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Burgess J, Marshall A, Rapteas L, Kevin JH, Marshall A, Malik RA, Frank B, Alam U. Automated immunohistochemistry of intra-epidermal nerve fibres in skin biopsies: A proof-of-concept study. J Peripher Nerv Syst 2024; 29:329-338. [PMID: 39164223 DOI: 10.1111/jns.12650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/15/2024] [Accepted: 07/25/2024] [Indexed: 08/22/2024]
Abstract
AIMS To develop a standardised, automated protocol for detecting protein gene product 9.5 (PGP9.5) positive intra-epidermal nerve fibres (IENFs) in skin biopsies, transitioning from the established manual technique to an automated platform. This automated method, although currently intended for research applications, may improve the accessibility of this diagnostic test for small fibre neuropathy in clinical settings. METHODS Skin biopsies (n = 274) from 100 participants (fibromyalgia syndrome n = 62; idiopathic small fibre neuropathy: n = 16; healthy volunteers: n = 22) were processed using an automated immunohistochemistry platform. IENF quantification was performed by blinded examiners, with reliability assessed via a two-way mixed-effects model to evaluate inter- and intra-observer variability. RESULTS The automated staining system reproduced intra-epidermal nerve fibre density (IENFD) counts consistent with free-floating sections (mean ± standard deviation: free-floating: 5.6 ± 3.4 fibres/mm; automated: 5.9 ± 3.2 fibres/mm). A median difference of 0.3 with a lower bound 95% Confidence Interval (CI) at -0.00005 established non-inferiority against a margin of -0.4 (p = .08). Specifically, the inter-class correlation coefficient (class denotes consistency in measured observations) was 99% (95% CI: 0.9-1), indicating excellent agreement between free-floating and automated methods. The inter- and intra-class coefficient between examiners were both 99% (95% CI: 0.9-0.1) for IENFD, demonstrating high reliability using sections stained using the automated method. INTERPRETATION Automated immunohistochemistry provides high-throughput reliable and reproducible intra-epidermal nerve fibre quantification. This method, although currently proof-of-concept, for research use only, may be more widely deployed in histopathology laboratories to increase the adoption of IENFD assessment for the diagnosis of peripheral neuropathies.
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Affiliation(s)
- Jamie Burgess
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Anne Marshall
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Leandros Rapteas
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - J Hamill Kevin
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Andrew Marshall
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | | | - Uazman Alam
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke-on-Trent, UK
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Hernández‐Cortés P, Hurtado‐Olmo P, Roda‐Murillo O, Martín‐Morales N, O'Valle F. Density mapping of nerve endings in the skin of the palm and flexor retinaculum of the hand. Application to open carpal tunnel release. J Anat 2022; 242:362-372. [PMID: 36374977 PMCID: PMC9919465 DOI: 10.1111/joa.13793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/20/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022] Open
Abstract
In order to re-evaluate the safest area to incise skin and the flexor retinaculum (FR) when performing a carpal tunnel release (CTR), we carried out a mapping study of the nerve endings in the skin and FR on cadaver specimens, which, unlike previous studies for the first time, includes histomorphometry and image digital analysis. After dividing the skin and FR into 20 and 12 sections, respectively, we carried out a histomorphological analysis of nerve endings. The analysis was performed by two neutral observers on 4-μm histological sections stained with hematoxylin-eosin (H-E), and Klüver-Barrera with picrosirius red (KB + PR) methods. A semi-automatic image digital analysis was also used to estimate the percentage of area occupied per nerve. We observed a lower quantity of nerve endings in the skin of the palm of the hand in line with the ulnar aspect of the 4th finger. The ulnar aspect of the FR was the most densely innervated. However, there are no statistically significant differences between sections in the percentage of area occupied per nerve both in the skin and in the FR. We concluded that there is not a safe area to incise when performing carpal tunnel surgery, but taking into account the quantity of nerve endings present in skin and FR, we recommend an incision on the axis of the ulnar aspect of 4th finger when incising skin and on the middle third of the FR for CTR.
