Elevated Preoperative Hemoglobin A1c Associated with Increased Wound Complications in Diabetic Patients Undergoing Primary, Open Carpal Tunnel Release

BACKGROUND

An increased rate of complications has been demonstrated with increasing hemoglobin A1c value for a variety of orthopedic procedures, including arthroplasty and spine surgery. The authors investigated the effects of elevated hemoglobin A1c value on postoperative complications at the time of carpal tunnel release.

METHODS

This retrospective, cohort study evaluated all diabetic patients with a preoperative hemoglobin A1c value within 90 days of primary, open carpal tunnel release at a single academic institution within the past 10 years. Binary hemoglobin A1c thresholds were tested for association with outcomes of superficial or deep infection, delayed wound healing, and persistent symptoms using chi-square analysis. Multivariable models with adjustment for baseline and operative factors were then constructed. Odds ratios and 95 percent confidence intervals were displayed.

RESULTS

Hemoglobin A1c value greater than or equal to 7.8 percent was most strongly associated with an increased risk of all-cause wound healing complications (p = 0.049) at an odds ratio of 4.2 (95 percent CI, 1.0 to 17.7) in adjusted analyses. Six patients (4 percent) experienced delayed wound healing and five patients (4 percent) developed a superficial infection. Six patients (4 percent) reported persistent carpal tunnel syndrome symptoms.

CONCLUSIONS

Diabetic patients undergoing open, primary carpal tunnel release with a hemoglobin A1c value of 7.8 percent or higher had a higher rate of postoperative wound complications compared to diabetic patients with improved preoperative glucose control. Diabetics with poor glycemic control should be counseled that their risk of postoperative complication is higher. Further work is needed to determine whether delaying surgery to optimize glucose control could result in a reduction of wound healing complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Association of a high normalized protein catabolic rate and low serum albumin level with carpal tunnel syndrome in hemodialysis patients

Carpal tunnel syndrome (CTS) is the most common mononeuropathy in patients with end-stage renal disease (ESRD). The association between chronic inflammation and CTS in hemodialysis (HD) patients has rarely been investigated. HD patients with a high normalized protein catabolic rate (nPCR) and low serum albumin level likely have adequate nutrition and inflammation. In this study, we assume that a low serum albumin level and high nPCR is associated with CTS in HD patients. We recruited 866 maintenance hemodialysis (MHD) patients and divided them into 4 groups according to their nPCR and serum albumin levels: (1) nPCR <1.2 g/kg/d and serum albumin level <4 g/dL; (2) nPCR ≥1.2 g/kg/d and serum albumin level <4 g/dL; (3) nPCR <1.2 g/kg/d and serum albumin level ≥4 g/dL; and (4) nPCR ≥1.2 g/kg/d and serum albumin level ≥4 g/dL. After adjustment for related variables, HD duration and nPCR ≥1.2 g/kg/d and serum albumin level <4 g/dL were positively correlated with CTS. By calculating the area under the receiver-operating characteristic curve, we calculated that the nPCR and HD duration cut-off points for obtaining the most favorable Youden index were 1.29 g/kg/d and 7.5 years, respectively. Advance multivariate logistic regression analysis revealed that in MHD patients, nPCR ≥1.29 g/kg/d and serum albumin <4 g/dL, and also HD duration >7.5 years were associated with CTS. A high nPCR and low serum albumin level, which likely reflect adequate nutrition and inflammation, were associated with CTS in MHD patients.

