Clinical evidence and mechanisms of growth factors in idiopathic and diabetes-induced carpal tunnel syndrome

Epidermal growth factor receptors unveiled: a comprehensive survey on mutations, clinical insights of global inhibitors, and emergence of heterocyclic derivatives as EGFR inhibitors

Mutations that overexpress the epidermal growth factor receptor (EGFR) are linked to cancers like breast (15-20%), head and neck (10-15%), colorectal (5-8%), and non-small cell lung cancer (10-50%), especially in East Asian populations. EGFR activation stimulates 'RAS/RAF/MEK/ERK, PI3K/Akt, and MAPK' pathways, which enhance cell division, survival, angiogenesis, and tumour growth while inhibiting apoptosis and metastasis. Secondary mutations (e.g. 'T790M', 'C797S'), off-target effects, and resistance due to alternate pathway activation reduce the efficacy of currently available EGFR inhibitors. To address these issues, 'novel heterocyclic inhibitors with structural versatility were developed to improve selectivity and binding affinity for mutant EGFR forms'. These new EGFR reduce side effects, enhance pharmacokinetics, and enhance therapeutic efficacy at low concentrations. This review focuses on 'EGFR mutations in various cancers' detailing the biochemical effects, clinical profiles, and binding interactions of globally approved EGFR inhibitors. Furthermore, it focuses into recent progress in nano-formulations and the development of heterocyclic derivatives that can successfully 'target mutant EGFRs' through varied synthesis methods. These inhibitors have the potential to have better binding affinities, selectivity's, and less side-effect. Further research required to refine the structures and develop nanoformulations of EGFR-targeted therapeutics in order to improve therapeutic efficiency and, provide more effective cancer treatments.

Exploring the causal relationships between type 2 diabetes and neurological disorders using a Mendelian randomization strategy

While there is ample evidence indicating an increased occurrence of general neurological conditions among individuals with diabetes, there has been limited exploration into the cause-and-effect connection between type 2 diabetes (T2D) and specific neurological disorders, including conditions like carpal tunnel syndrome and Bell's palsy. We used Mendelian randomization (MR) approach to investigate the causal effects of T2D on 67 neurological diseases. We primarily utilized the inverse-variance weighted method for the analysis, and also employed the weighted median and MR-Egger methods in our study. To detect and correct potential outliers, MR-PRESSO analysis was used. Heterogeneity was assessed using Cochrane Q-values. The MR analyses found a possible relationship between T2D and a risk increase of 8 diseases at suggestive level of evidence (P < .05). Notably, among the positive findings that met the false discovery rate threshold, nerve, nerve root, and plexus disorders (odds ratio [OR] = 1.11; 95% confidence interval [CI] = 1.08-1.15); neurological diseases (OR = 1.05; 95% CI = 1.03-1.07) and carpal tunnel syndrome (OR = 1.10; 95% CI = 1.05-1.16) were identified. Our findings affirm a cause-and-effect association between T2D and certain neurological disorders.

Effects of Physical Cues on Stem Cell-Derived Extracellular Vesicles toward Neuropathy Applications

The peripheral nervous system undergoes sufficient stress when affected by diabetic conditions, chemotherapeutic drugs, and personal injury. Consequently, peripheral neuropathy arises as the most common complication, leading to debilitating symptoms that significantly alter the quality and way of life. The resulting chronic pain requires a treatment approach that does not simply mask the accompanying symptoms but provides the necessary external environment and neurotrophic factors that will effectively facilitate nerve regeneration. Under normal conditions, the peripheral nervous system self-regenerates very slowly. The rate of progression is further hindered by the development of fibrosis and scar tissue formation, which does not allow sufficient neurite outgrowth to the target site. By incorporating scaffolding supplemented with secretome derived from human mesenchymal stem cells, it is hypothesized that neurotrophic factors and cellular signaling can facilitate the optimal microenvironment for nerve reinnervation. However, conventional methods of secretory vesicle production are low yield, thus requiring improved methods to enhance paracrine secretions. This report highlights the state-of-the-art methods of neuropathy treatment as well as methods to optimize the clinical application of stem cells and derived secretory vesicles for nerve regeneration.