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Affiliation(s)
- Pedro Hernández‐Cortés
- Upper Limb Surgery Unit, Orthopaedic Surgery DepartmentSan Cecilio University Hospital of GranadaGranadaSpain,Surgery Department, School of MedicineGranada UniversityGranadaSpain,Biosanitary Research Institut of Granada (IBS Granada)GranadaSpain
| | - Patricia Hurtado‐Olmo
- Upper Limb Surgery Unit, Orthopaedic Surgery DepartmentSan Cecilio University Hospital of GranadaGranadaSpain
| | - Olga Roda‐Murillo
- Department of Human Anatomy, School of MedicineGranada UniversityGranadaSpain
| | - Natividad Martín‐Morales
- Biomedical Research Centre of Granada (CIBM)GranadaSpain,Pathology Department, School of MedicineGranada UniversityGranadaSpain
| | - Francisco O'Valle
- Biomedical Research Centre of Granada (CIBM)GranadaSpain,Pathology Department, School of MedicineGranada UniversityGranadaSpain
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Corrà MF, Sousa M, Reis I, Tanganelli F, Vila-Chã N, Sousa AP, Magalhães R, Sampaio P, Taipa R, Maia L. Advantages of an Automated Method Compared With Manual Methods for the Quantification of Intraepidermal Nerve Fiber in Skin Biopsy. J Neuropathol Exp Neurol 2021; 80:685-694. [PMID: 34041546 PMCID: PMC8357338 DOI: 10.1093/jnen/nlab045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Intraepidermal nerve fiber density (IENFD) measurements in skin biopsy are performed manually by 1–3 operators. To improve diagnostic accuracy and applicability in clinical practice, we developed an automated method for fast IENFD determination with low operator-dependency. Sixty skin biopsy specimens were stained with the axonal marker PGP9.5 and imaged using a widefield fluorescence microscope. IENFD was first determined manually by 3 independent observers. Subsequently, images were processed in their Z-max projection and the intradermal line was delineated automatically. IENFD was calculated automatically (fluorescent images automated counting [FIAC]) and compared with manual counting on the same fluorescence images (fluorescent images manual counting [FIMC]), and with classical manual counting (CMC) data. A FIMC showed lower variability among observers compared with CMC (interclass correlation [ICC] = 0.996 vs 0.950). FIMC and FIAC showed high reliability (ICC = 0.999). A moderate-to-high (ICC = 0.705) was observed between CMC and FIAC counting. The algorithm process took on average 15 seconds to perform FIAC counting, compared with 10 minutes for FIMC counting. This automated method rapidly and reliably detects small nerve fibers in skin biopsies with clear advantages over the classical manual technique.
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Affiliation(s)
- Marta Francisca Corrà
- From the Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto (MFC, RM, RT, LM); Department of Neurology, Centro Hospitalar Universitário do Porto (CHUP) (MFC, IR, NV-C, APS, RM, RT, LM); Instituto de investigação e inovação em Saúde da Universidade do Porto (i3S) (MS, PS, LM), Porto, Portugal; Department of Medicine IV, Geriatrics, University Hospital, LMU Munich, Munich, Germany (FT)
| | - Mafalda Sousa
- From the Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto (MFC, RM, RT, LM); Department of Neurology, Centro Hospitalar Universitário do Porto (CHUP) (MFC, IR, NV-C, APS, RM, RT, LM); Instituto de investigação e inovação em Saúde da Universidade do Porto (i3S) (MS, PS, LM), Porto, Portugal; Department of Medicine IV, Geriatrics, University Hospital, LMU Munich, Munich, Germany (FT)
| | - Inês Reis
- From the Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto (MFC, RM, RT, LM); Department of Neurology, Centro Hospitalar Universitário do Porto (CHUP) (MFC, IR, NV-C, APS, RM, RT, LM); Instituto de investigação e inovação em Saúde da Universidade do Porto (i3S) (MS, PS, LM), Porto, Portugal; Department of Medicine IV, Geriatrics, University Hospital, LMU Munich, Munich, Germany (FT)
| | - Fabiana Tanganelli
- From the Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto (MFC, RM, RT, LM); Department of Neurology, Centro Hospitalar Universitário do Porto (CHUP) (MFC, IR, NV-C, APS, RM, RT, LM); Instituto de investigação e inovação em Saúde da Universidade do Porto (i3S) (MS, PS, LM), Porto, Portugal; Department of Medicine IV, Geriatrics, University Hospital, LMU Munich, Munich, Germany (FT)
| | - Nuno Vila-Chã
- From the Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto (MFC, RM, RT, LM); Department of Neurology, Centro Hospitalar Universitário do Porto (CHUP) (MFC, IR, NV-C, APS, RM, RT, LM); Instituto de investigação e inovação em Saúde da Universidade do Porto (i3S) (MS, PS, LM), Porto, Portugal; Department of Medicine IV, Geriatrics, University Hospital, LMU Munich, Munich, Germany (FT)
| | - Ana Paula Sousa
- From the Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto (MFC, RM, RT, LM); Department of Neurology, Centro Hospitalar Universitário do Porto (CHUP) (MFC, IR, NV-C, APS, RM, RT, LM); Instituto de investigação e inovação em Saúde da Universidade do Porto (i3S) (MS, PS, LM), Porto, Portugal; Department of Medicine IV, Geriatrics, University Hospital, LMU Munich, Munich, Germany (FT)
| | - Rui Magalhães
- From the Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto (MFC, RM, RT, LM); Department of Neurology, Centro Hospitalar Universitário do Porto (CHUP) (MFC, IR, NV-C, APS, RM, RT, LM); Instituto de investigação e inovação em Saúde da Universidade do Porto (i3S) (MS, PS, LM), Porto, Portugal; Department of Medicine IV, Geriatrics, University Hospital, LMU Munich, Munich, Germany (FT)