The evaluation of vitamin D levels in patients with carpal tunnel syndrome

The aim of this study was to evaluate the relationship between 25-hydroxyvitamin D (25(OH)D) levels and carpal tunnel syndrome (CTS). 25(OH)D levels were checked in 108 consecutive patients with CTS symptoms and 52 healthy controls. All patients underwent nerve conduction studies and completed Boston Carpal Tunnel Questionnaire (BQ) symptom severity and functional status scales to quantify symptom severity, pain status and functional status. There were 57 patients with electrophysiological confirmed CTS (EP+ group) and 51 electrophysiological negative symptomatic patients (EP- group). 25(OH) D deficiency (25(OH)D < 20 ng/ml) was found in 96.1 % of EP- group, in 94.7 % of EP+ group and in 73.8 % of control group. 25(0H) D level was found significantly lower both in EP+ and EP- groups compared to control group (p = 0.006, p < 0.001, respectively). Although mean vitamin D level in EP- group was lower than EP+ group, statistically difference was not significant between EP+ and EP- groups (p = 0.182). BQ symptom severity and functional status scores and BQ pain sum score were not significantly different between EP+ and EP- groups. We found no correlation with 25(OH) D level for BQ symptom severity, functional status and pain sum scores. 25(OH) D deficiency is a common problem in patients with CTS symptoms. As evidenced by the present study, assessment of serum 25(OH)D is recommended in CTS patients even with electrophysiological negative results.

The HAPPY study (Holistic Approach to Pregnancy and the first Postpartum Year): design of a large prospective cohort study

BACKGROUND

The HAPPY study is a large prospective longitudinal cohort study in which pregnant women (N ≈ 2,500) are followed during the entire pregnancy and the whole first year postpartum. The study collects a substantial amount of psychological and physiological data investigating all kinds of determinants that might interfere with general well-being during pregnancy and postpartum, with special attention to the effect of maternal mood, pregnancy-related somatic symptoms (including nausea and vomiting (NVP) and carpal tunnel syndrome (CTS) symptoms), thyroid function, and human chorionic gonadotropin (HCG) on pregnancy outcome of mother and foetus.

METHODS/DESIGN

During pregnancy, participants receive questionnaires at 12, 22 and 32 weeks of gestation. Apart from a previous obstetric history, demographic features, distress symptoms, and pregnancy-related somatic symptoms are assessed. Furthermore, obstetrical data of the obstetric record form and ultrasound data are collected during pregnancy. At 12 and 30 weeks, thyroid function is assessed by blood analysis of thyroid stimulating hormone (TSH), free thyroxine (FT4) and thyroid peroxidase antibodies (TPO-Ab), as well as HCG. Also, depression is assessed with special focus on the two key symptoms: depressed mood and anhedonia. After childbirth, cord blood, neonatal heel screening results and all obstetrical data with regard to start of labour, mode of delivery and complications are collected. Moreover, mothers receive questionnaires at one week, six weeks, four, eight, and twelve months postpartum, to investigate recovery after pregnancy and delivery, including postpartum mood changes, emotional distress, feeding and development of the newborn.

DISCUSSION

The key strength of this large prospective cohort study is the holistic (multifactorial) approach on perinatal well-being combined with a longitudinal design with measurements during all trimesters of pregnancy and the whole first year postpartum, taking into account two physiological possible markers of complaints and symptoms throughout gestation: thyroid function and HCG. The HAPPY study is among the first to investigate within one design physiological and psychological aspects of NVP and CTS symptoms during pregnancy. Finally, the concept of anhedonia and depressed mood as two distinct aspects of depression and its possible relation on obstetric outcome, breastfeeding, and postpartum well-being will be studied.

First identification of resident and circulating fibrocytes in Dupuytren's disease shown to be inhibited by serum amyloid P and Xiapex