Serum Transforming Growth Factor β1 and Its Genetic Variants Are Associated with Increased Macrophage Inflammatory Protein 1β and Susceptibility to Idiopathic Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a common entrapment neuropathy in which one of the body's peripheral nerves becomes pinched or crushed. Transforming growth factor beta 1 (TGF-β1) plays an important role in the pathogenesis of CTS. An association between TGF-β1 polymorphisms and the susceptibility or progression of a number of diseases has been reported. In this study, three TGF-β1 single nucleotide polymorphisms (SNPs), serum TGF-β1, and macrophage inflammatory protein 1 beta (MIP-1β) were investigated as potential diagnostic markers for the progression of CTS in Egyptian patients. One hundred CTS patients and 100 healthy controls were recruited for the study. TGF-β1 SNPs +915G/C, -509C/T and -800G/A were determined by TaqMan genotyping assay. Serum TGF-β1 and MIP-1β levels were measured by ELISA. Serum TGF-β1 and MIP-1β levels increased significantly and were strongly correlated with the occurrence of CTS. The C allele of +915G/C, the T allele of -509C/T, and the G allele of -800G/A occurred more frequently in patients from CTS than in controls. The serum levels of TGF-β1 and MIP-1β in the group of carriers of the genotypes +915G/C GC and CC, the genotype -509C/T TT and the genotype -800G/A GA and AA were significantly higher in CTS patients. TGF-β1 and its +915G/C, -509C/T, and -800G/A SNPs and MIP-1β could be useful prognostic markers for the occurrence of CTS.

Drug loaded implantable devices to treat cardiovascular disease

INTRODUCTION

It is widely acknowledged that cardiovascular diseases (CVDs) continue to be the leading cause of death globally. Furthermore, CVDs are the leading cause of diminished quality of life for patients, frequently as a result of their progressive deterioration. Medical implants that release drugs into the body are active implants that do more than just provide mechanical support; they also have a therapeutic role. Primarily, this is achieved through the controlled release of active pharmaceutical ingredients (API) at the implementation site.

AREAS COVERED

In this review, the authors discuss drug-eluting stents, drug-eluting vascular grafts, and drug-eluting cardiac patches with the aim of providing a broad overview of the three most common types of cardiac implant.

EXPERT OPINION

Drug eluting implants are an ideal alternative to traditional drug delivery because they allow for accurate drug release, local drug delivery to the target tissue, and minimise the adverse side effects associated with systemic administration. Despite the fact that there are still challenges that need to be addressed, the ever-evolving new technologies are making the fabrication of drug eluting implants a rewarding therapeutic endeavour with the possibility for even greater advances.

Prevalence of carpal tunnel syndrome in patients with long-term type 2 diabetes mellitus

Generally, Carpal tunnel syndrome (CTS) is more common in diabetes mellitus (DM), especially in subjects with coexisting diabetic polyneuropathy (DPN) and/or long-term DM. Based on the analysis of nerve conduction velocity (NCV), the prevalence of CTS and the features of nerve injury were retrospectively explored in type 2 diabetes mellitus (T2DM) patients. In this cohort, there were 353 T2DM patients who were hospitalized in Taiyuan Central Hospitalbetween January 2018 and January 2019. The pathological rates of NCVs between the left and right median nerves were compared, including the gender effect. The examinations were mainly directed to analyze the median nerve injury features. Among 353 patients, 139 patients (39.3%) presented with CTS. These 139 T2DM patients with CTS were then divided into groups based on the nerve injury location and injured nerve type. The prevalence of sensory nerve injury (SNI) was higher than that of motor nerve injury (MNI). The CTS patients had a significantly higher occurrence rate of SNI than MNI (P < 0.05). The abnormal rate of sensory nerve conduction velocity (SCV, P = 0.01) and motor nerve conduction velocity (MCV, P < 0.05) were higher in the right median nerve. No significant differences were detected for other nerves on either side. Significant differences in abnormal rates of SCV of the left (P = 0.04) and the right (P = 0.03) median nerves between the two genders were found. There were no significant abnormalities for other nerves on either side and either gender. Early screening of NCV is needed for T2DM patients to detect CTS with a high prevalence rate. This study suggests that early detection of NCV can identify CTS in the absence of clinical conditions and SNI may occur earlier in long-term T2DM patients with CTS.

