes. The pathology in type 1 diabetes was more extensive than in type 2 diabetes.

CONCLUSIONS/INTERPRETATION

The results of this study show that the human peripheral nerves have access to the autophagy machinery, and this pathway may be regulated differently in type 1 and type 2 diabetes; insulin, presence of extensive neuropathy, and/or other factors such as duration of diabetes and HbA1c level may underlie this differential regulation.

Return to work after a serious hand injury

OBJECTIVES

This paper explores factors important for return to work (RTW) in people who have sustained a serious hand injury.

PARTICIPANTS

Forty people aged 19-64, with a severe or major hand injury were recruited consecutively during 2005-2007.

METHODS

A self-administered and study specific questionnaire, including demographic data and standardised questionnaires for function, disability, daily occupations, health, quality of life, sense of coherence and several open questions was sent out by mail twelve months after injury. Open questions regarding RTW were also included.

RESULTS

The results showed that 27 people had returned to work within twelve months and 13 had not. Factors related to RTW and general work motivations were divided into individual factors, and factors related to the work environment and rehabilitation. The most prominent differences between the groups were individual factors, such as higher perceived disability, reduced hand function, and dissatisfaction with daily occupations resulting in a lower physical quality of life. The no RTW group had also more ward days (inpatient care) and lower sense of coherence.

CONCLUSIONS

These findings support the idea that the RTW process can be more dependent on the person's own ability and motivation than on the severity of the hand injury. Suggestions for intervention and further studies are presented in the discussion.

PXL01 in sodium hyaluronate for improvement of hand recovery after flexor tendon repair surgery: randomized controlled trial

Background

Postoperative adhesions constitute a substantial clinical problem in hand surgery. Fexor tendon injury and repair result in adhesion formation around the tendon, which restricts the gliding function of the tendon, leading to decreased digit mobility and impaired hand recovery. This study evaluated the efficacy and safety of the peptide PXL01 in preventing adhesions, and correspondingly improving hand function, in flexor tendon repair surgery.

Methods

This prospective, randomised, double-blind trial included 138 patients admitted for flexor tendon repair surgery. PXL01 in carrier sodium hyaluronate or placebo was administered around the repaired tendon. Efficacy was assessed by total active motion of the injured finger, tip-to-crease distance, sensory function, tenolysis rate and grip strength, and safety parameters were followed, for 12 months post-surgery.

Results

The most pronounced difference between the treatment groups was observed at 6 months post-surgery. At this timepoint, the total active motion of the distal finger joint was improved in the PXL01 group (60 vs. 41 degrees for PXL01 vs. placebo group, p = 0.016 in PPAS). The proportion of patients with excellent/good digit mobility was higher in the PXL01 group (61% vs. 38%, p = 0.0499 in PPAS). Consistently, the PXL01 group presented improved tip-to-crease distance (5.0 vs. 15.5 mm for PXL01 vs. placebo group, p = 0.048 in PPAS). Sensory evaluation showed that more patients in the PXL01 group felt the thinnest monofilaments (FAS: 74% vs. 35%, p = 0.021; PPAS: 76% vs. 35%, p = 0.016). At 12 months post-surgery, more patients in the placebo group were considered to benefit from tenolysis (30% vs. 12%, p = 0.086 in PPAS). The treatment was safe, well tolerated, and did not increase the rate of tendon rupture.

Conclusions

Treatment with PXL01 in sodium hyaluronate improves hand recovery after flexor tendon repair surgery. Further clinical trials are warranted to determine the most efficient dose and health economic benefits.

Trial Registration

ClinicalTrials.gov NCT01022242; EU Clinical Trials 2009-012703-25.

Gender differences in nerve regeneration after sciatic nerve injury and repair in healthy and in type 2 diabetic Goto-Kakizaki rats

Background

In view of the global increase in diabetes, and the fact that recent findings indicate that diabetic neuropathy is more frequently seen in males, it is crucial to evaluate any gender differences in nerve regeneration in diabetes. Our aim was to evaluate in short-term experiments gender dissimilarities in axonal outgrowth in healthy and in genetically developed type 2 diabetic Goto-Kakizaki (GK) rats, and also to investigate the connection between activated (i.e. ATF-3, Activating Transcription Factor 3) and apoptotic (cleaved caspase 3) Schwann cells after sciatic nerve injury and repair. Female and male diabetic GK rats, spontaneously developing type 2 diabetes, were compared with corresponding healthy Wistar rats. The sciatic nerve was transected and instantly repaired. After six days the nerve was harvested to measure axonal outgrowth (i.e. neurofilament staining), and to quantify the number of ATF-3 (i.e. activated) and cleaved caspase 3 (i.e. apoptotic) stained Schwann cells using immunohistochemistry.