Dupuytren's disease (DD) is a common progressive fibroproliferative disorder causing permanent digital contracture. Proliferative myofibroblasts are thought to be the cells responsible for DD initiation and recurrence, although their source remains unknown. DD tissue has also been shown to harbor mesenchymal and hematopoietic stem cells. Fibrocytes are circulating cells that show characteristics of fibroblasts and they express surface markers for both hematopoietic and mesenchymal stromal cells. Fibrocytes differentiate from peripheral CD14+ mononuclear cells, which can be inhibited by serum amyloid P (SAP). In this study we have demonstrated the presence of fibrocytes in DD blood and tissue, moreover we have evaluated the effects of SAP and Xiapex (Collagenase Clostridium histolyticum) on fibrocytes derived from DD. H&E staining showed typical Spindle shaped morphology of fibrocytes. FACS analysis based on a unique combination of 3 markers, revealed the increased presence of fibrocytes in blood and tissue of DD patients. Additionally, immunohistology of DD nodule and cord tissue showed the presence of collagen 1+/CD34+ cells. No difference in plasma SAP levels was observed between DD and control. Higher concentrations of SAP significantly inhibited fibrocytes differentiated from DD derived monocytes compared to control. DD fascia derived fibrocytes showed resistance to growth inhibition by SAP, particularly nodule derived fibrocytes showed robust growth even at higher SAP concentrations compared to control. DD derived fibrocytes were positive for typical fibrocyte dual markers, i.e. Collagen 1/LSP-1 and collagen 1/CD34. Xiapex was more effective in inhibiting the growth of nodule derived cells compared to commercially available collagenase A. Our results show for the first time the increased presence of fibrocytes in DD patient's blood and disease tissue compared to control tissue. Additionally, we evaluate the response of these fibrocytes to SAP and Xiapex therapy.

Total oxidative stress and antioxidant status in patients with carpal tunnel syndrome

OBJECTIVES

Studies in the carpal tunnel syndrome (CTS) are supported ischemia-induced changes rather than inflammation of the flexor tenosynovium. In this study, total antioxidant status (TAS), total oxidative stress (TOS) and oxidative stress index (OSI) in patients with CTS has been investigated.

METHODS

Forty-three patients (38 female and 5 male, 81 hands in total) diagnosed as CTS after the physical examination and electrophysiological findings included in study. The mean age of patients was 43.30 ± 10.49 years.

RESULTS

Bilateral CTS in 38 (88%) patients and unilateral CTS in five patients were detected. Dominant hand was involved in all patients. The mean symptoms duration was 30.9 months (range, 5-67 months). TAS in patients with CTS was significantly lower compared with control (1.01 ± 0.14 versus 1.11 ± 0.20 mmol Trolox equiv./l), (P = 0.008). TOS and OSI in patients with CTS were significant higher compared with control (15.60 ± 7.03 versus 11.86 ± 2.18 µmol H2O2 equiv./l and 1.57 ± 0.72 versus 1.09 ± 0.28), (respectively P = 0.002 and <0.001).

CONCLUSION

This study shows that there is a change in the oxidative stress and antioxidant defences in patients with CTS. Increased TOS and OSI and decreased TAS might be stimulate fibrosis through disturbed signaling pattern in the tenosynovium and median nerve. These processes might play a role in occurrence and progression of CTS.

Use of screening blood tests in patients with carpal tunnel syndrome

Is it is worth performing screening investigations in patients with carpal tunnel syndrome without clinical evidence of other diseases?

Does a carpal tunnel syndrome predict an underlying disease?

Carpal tunnel syndrome (CTS) may be the presenting symptom of an underlying disease such as diabetes mellitus, hypothyroidism or connective tissue disease (CTD). It was investigated whether additional blood tests (glucose level, thyroid-stimulating hormone level and erythrocyte sedimentation rate) are useful to detect diabetes mellitus, hypothyroidism or CTD in patients with CTS who have not been diagnosed with these diseases before. A group of 516 consecutive patients electromyographically diagnosed with CTS without known diabetes mellitus, hypothyroidism or CTD underwent blood tests and were followed up for incident diabetes mellitus, hypothyroidism or CTD to investigate whether these additional blood tests are useful to detect these diseases in patients with CTS. In our CTS population, only two patients were newly diagnosed with diabetes mellitus, two with hypothyroidism and none with CTD. In general, systematic screening for incident diabetes mellitus, hypothyroidism and CTD through additional blood tests seems to be of little additional value in otherwise typical cases of CTS.