Predictive factors and clinical effects of diabetic hand: A prospective study with 1-year follow-up

AIMS

Diabetes mellitus is considered an etiological factor for hand-related conditions that are grouped under the term "diabetic hand" (DH), which includes limited joint mobility, Dupuytren's contracture, carpal tunnel syndrome, and trigger finger. This study aimed to identify predictive factors and the clinical effects of DH development among patients with diabetes.

PATIENTS AND METHODS

Consecutive Japanese adults with diabetes were prospectively recruited at a single outpatient center. We assessed the presence of DH at baseline and at the 1-year follow-up, which was considered present if the patient exhibited one or more of the hand disorders at either examination.

RESULTS

The 590 eligible subjects had a mean age of 57 years and included 155 patients (26%) with DH. Binary logistic regression analysis revealed that DH was significantly associated with older age, longer diabetes duration, and higher body mass index. Patients with DH had significantly lower hand function and quality of life (QOL) scores. We assessed 476 patients at the 1-year follow-up, including 96 patients (20%) who had DH at baseline. Although 25 of the 96 patients (26%) experienced resolution of DH without specific treatment, 83 of 380 patients (22%) without DH at baseline had developed new DH-related conditions. At the 1-year follow-up, the group with DH was significantly older than that without DH.

CONCLUSION

Older age and prolonged duration of diabetes predicted the development of DH. Patients who are not old and do not have a prolonged duration of diabetes may experience DH resolution without specific treatment.

Systemic inflammatory markers in neuropathic pain, nerve injury, and recovery

ABSTRACT

The role that inflammation plays in human nerve injury and neuropathic pain is incompletely understood. Previous studies highlight the role of inflammation in the generation and maintenance of neuropathic pain, but the emerging evidence from the preclinical literature for its role in the resolution of neuropathic pain remains to be explored in humans. Here, we use carpal tunnel syndrome (CTS) as a human model system of nerve injury and neuropathic pain to determine changes in serum cytokine protein levels and gene expression levels before (active stage of disease) and after carpal tunnel decompression surgery (recovery). Fifty-five patients with CTS were studied, and 21 healthy age-matched and gender-matched participants served as controls. In the active stage of the disease (CTS before surgery vs healthy controls), PTGES2 mRNA was decreased in patients (adjusted P = 0.013), while transforming growth factor-β and C-C motif chemokine ligand 5 protein levels were increased (adjusted P = 0.016 and P = 0.047, respectively). In the resolution phase (CTS before surgery vs after surgery), IL-9 mRNA was increased after surgery (adjusted P = 0.014) and expression of IL-6 mRNA and IL-4 protein levels were increased before surgery (adjusted P = 0.034 and P = 0.002, respectively). IL-9 mRNA expression negatively correlated with several (neuropathic) pain scores. By contrast, protein levels of IL-4 positively correlated with pain scores. In conclusion, we demonstrate specific dysregulation of systemic cytokine expression in both the active and resolution phases of nerve injury and neuropathic pain. IL-9 represents an interesting candidate associated with resolution of nerve injury and neuropathic pain.

Personal factors associated with carpal tunnel syndrome (CTS): a case-control study

BACKGROUND

Carpal tunnel syndrome (CTS) is one of the most common nerve entrapments in the upper limb. In Saudi Arabia, few studies have investigated CTS in the general population. This study aimed to determine the association between personal factors and CTS.

METHODS

A case-control study involved adults aged 18 and above. Cases were recruited from electrophysiology lab records as consecutive case series, while controls were individuals who were free of CTS symptoms according to the Boston Carpal Tunnel Questionnaire (BCTQ). The electronic medical records of participants were reviewed to obtain age, height, weight, medical conditions, and mobile numbers. Cases and controls were contacted via phone to complete a questionnaire that was designed based on previous literature. We used multivariate binary logistic regression to identify the personal factors significantly associated with CTS.