Results

Axonal outgrowth was generally longer in male than in female rats and also longer in healthy than in diabetic rats. Differences were observed in the number of activated Schwann cells both in the distal nerve segment and close to the lesion site. In particular the female diabetic rats had a lower number. There were no gender differences in number of cleaved caspase 3 stained Schwann cells, but rats with diabetes exhibited more (such cleaved caspase 3 stained Schwann) cells both at the lesion site and in the distal part of the sciatic nerve. Axonal outgrowth correlated with the number of ATF3 stained Schwann cells, but not with blood glucose levels or the cleaved caspase 3 stained Schwann cells. However, the number of cleaved caspase 3 stained Schwann cells correlated with the blood glucose level.

Conclusions

We conclude that there are gender differences in nerve regeneration in healthy rats and in type 2 diabetic GK rats.

Molecular and pathological studies in the posterior interosseous nerve of diabetic and non-diabetic patients with carpal tunnel syndrome

AIMS/HYPOTHESIS

We sought to establish the molecular and pathological changes predisposing diabetic and non-diabetic patients to the development of carpal tunnel syndrome (CTS).

METHODS

The posterior interosseous nerve (PIN) was biopsied in 25 diabetic and 19 non-diabetic patients undergoing carpal tunnel decompression for CTS. Detailed morphometric and immunohistological analyses were performed in the nerve biopsy.

RESULTS

In diabetic patients median nerve distal motor latency was prolonged (p < 0.05 vs non-diabetic patients), PIN myelinated fibre density (p < 0.05), fibre area (p < 0.0001) and axon area (p < 0.0001) were reduced, the percentage of unassociated Schwann cell profiles (p < 0.0001) and unmyelinated axon density (p < 0.0001) were increased and the axon diameter was reduced (p < 0.0001). Endoneurial capillary basement membrane area was increased (p < 0.0001) in diabetic patients, but endothelial cell number was increased (p < 0.01) and luminal area was reduced (p < 0.05) in non-diabetic patients with CTS. There was no difference in the expression of hypoxia-inducible factor 1α between diabetic and non-diabetic patients with CTS. However, the expression of vascular endothelial growth factor A (VEGF) (p < 0.05) and its receptors VEGFR-1 (p < 0.01) and VEGFR-2 (p < 0.05) was significantly increased in diabetic patients, particularly those with type 1 diabetes, and related to the severity of nerve fibre pathology.

CONCLUSIONS/INTERPRETATION

This study demonstrates increased nerve fibre and microvascular pathology in relation to enhanced expression of VEGF and its receptors in a non-compressed nerve in diabetic compared with non-diabetic patients with CTS. It therefore provides a potential molecular and pathological basis for the predisposition of diabetic patients to the development of CTS.

Hand Function in Adults with Radial Longitudinal Deficiency

BACKGROUND

Functional impairment in individuals with radial longitudinal deficiency can be influenced by several factors, including a short and bowed forearm, radial deviation of the wrist, a non-functional or absent thumb, limited finger motion, and impaired grip strength, but their relationship with activity and participation in adults with radial deficiency is not known.

METHODS

Twenty individuals, eighteen to sixty years of age, who had Bayne type-II to V radial longitudinal deficiency, were examined in the context of the International Classification of Functioning, Disability and Health. Body function and structure were evaluated by measures of range of motion, grip strength, key pinch, sensibility, and radiographic parameters. Activity was evaluated by the Box and Block Test and the Sollerman test, and participation was evaluated by QuickDASH (the short form of the Disabilities of Arm, Shoulder and Hand outcome measure) and by the Medical Outcomes Study 12-Item Short Form Health Survey. Statistical correlations among assessments of body function and structure, activity, and participation were examined.