Soft tissue rheumatic lesions and HIV infection in Zambians

OBJECTIVE

To explore the relationship between human immunodeficiency virus (HIV) infection and soft tissue rheumatic lesions in HIV-positive black Zambians.

METHODS

We performed a prospective study of all patients over 18 years of age attending a rheumatic clinic in a teaching hospital. All patients underwent routine blood tests, and radiographs were performed when indicated. HIV status was determined by ELISA, and clinical staging was determined by World Health Organization criteria. Patients with isolated sacroiliac pain, enthesitis, or a soft tissue lesion were selected for analysis. For HIV-positive patients, only those in clinical stage 1 (asymptomatic or persistent generalized lymphadenopathy) were selected.

RESULTS

Our study cohort comprised 120 patients (41 men, 79 women, age 23-70 yrs). Diagnosis and number (% HIV positive) were distributed as follows: sacroiliitis, 14 (100%); heel pain, 14 (100%); costochondritis, 3 (100%); polyenthesitis (> or = 4 sites), 20 (100%); carpal tunnel syndrome, 8 (63%); rotator cuff syndrome, 18 (30%); tendinitis, 8 (25%); sciatica/cervical spondylosis, 12 (16%); sacroiliac strain, 7 (0%); and de Quervain's tenosynovitis, 16 (0%). HIV seroprevalence was 54% overall, 74% in those under 45 years of age, and 17% in those over 45 years of age. Population prevalence of HIV in Lusaka is about 30% in the 30-40-year age range. Mean erythrocyte sedimentation rate (ESR) in 65 patients positive for HIV was 80 mm/h and in 55 patients negative for HIV, 18 mm/h. Within each subgroup the mean ESR was significantly higher in HIV-positive patients.

CONCLUSION

A young age and a raised ESR are both good indications of HIV infection in Zambian patients with soft tissue lesions. Enthesitis is a distinct HIV-related phenomenon, either an early form or a forme fruste of HIV-related spondyloarthropathy.

A Possible Involvement of the Carboxymethylation Process in Carpal Tunnel Syndrome in Hemodialysis Patients

A median motor nerve latency (DML) is generally prolonged in the carpal tunnel syndrome (CTS) of hemodialysis patients. Meanwhile, the advanced glycation process of proteins has been reported to be involved in the pathogenesis of the dialysis related amyloidosis. To investigate the role of carboxymethylation in dialysis related CTS, we measured a circulating carboxymethyllysine-hemoglobin (CML-Hb) level and nerve conduction velocity in 44 hemodialysis patients. The circulating CML-Hb level was 6.56 +/- 3.18 nmol CML/mg Hb, median motor nerve conduction velocity (NCV) was 49.8 +/- 4.64 m/s, median DML was 4.44 +/- 1.06 ms, and difference between median DML and ulnar DML (Delta DML) was 1.68 +/- 1.09 ms. Median and ulnar nerve NCV showed no correlation with circulating CML-Hb level. Both median DML and Delta DML were significantly correlated with CML-Hb (r = 0.429, P = 0.003, r = 0.472, P = 0.001). This study provided additional clinical evidence of an involvement of an advanced glycation process in the pathogenesis in CTS in hemodialysis patients.

[The effect of pharmacopuncture on the blood biochemical indices of patients with tunnel syndromes of the hands]

Concentrations of serotonin, beta-endorphine, myoglobin, basic myelin protein were measured in blood of patients with tunnel hand syndromes treated by actovegin or physiological solution pharmacopuncture and acupuncture to the same acupuncture points (AP). The above biochemical indices showed similar changes in pharmacopuncture with actovegin and the solution. These changes were different in acupuncture. This indicates specificity of AP stimulation by introduction of fluid, but not specificity of drug effects.