RESULTS

A total of 95 cases and 190 controls were included. Most of the participants were female (84.2%) and Saudi (93%). Most of cases were above 45 years of age (73.7%), while 84.7% were 45 year - old or younger among the control group. Stratified logistic regression showed that performance of household chores was significantly associated with CTS. While physical exercise associated with decreased odds of CTS.

CONCLUSIONS

This study adds to the body of evidence on personal factors associated with CTS. However, the degree of differences in the age structure of the cases compared with the controls suggest that there is a considerable potential for residual confounding affecting the results.

TRIAL REGISTRATION NUMBER

Not applicable.

Blocking CTGF/CCN2 reverses neural fibrosis and sensorimotor declines in a rat model of overuse-induced median mononeuropathy

Encapsulation of median nerves is a hallmark of overuse-induced median mononeuropathy and contributes to functional declines. We tested if an antibody against CTGF/CCN2 (termed FG-3019 or Pamrevlumab) reduces established neural fibrosis and sensorimotor declines in a clinically relevant rodent model of overuse in which median mononeuropathy develops. Young adult female rats performed a high repetition high force (HRHF) lever-pulling task for 18 weeks. Rats were then euthanised at 18 weeks (HRHF untreated), or rested and systemically treated for 6 weeks with either an anti-CCN2 monoclonal antibody (HRHF-Rest/FG-3019) or IgG (HRHF-Rest/IgG), with results compared with nontask control rats. Neuropathology was evident in HRHF-untreated and HRHF-Rest/IgG rats as increased perineural collagen deposition and degraded myelin basic protein (dMBP) in median nerves, and increased substance P in lower cervical dorsal root ganglia (DRG), compared with controls. Both groups showed functional declines, specifically, decreased sensory conduction velocity in median nerves, noxious cold temperature hypersensitivity, and grip strength declines, compared with controls. There were also increases of ATF3-immunopositive nuclei in ventral horn neurons in HRHF-untreated rats, compared with controls (which showed none). FG-3019-treated rats showed no increase above control levels of perineural collagen or dMBP in median nerves, Substance P in lower cervical DRGs, or ATF3-immunopositive nuclei in ventral horns, and similar median nerve conduction velocities and thermal sensitivity, compared with controls. We hypothesize that neural fibrotic processes underpin the sensorimotor declines by compressing or impeding median nerves during movement, and that inhibiting fibrosis using an anti-CCN2 treatment reverses these effects.

Biotechnology Applied to Cosmetics and Aesthetic Medicines

Biotechnology uses microorganisms and/or enzymes to obtain specific products through fermentative processes and/or genetic engineering techniques. Examples of these products are active ingredients, such as hyaluronic acid, kojic acid, resveratrol, and some enzymes, which are used in skin anti-aging products. In addition, certain growth factors, algae, stem cells, and peptides have been included in cosmetics and aesthetic medicines. Thus, biotechnology, cosmetics and aesthetic medicines are now closely linked, through the production of high-quality active ingredients, which are more effective and safer. This work describes the most used active ingredients that are produced from biotechnological processes. Although there are a vast number of active ingredients, the number of biotechnological active ingredients reported in the literature is not significantly high.

Distribution of Highly Prevalent Musculoskeletal Disorders and Their Association With Diabetes Complications in a Population of 140 Individuals With Type 1 Diabetes: A Retrospective Study in a French Diabetes Center

Although they are usually not considered to be diabetes complications, musculoskeletal disorders (MSKDs) are common in individuals with type 1 or type 2 diabetes and can strongly interfere with daily diabetes care, especially in people using diabetes technologies. The authors of this retrospective study in a population of 140 patients with type 1 diabetes report the distribution of subtypes of MSKDs and speculate about the mechanisms involved. The authors emphasize the need for multidisciplinary care involving not only the diabetes care team but also orthopedic surgeons. This report should lead to large, prospective studies to increase knowledge about these under-studied complications.