RESULTS

The mean total active motion of the wrist (43°) and mean total active motion of the digits (377°) were less than the norms. The mean radial deviation of the wrist was 31°. The mean grip strength (4.0 kg), key pinch (1.4 kg), and scores for the Box and Block Test (55 blocks per minute) and the Sollerman test on hand function (56 points) were considerably lower than the norms. The mean scores were 18 points for QuickDASH, 51 points for Short Form-12 physical component summary, and 53 points for Short Form-12 mental component summary. Significant relationships were found between the Box and Block Test and grip strength (p = 0.012), key pinch (p < 0.001), and total active motion of digits (p < 0.001); between the Sollerman test and the total active motion of elbow (p < 0.001) and the total active motion of digits (p < 0.001); between the QuickDASH and forearm length (p < 0.001), the total active motion of elbow (p = 0.001), and the total active motion of digits (p < 0.001); between the Short Form-12 physical component summary and grip strength (p = 0.016), forearm length (p < 0.001), total active elbow motion (p < 0.001), and total active digit motion (p < 0.001); and between the Short-Form-12 mental component summary and radial deviation of the wrist (p = 0.019). No significant correlations were found between the radiographic measurement of the radial deviation of the wrist (total forearm angle) and the Box and Block Test (p = 0.244), the Sollerman test (p = 0.775), QuickDASH (p = 0.156), Short Form-12 physical component summary (p = 0.107), or Short Form-12 mental component summary (p = 0.129).

CONCLUSIONS

In individuals with radial longitudinal deficiency, grip strength, key pinch, forearm length, and elbow and digital motion seem to be more important for the individual's activity and participation than the radial angulation of the wrist.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Nerve injury-induced c-Jun activation in Schwann cells is JNK independent

We investigated (a) if activation of the mitogen activated protein kinase (MAPK) pathway was linked to the stress activated protein kinase (SAPK) pathway and (b) if JNK was required for activation of c-Jun in Schwann cells of rat sciatic nerve following injury. To this aim, ERK1/2 and the transcription factors c-Jun and ATF-3 were studied by immunohistochemistry in segments of transected nerves. We utilized pharmacological inhibitors of both signal transduction pathways in vitro to determine the effects on downstream signalling events, such as c-Jun activation, and on Schwann cell survival and proliferation. A transection induces c-Jun and ATF-3 transcription in Schwann cells. These events are followed by Schwann cell activation of c-Jun in the injured nerve. The MAPK inhibitor U0126 blocked ERK1/2 activation and reduced Schwann cell proliferation as well as induction of c-Jun transcription. The JNK inhibitor SP600125 reduced Schwann cell proliferation, but did not affect the expression of ERK1/2 or injury-induced increases in c-Jun or ATF-3 levels. Importantly, nerve injury induces Schwann cell activation of c-Jun by phosphorylation, which, in contrast to in sensory neurons, is JNK independent. MAP kinases, other than JNK, can potentially activate c-Jun in Schwann cells following injury; information that is crucial to create new nerve reconstruction strategies.

Surgical treatment of Dupuytren's disease - outcome and health economy in relation to smoking and diabetes

Background

The conventional treatment for Dupuytren’s disease is surgery. The introduction of alternative treatment strategies creates a need to track outcomes and costs relating to surgical treatment and risk factors, such as smoking and diabetes. This was the aim of the present study.

Methods

In a prospective study, the outcome of open surgical treatment for finger flexion contracture in Dupuytren’s disease (175 patients; 182 surgical procedures) was studied by evaluating valid QuickDASH forms answered by subjects before surgery and one year postoperatively. Data were also obtained from medical records, and preoperative declarations concerning health.

Results

In all subjects (median [25% - 75% percentiles] age 68 [62-73]), the QuickDASH score improved from 22 [9-36] to 5 [0-18]. Smokers (27/179 procedures) were younger and had a more severe degree of disease and dysfunction preoperatively than non-smokers, but the outcome of surgery did not differ between the groups. Subjects with diabetes (20/181 procedures) were younger than those without diabetes, but their disease severity or outcome did not differ. Hand specialists operated faster than residents, but the surgical outcome did not differ. Healthcare costs for surgery for Dupuytren’s contracture were $ 2392 (€ 1859), which were not higher among smokers or subjects with diabetes. Only 22 patients remained in hospital (2 [1-2.3] days) and 28 patients needed sick leave (28 [21-31] days). The occurrence of necrosis of skin flaps (12%) or infections (6%) was no more frequent among smokers or those with diabetes.

Conclusions

There is no difference in surgical outcome for finger flexion contracture in Dupuytren’s disease between smokers and non-smokers or between subjects with or without diabetes, although smokers had more severe preoperative contracture. The costs for surgical treatment for finger flexion contracture in Dupuytren’s disease should be viewed in relation to that for other treatment strategies.

Carpal tunnel release in patients with diabetes: a 5-year follow-up with matched controls

PURPOSE

To compare clinical outcomes 5 years after carpal tunnel release among patients with and without diabetes.