Expression of VLA-4 on peripheral mononuclear cells in patients on chronic haemodialysis with carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is a major complication in long-term haemodialysis patients and is thought to be a form of haemodialysis-associated amyloidosis. CTS may be due to the deposition of amyloid as well as local inflammatory process in the carpal tunnel. Although macrophage-like cells infiltrating the tenosynovium of carpal tunnel are known to express mRNA for adhesion molecules, the level of expression of adhesion molecules on peripheral blood mononuclear cells (PBMC) in patients with CTS is unknown.

METHODS

We compared the expression of very late activation antigen (VLA-4) on PBMC by flow cytometry in 14 patients on haemodialysis (6-21 years) with CTS, nine on haemodialysis (1-6 years) but without CTS and six patients on chronic ambulatory peritoneal dialysis (CAPD, 1-5 years) without CTS.

RESULTS

The expression of VLA-4 on peripheral lymphocytes was not different among the groups. However, the FACScan fluorescence histogram of VLA-4 expression on peripheral monocytes showed a bimodal pattern in the CTS group, and the rate of the high intensity portion of the expressed VLA-4 on monocytes was significantly higher in CTS than other groups (P<0.05). The observed differences were not based on differences in the type of the dialysis membrane. We also examined the adhesion of PBMC to fibronectin-coated plates. The number of adherent PBMC was significantly higher in patients with CTS than in other groups (P<0.05).

CONCLUSION

Our results suggest that increased expression of VLA-4 on peripheral monocytes and augmented adhesion capacity of PBMC to fibronectin may be involved in the development of CTS in haemodialysis patients.

N epsilon-(carboxymethyl)lysine in blood from maintenance hemodialysis patients may contribute to dialysis-related amyloidosis

BACKGROUND

Recent studies demonstrated not only that advanced glycation end product could be found in amyloid tissue from patient with dialysis related amyloidosis, but also that amyloid beta2-microglobulin was modified with N(epsilon)-(carboxymethyl)lysine (CML). We wanted to determine if CML could be a biomarker in these patients.

METHODS

To raise polyclonal anti-carboxymethyllysine antibody, human serum albumin was carboxymethylated by glyoxylic acid and was immunized to rabbits as antigen. Carboxymethyllysine-hemoglobin (CML-Hb) levels were measured by the dot blotting method using this antibody.

RESULTS

The levels of CML-Hb were 6.68 +/- 3.10 nmol CML/mg Hb in nondiabetic hemodialysis patients (N = 70), 6.39 +/- 3.43 nmol CML/mg Hb in diabetic hemodialysis patient (N = 21), and 3.13 +/- 0.88 nmol CML/mg Hb in 47 healthy volunteers. For clinical signs of dialysis-related amyloidosis, 70 nondiabetic hemodialysis patients were scored according Gejyo's criteria. The CML-Hb levels in patients with a high amyloid score as well as a low amyloid score were significantly higher than in patients with negative amyloid score (8.89 +/- 3.53 nmol CMLmg Hb, 7.28 +/- 2.32 nmol CML/mg Hb vs. 5.11 +/- 2.09 nmol CML/mg Hb, P < 0.001, P < 0.05). Furthermore, the CML-Hb levels correlated significantly with serum values of the methylguanidine over creatinine ratio and hyaluronate.

CONCLUSIONS

We suggest that CML-Hb is increased in blood from patients on maintenance hemodialysis and is thus a potential biomarker of oxidative damage in these patients. Moreover, CML-modification of protein may play a pathogenic role in the development of dialysis related amyloidosis.