| | - Paula Sampaio
- From the Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto (MFC, RM, RT, LM); Department of Neurology, Centro Hospitalar Universitário do Porto (CHUP) (MFC, IR, NV-C, APS, RM, RT, LM); Instituto de investigação e inovação em Saúde da Universidade do Porto (i3S) (MS, PS, LM), Porto, Portugal; Department of Medicine IV, Geriatrics, University Hospital, LMU Munich, Munich, Germany (FT)
| | - Ricardo Taipa
- From the Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto (MFC, RM, RT, LM); Department of Neurology, Centro Hospitalar Universitário do Porto (CHUP) (MFC, IR, NV-C, APS, RM, RT, LM); Instituto de investigação e inovação em Saúde da Universidade do Porto (i3S) (MS, PS, LM), Porto, Portugal; Department of Medicine IV, Geriatrics, University Hospital, LMU Munich, Munich, Germany (FT)
| | - Luís Maia
- From the Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto (MFC, RM, RT, LM); Department of Neurology, Centro Hospitalar Universitário do Porto (CHUP) (MFC, IR, NV-C, APS, RM, RT, LM); Instituto de investigação e inovação em Saúde da Universidade do Porto (i3S) (MS, PS, LM), Porto, Portugal; Department of Medicine IV, Geriatrics, University Hospital, LMU Munich, Munich, Germany (FT)
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Van Acker N, Ragé M, Sluydts E, Knaapen MWM, De Bie M, Timmers M, Fransen E, Duymelinck C, De Schepper S, Anand P, Meert T, Plaghki L, Cras P. Automated PGP9.5 immunofluorescence staining: a valuable tool in the assessment of small fiber neuropathy? BMC Res Notes 2016; 9:280. [PMID: 27215701 PMCID: PMC4878004 DOI: 10.1186/s13104-016-2085-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 05/11/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND In this study we explored the possibility of automating the PGP9.5 immunofluorescence staining assay for the diagnosis of small fiber neuropathy using skin punch biopsies. The laboratory developed test (LDT) was subjected to a validation strategy as required by good laboratory practice guidelines and compared to the well-established gold standard method approved by the European Federation of Neurological Societies (EFNS). To facilitate automation, the use of thinner sections. (16 µm) was evaluated. Biopsies from previously published studies were used. The aim was to evaluate the diagnostic performance of the LDT compared to the gold standard. We focused on technical aspects to reach high-quality standardization of the PGP9.5 assay and finally evaluate its potential for use in large scale batch testing. RESULTS We first studied linear nerve fiber densities in skin of healthy volunteers to establish reference ranges, and compared our LDT using the modifications to the EFNS counting rule to the gold standard in visualizing and quantifying the epidermal nerve fiber network. As the LDT requires the use of 16 µm tissue sections, a higher incidence of intra-epidermal nerve fiber fragments and a lower incidence of secondary branches were detected. Nevertheless, the LDT showed excellent concordance with the gold standard method. Next, the diagnostic performance and yield of the LDT were explored and challenged to the gold standard using skin punch biopsies of capsaicin treated subjects, and patients with diabetic polyneuropathy. The LDT reached good agreement with the gold standard in identifying small fiber neuropathy. The reduction of section thickness from 50 to 16 µm resulted in a significantly lower visualization of the three-dimensional epidermal nerve fiber network, as expected. However, the diagnostic performance of the LDT was adequate as characterized by a sensitivity and specificity of 80 and 64 %, respectively. CONCLUSIONS This study, designed as a proof of principle, indicated that the LDT is an accurate, robust and automated assay, which adequately and reliably identifies patients presenting with small fiber neuropathy, and therefore has potential for use in large scale clinical studies.
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Affiliation(s)
- Nathalie Van Acker
- />Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- />HistoGeneX NV, Pr J Charlottelaan 10, Berchem, 2600 Antwerp, Belgium
| | - Michael Ragé
- />Institute of Neuroscience, Université Catholique de Louvain, Avenue Mounier 53, B1.53.04, 1200 Brussels, Belgium
| | - Ellen Sluydts
- />HistoGeneX NV, Pr J Charlottelaan 10, Berchem, 2600 Antwerp, Belgium
| | | | - Martine De Bie
- />HistoGeneX NV, Pr J Charlottelaan 10, Berchem, 2600 Antwerp, Belgium
| | - Maarten Timmers
- />Janssen Research and Development, Janssen Pharmaceutica NV, Turnhoutseweg 30, 2340 Beerse, Belgium
- />Reference Center for Biological Markers of Dementia (BIODEM), Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
| | - Erik Fransen
- />StatUa Center for Statistics, University of Antwerp, Antwerp, Belgium
| | - Carla Duymelinck
- />HistoGeneX NV, Pr J Charlottelaan 10, Berchem, 2600 Antwerp, Belgium
| | | | - Praveen Anand
- />Peripheral Neuropathy Unit, Hammersmith Hospital, Du Cane Road, London, W12 0HS UK
| | - Theo Meert
- />Janssen Research and Development, Janssen Pharmaceutica NV, Turnhoutseweg 30, 2340 Beerse, Belgium
| | - Léon Plaghki
- />Institute of Neuroscience, Université Catholique de Louvain, Avenue Mounier 53, B1.53.04, 1200 Brussels, Belgium
| | - Patrick Cras
- />Department of Neurology, Antwerp University Hospital, Born Bunge Institute, University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
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