METHODS

In a prospective consecutive series, 35 patients with diabetes (median age, 54 y; 15 type 1 and 20 type 2 diabetes) with carpal tunnel syndrome were age- and sex-matched with 31 control patients without diabetes (median age, 51 y) with idiopathic carpal tunnel syndrome. Exclusion criteria were other nerve entrapment, cervical radiculopathy, inflammatory joint disease, thyroid disorder, previous wrist fracture, and long-term exposure to vibrating tools. Participants were examined independently at baseline, 1 year, and 5 years after surgery for sensory function (Semmes-Weinstein), motor function (abductor pollicis brevis muscle strength and grip strength), cold intolerance, and completion of the Boston Carpal Tunnel Questionnaire symptom severity and functional status score.

RESULTS

Five years after surgery, the overall attendance rate for clinical examinations and completion of the Boston Carpal Tunnel Questionnaire were 86% and 95%, respectively. Between 1 and 5 years after surgery, there was a tendency toward a decrease in sensory function but an increase in motor function, with no statistically significant difference between groups. Cold intolerance demonstrated long-term significant improvement for patients with diabetes. The improvement in symptom severity and functional status score, as well as the large effect size, were maintained at 5 years in both patient groups.

CONCLUSIONS

Long-term improvement in patients with diabetes remained after carpal tunnel release to the same extent as for patients without diabetes. Furthermore, improvement in cold intolerance in patients with diabetes suggests the potential for the long-term regeneration of small nerve fibers.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

Evaluation of clinical tools and their diagnostic use in distal symmetric polyneuropathy

AIMS

To compare the diagnostic usefulness of tuning fork, monofilament, biothesiometer and skin biopsies in peripheral neuropathy in individuals with varying glucose metabolism.

METHODS

Normoglycaemic, impaired glucose tolerance (IGT) and type 2 diabetes (T2DM) individuals were recruited. Nerve conduction studies (NCS) and thermal threshold tests were performed. Vibrotactile sense was tested with a biothesiometer and a 128-Hz tuning fork. Touch/pressure perception was examined with a 10-g monofilament. Skin biopsies were performed and intraepidermal nerve fibres were quantified. Distal symmetric polyneuropathy (DSPN) was defined as neuropathy disability score ≥2 and abnormal NCS. Thermal threshold tests were used to define small nerve fibre neuropathy (sDSPN) in cases where NCS (large nerve fibres) were normal.

RESULTS

The prevalence of DSPN and sDSPN in the whole group (n=119) was 18% and 23%, respectively. For the biothesiometer, a cut-off of ≥24.5V had a sensitivity of 82% and specificity of 70% (AUC=0.81, 95% CI 0.71-0.91) when evaluating DSPN. An intraepidermal nerve fibre density cut-off of ≤3.39fibres/mm showed a sensitivity of 74% and specificity of 70% in the detection of sDSPN, whereas the sensitivity of the tuning fork and the biothesiometer were relatively low, 46% and 67%, respectively. When combining skin biopsies with the tuning fork, 10 more sDSPN cases were identified. Adding skin biopsy to the combination of the tuning fork and biothesiometer increased the sensitivity of finding sDSPN cases, but not DSPN, from 81% to 93%.

CONCLUSION

Using a biothesiometer in clinical routine might be a sensitive method to detect large nerve fibre dysfunction in the lower extremity, whereas skin biopsies in combination with methods measuring vibrotactile sense could increase the diagnostic sensitivity of detecting peripheral neuropathy at an early stage.

Self-reported cold sensitivity in patients with traumatic hand injuries or hand-arm vibration syndrome - an eight year follow up

BACKGROUND

Cold sensitivity is a common complaint following hand injuries. Our aim was to investigate long-term self-reported cold sensitivity, and its predictors and the importance of sense of coherence (SOC), 8 years after a hand injury as well as in patients treated for Hand Arm Vibration Syndrome (HAVS) during the same time period.

METHODS

Responses to the Cold Intolerance Symptom Severity (CISS) questionnaire and the Sense of Coherence (SOC) questionnaire were investigated in hand injured patients (n = 64) and in patients with HAVS (n = 26). The Mann-Whitney U-Test was used to identify significant differences between subgroups. When analysing predictors for cold sensitivity severity, the Spearman rank correlation (rS coefficient) were used for quantitative predictive variables, Mann-Whitney U-Test for dichotomous variables and Kruskal-Wallis Test for multiple categorical data. The Wilcoxon's signed rank test was used to investigate longitudinal changes in outcome.