The relationship of vitamin B6 status to median nerve function and carpal tunnel syndrome among active industrial workers

Case reports and small case series suggest that vitamin B6 deficiency is an important etiologic factor in carpal tunnel syndrome (CTS). This hypothesis has never examined in a randomly selected study population, particularly among active workers. We examined 125 randomly selected active workers from two industrial plants. Each worker completed a self-administered symptom questionnaire and underwent electrodiagnostic testing of the median and ulnar sensory nerves. Laboratory biochemical analyses of vitamin B6 status were also performed using the erythrocyte glutamic pyruvic transaminase assay, and quantification of plasma pyridoxal-5'-phosphate. Measurements of vitamin B6 status were unrelated to self-reported symptoms potentially consistent with CTS, electrophysiologically determined median or ulnar nerve function, and CTS defined on the basis of self-reported symptoms and electrophysiologic measurements. These results suggest that CTS among active industrial workers is unrelated to vitamin B6 status. Furthermore, in our opinion, empiric prescription of vitamin B6 to patients with CTS is unwarranted and potentially hazardous.

Carpal tunnel syndrome during pregnancy: prevalence and blood level of pyridoxine

The prevalence of CTS in third trimester pregnant women in the study in 28 per cent. With the use of NCS it was able to detect nearly 80 per cent of them who had no symptoms or signs. There was no association between the level of vitamin B6 or B6 deficiency and CTS. Since CTS may result in a permanent disability if undiagnosed or left untreated it is essential to make an early diagnosis and treat it especially older women and those who are edematous.

Carpal tunnel syndrome in patients undergoing CAPD: a collaborative study in 143 centers

Patients undergoing continuous ambulatory peritoneal dialysis (CAPD) who developed carpal tunnel syndrome (CTS) were retrospectively studied in 143 centers in Japan. Among the total 5,050 patients undergoing CAPD between 1980 and 1993 only 7 patients (0.14%) given CAPD developed CTS. Five of these 7 patients treated solely with CAPD developed CTS 12-108 months after starting CAPD. The remaining 2 patients who were initially treated with HD for 7-9 years and then switched to CAPD developed this complication 9 years after starting CAPD. All 7 patients were women, ranging in age from 32 to 70 (average 52) years. We detected the presence of amyloid deposits in 2 of 5 specimens and beta 2-microglobulin in 2 of 4 specimens from these patients. It was concluded that CAPD minimizes the emergence of CTS although constant surveillance is necessary to detect CTS in patients during CAPD.

Behavior of beta 2-microglobulin (B2-m) serum levels in uremic patients

This study was performed in 97 hemodialysis patients (85 on HD and 12 on CAPD) to investigate the possible correlation between B2-m and hemodialysis-related amyloidosis syndromes (HRA-S); differences in B2-m and HRA behavior between patients hemodialysed with cellulose and synthetic membranes were also included in the present study. Data indicate that B2-m levels are not correlated with dialysis length or with the type of membrane used for the dialysis. On the contrary, in 16 patients with the Carpal Tunnel Syndrome, a significant correlation was found between the CTS, the dialysis length and the type of membrane (greater incidence with cellulosic membranes).

[The factors promoting dystrophic pathology of the hand and duodenal peptic ulcer in women]

The authors have made an attempt to make exact the reasons of the frequent association of hand dystrophic pathology and duodenal ulceration disease in women. It is revealed that pointed diseases are to be the late symptoms of equally directed alterations in the organism, including neuro-humoral and immune mechanisms of adaptation, occurring in women even in sexual maturing period and being the favourable background for occurrence of various diseases including hand dystrophic pathology and duodenal ulcerative disease.

Relationship between plasma levels of hyaluronic acid and amyloid-associated osteoarthropathy in chronic hemodialysis patients

Plasma levels of hyaluronic acid (HA) and acute-phase reactants were determined in chronic hemodialysis patients with or without carpal tunnel syndrome (CTS) and/or shoulder pain, which are characteristic symptoms of amyloid-associated osteoarthropathy. While levels of acute-phase reactants tended to be higher in the patients with CTS and/or shoulder pain than in patients without these symptoms, the difference was not significant. However, plasma levels of HA were significantly higher in the patients with these symptoms. Analysis of plasma levels of HA in age-matched patients also demonstrated a significant correlation between elevated levels of HA and the presence of CTS and/or shoulder pain. Among the patients with CTS and/or shoulder pain, those patients with bone cysts in the carpal bone or humeral head had significantly higher plasma levels of HA than patients without bone cysts. Thus, there appears to be a relationship between elevated plasma HA and amyloid-associated osteoarthropathy in chronic hemodialysis patients that is more specific than any correlation with levels of acute-phase reactants.