Comparison of amniotic membrane transplantation and carpal tunnel syndrome release surgery (CTRS) and CTRS alone: Clinical outcomes at 1-year follow-up

Carpal tunnel syndrome (CTS) is the most common focal entrapment mononeuropathy, comprising medium nerve chronic inflammation and fibrosis. Although carpal tunnel release surgery (CTRS) has demonstrated to be effective, around 3% to 25% of CTRS show recurrence. Amniotic membrane transplantation (AMT) has been used in different pathologies inhibiting inflammation and fibrosis and promoting nerve repair. The aim of this study was to determine the efficacy of AMT in CTRS. The present study comprised a randomized, single-blind controlled trial to compare the 1-year follow-up outcomes of AMT in CTRS (AMT group) or CTRS alone (control group) in patients with CTS. Thirty-five patients with unilateral or bilateral CTS were enrolled, and 47 wrists were randomized into two groups: the AMT group and the control group. To compare the outcomes, three different questionnaires scores (Boston Carpal Tunnel Syndrome Questionnaire, Disabilities of the Arm, Shoulder, and Hand, and Historical-Objective scale) were used. Evaluations were assessed at baseline and at 15 days, 1, 3, 6, and 12 months after surgery. Compared with the control group, the AMT group showed significant (p < 0.05) reductions in all scores from 6 months after surgery until the end of the study. Both AMT and control groups showed significant intragroup differences in all scores, since the first month after surgery until the end of the study in comparison with the baseline scores. Taken together, these results indicate that CTRS in conjunction with AMT is more effective than CTRS alone in patients with CTS at 1-year follow-up. Clinical Trial: NCT04075357; Amniotic Membrane in Carpal Tunnel Syndrome.

Correlation of neutrophil/lymphocyte and platelet/lymphocyte ratios with the severity of idiopathic carpal tunnel syndrome

BACKGROUND

The aim of the present study was to investigate the correlation of the neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio with the severity of idiopathic carpal tunnel syndrome (CTS).

METHODS

A total of 407 patients with idiopathic CTS (neurophysiologically 150 mild, 144 moderate, and 113 severe) and 206 subjects without CTS were included (control group).

RESULTS

There was a positive correlation between the severity of CTS and NLR (r = 0.224; P < 0.001), age (r = 0.333; P < 0.001), and body mass index (r = 0.251; P < 0.001). A 1-unit increase in NLR level was associated with an approximately 1.7-fold higher incidence of CTS (P = 0.002; odds ratio = 1.668; 95% confidence interval = 1.199-2.319).

CONCLUSIONS

Our results suggest that neurophysiologically more severe CTS is associated with higher NLR levels. The role of systemic inflammation in CTS should be investigated in further studies.

Recent Advances in the Understanding and Management of Carpal Tunnel Syndrome: a Comprehensive Review

PURPOSE OF REVIEW

Carpal tunnel syndrome (CTS) is an entrapment neuropathy that involves the compression of the median nerve at the wrist and is considered the most common of all focal entrapment mononeuropathies. CTS makes up 90% of all entrapment neuropathies diagnosed in the USA and affects millions of Americans.

RECENT FINDINGS

Age and gender likely play a role in the development of CTS, but additional studies may further elucidate these associations. Of known associated risk factors, diabetes mellitus seems to have the greatest association with CTS. One of the most commonly reported symptoms in CTS is a "pins-and-needles" sensation in the first three fingers and nocturnal burning pain that is relieved with activity upon waking. Treatment for CTS is variable depending on the severity of symptoms. Conservative management of CTS is usually considered first-line therapy. In cases of severe sensory or motor deficit, injection therapy or ultimately surgery may then be considered. Still CTS is often difficult to treat and may be reoccurring. Novel treatment modalities such as laser and shockwave therapy have demonstrated variable efficacy though further studies are needed to assess for safety and effect. Given the unknown and potentially complex etiology of CTS, further studies are needed to explore combinations of diagnostic and therapeutic modalities.