RESULTS

There was a significant change in total CISS score for patients with traumatic hand injury, indicating fewer problems with cold sensitivity over time. Symptoms, such as stiffness, weakness and skin colour change on cold exposure, caused fewer problems, but perceived pain/aching and numbness remained unchanged as well as time needed for relief of symptoms on return to a warm environment. The negative impact of cold sensitivity on daily activities and at work was reduced, but problems when engaged in hobbies or when being exposed to cold wintry weather remained unchanged. None of the investigated predictors related to the hand injury were significantly associated with a change in cold sensitivity at the 8-year follow up. In contrast, no significant change in cold sensitivity was noted in the patients with HAVS for any of the situations included in the CISS questionnaire. A lower sense of coherence score correlated significantly with worse cold sensitivity (CISS score) in both patient groups.

CONCLUSIONS

The negative impact of cold sensitivity on daily life was reduced for patients with traumatic hand injury, but did not change over time in patients with HAVS. A low SOC is associated with worse cold sensitivity in such groups of patients. Information about relieving strategies should be provided for patients with cold sensitivity.

Low myelinated nerve-fibre density may lead to symptoms associated with nerve entrapment in vibration-induced neuropathy

Prolonged exposure to hand-held vibrating tools may cause a hand-arm vibration syndrome (HAVS), sometimes with individual susceptibility. The neurological symptoms seen in HAVS are similar to symptoms seen in patients with carpal tunnel syndrome (CTS) and there is a strong relationship between CTS and the use of vibrating tools. Vibration exposure to the hand is known to induce demyelination of nerve fibres and to reduce the density of myelinated nerve fibres in the nerve trunks. In view of current knowledge regarding the clinical effects of low nerve-fibre density in patients with neuropathies of varying aetiologies, such as diabetes, and that such a low density may lead to nerve entrapment symptoms, a reduction in myelinated nerve fibres may be a key factor behind the symptoms also seen in patients with HAVS and CTS. Furthermore, a reduced nerve-fibre density may result in a changed afferent signal pattern, resulting in turn in alterations in the brain, further prompting the symptoms seen in patients with HAVS and CTS. We conclude that a low nerve-fibre density lead to symptoms associated with nerve entrapment, such as CTS, in some patients with HAVS.

Neuropeptide Y autoantibodies in patients with long-term type 1 and type 2 diabetes and neuropathy

AIMS

The neurotransmitter Neuropeptide Y (NPY) was previously reported as a minor autoantigen in newly diagnosed type 1 diabetes (T1D) patients. The single nucleotide polymorphism at rs16139 (T1128C, L7P) in the NPY gene was associated with an increased risk for the development of type 2 diabetes (T2D). We aimed to develop a radiobinding assay for NPY-L (Leucine) and NPY-P (Proline) autoantibodies (A) to study the levels and the association with other islet autoantibodies and neuropathy.

METHODS

Autoantibodies against NPY-L, NPY-P, ZnT8, GAD65 and IA-2 were studied in T1D (n=48) and T2D (n=26) patients with duration up to 42 and 31years. A subgroup of T1D (n=32) patients re-examined, 5-8years after first visit, was tested for peripheral (Z-score) and autonomic neuropathy (E/I ratio).

RESULTS

NPY-LA and NPY-PA were detected in 23% and 19% in T1D (p<0.001), and 12% and 23% in T2D patients (p<0.001) compared to 2.5% controls (n=398). The levels of NPYA declined during follow-up in the T1D patients (p<0.001). The neuropathy was not related to the NPYA or the other islet autoantibodies.

CONCLUSIONS

Regardless of the absence of an association between NPYA and neuropathy, NPY may contribute to the pathogenesis of T1D and T2D as a minor autoantigen.

Identification of pregnancies at increased risk of brachial plexus birth palsy - the construction of a weighted risk score

OBJECTIVE

Since it is difficult to identify women at increased risk of fetal brachial plexus birth palsy (BPBP) during labor and delivery, we aimed to construct and validate a risk score.

METHODS

A retrospective case-control study was undertaken in 2001 and 2006 in an urban context in Malmö, Sweden. A risk score was constructed for all women who had received routine municipal maternal health care at Skåne University Hospital (n = 10 459). The model was validated among all pregnant women with BPBP and controls in Sweden between 2006 and 2007.

RESULTS

The likelihood of BPBP increased as the risk score rose: 3.1% of the women studied had a risk score ≥5, including 32.1% of the BPBP cases, where the risk showed a 38-fold increase, as compared to those with a risk score ≤1 (2/3 of the population).

CONCLUSION

Our findings indicate that it is possible to identify women at increased risk of having a child with BPBP by using variables observable in advance of delivery.

[Dissection is still important when learning anatomy]

Dissection and prosection require a donation programme of cadavers for education and research. The importance of maintaining the donation programme and the significance of dissection as a teaching method when learning anatomic structures and obtaining surgical skills are evaluated.