Lack of hyperlipidemia in carpal tunnel syndrome

115 females with a definitive diagnosis of a carpal tunnel syndrome (CTS) are compared with a corresponding age-matched group of healthy females with regard to their lipidemic parameters. The incidence of hyperlipoproteinemias in CTS patients was equal to that in the control group so that hyperlipoproteinemia is unlikely to be a probable cause of the entrapment syndrome. A statistically significant increase in the level of alpha-lipoprotein (high-density lipoprotein) was found which cannot be readily explained.

Increased concentrations of free light chain lambda in sera from chronic hemodialysis patients

Serum levels of FLc were determined in 5 pre-HD CRF patients, 63 CRF patients receiving HD therapy, 15 CAPD and 40 healthy volunteers. The highest serum FLc concentration was observed in patients receiving HD. Concentrations of kappa- and lambda FLc were higher than normal in patients with CRF, and were about 4-fold and 1.8 fold greater than control values in HD patients, with a predominance of lambda chains. This HD-associated elevation of serum FLc strongly suggests a role for FLc in the etiology of light chain deposit disease and AL-amyloidosis. Lambda-FLc and beta 2-m exhibited similar patterns of change in the serum during the course of HD therapy. Further studies may reveal other pathological conditions other than CRF in which these polypeptides may play a role.

Soluble interleukin 2 receptor and tissue polypeptide antigen serum concentrations in end-stage renal failure

Serum concentrations of soluble interleukin 2 receptor (IL-2R) were measured in 65 hemodialysis patients and compared with serum levels of beta 2-microglobulin and tissue polypeptide antigen (TPA). Elevated IL-2R levels, found in 85% of examined patients, correlated with elevated TPA serum concentrations (p less than 0.05). Patients with high IL-2R levels were significantly younger (p less than 0.05) than patients with low levels. Primary renal disease and residual renal function had no significant influence on TPA or IL-2R serum concentrations. In 16 patients with carpal tunnel syndrome, increased serum concentrations of IL-2R (p less than 0.005) and TPA (p less than 0.001) were found. We conclude that a non-specific dialysis-induced activation of epithelial and lymphoid cells rather than a specific immune response could explain the concomitant elevation of IL-2R and TPA serum concentrations in hemodialyzed patients. Patients with pronounced cell turnover, reflected by elevated IL-2R and TPA levels, may show an increased susceptibility to dialysis-associated amyloidosis.

Vitamin B6 levels in patients with carpal tunnel syndrome

Vitamin B6 levels were determined in patients with idiopathic carpal tunnel syndrome. Results from this limited study strongly suggest that vitamin B6 deficiency may accompany carpal tunnel syndrome. This study did not address the question of the causal relationship between vitamin B6 status and development of symptoms.

Carpal tunnel syndrome and vitamin B6

Twelve patients with carpal tunnel syndrome were studied. Clinical and electrophysiological data were obtained and an estimation of vitamin B6 (pyridoxine) status by an assay of erythrocyte aspartate aminotransferase and coenzyme stimulation assay were done. None of the patients was found to have vitamin B6 deficiency. Patients were treated with 150 mg of pyridoxine daily for 3 months. Erythrocyte aspartate aminotransferase increased significantly (p less than 0.001) in all the patients. In 6 patients there were clinical and electrophysiological improvement and erythrocyte aspartate aminotransferase increased more than in the other 6 patients. The data obtained appear to indicate that although vitamin B6 deficiency is not common in carpal tunnel syndrome patients, pyridoxine supplementation can be recommended as adjuvant treatment in those patients undergoing surgery.

[Tunnel syndromes and blood glucose anomalies]

The fasting blood glucose was studied in 406 patients with carpal tunnel syndrome. We found 3.3% patients with diabetes mellitus and 15% with abnormal blood glucose levels. A prospective study was performed in 36 patients (oral glucose tolerance test, and blood lipid parameters). 45% of the patients in this group had an abnormal OGTT and 52% presented with hyperlipoproteinemia.

Detection of novel beta 2-microglobulin in the serum of hemodialysis patients and its amyloidogenic predisposition

Serum from 8 undialyzed patients and 30 dialyzed patients was examined by immunoblotting using anti beta 2-microglobulin (beta 2M) serum after two-dimensional gel electrophoresis (2.DE). One major spot and three minor spots were detected in the ultrafiltrate as well as in the serum. One major spot was determined to be native beta 2M and three minor spots were found to be novel beta 2M. Novel beta 2M had a lower molecular weight (MW) and a higher acidic isoelectric point (pI). Novel beta 2M was recognized in the sera of 5 out of 20 hemodialysis (HD) patients without carpal tunnel syndrome (CTS), 2 of whom had been on HD from 5 to 10 years and 3 for more than 10 years, as well as in the sera of all 10 patients with CTS. By chromatofocusing, pI of novel beta 2M was 5.2, while pI of native beta 2M was 5.7. When the tissue specimen of transverse carpal ligament of 2 HD patients with CTS was examined by immunoblotting after 2.DE, the spot of novel beta 2M was larger than that of native beta 2M. It is possible that some metabolic abnormality of beta 2M occurs through long-term hemodialysis, and it is possible that novel beta 2M might relate to amyloidogenic predisposition.

Carpal tunnel syndrome and acromegaly

50 patients with acromegaly and carpal tunnel syndrome have been examined electrophysiologically before and after transnasal operation of the pituitary adenoma. 32 of the 50 patients (64%) had symptoms of carpal tunnel syndrome. 13 of them had neurological deficits. 28 of the examined patients had pathological neurographical findings only. About 1 week post-operatively DL was decreased in 43%; in 10 out of 13 patients with neurological deficits DL decreased. GH was normalized in 80% and reduced to 5-10 micrograms/l in a further 10%. The investigation did not show whether the carpal tunnel syndrome only depended on a GH increase or on other factors also such as e.g., on the duration of symptoms or tissue changes. None of the patients had the transversal carpal ligament operated on. The coincidence between acromegaly and carpal tunnel syndrome was 64%. In 3 cases the carpal tunnel syndrome was the leading sign to the diagnosis of acromegaly.

Carpal tunnel syndrome and routine blood chemistries

A total of 110 of the 175 patients examined had symptomatic carpal tunnel syndrome. We were able to isolate 10 patients with carpal tunnel syndrome and electrical evidence of an associated peripheral neuropathy from these 110 patients. We feel that patients with peripheral neuropathies probably warrant an extensive laboratory evaluation for primary and treatable disorders. In contrast, we feel patients with isolated carpal tunnel syndrome, normal ulnar latencies, and normal ankle jerk reflexes do not warrant initial erythrocyte sedimentation rates, thyroid profiles, or blood sugars unless there are other historical or physical factors that suggest a predisposition to diabetes mellitus, thyroid disease, or rheumatic disorders.

Nocturnal prolactin secretion in carpal tunnel syndrome

The correlation between plasma PRL levels and CTS was investigated in 21 patients in whom a specific causal agent of CTS could not be identified. No correlation between plasma PRL levels and other clinical and neurophysiological data was detected.

Pyridoxine metabolism in carpal tunnel syndrome with and without peripheral neuropathy

The role of insufficient pyridoxine as an etiologic factor in the development of carpal tunnel syndrome (CTS) has been reported and has led to the empirical use of pyridoxine to treat CTS. Previous studies have not employed standardized electrodiagnostic criteria to objectively determine the presence of CTS or to rule out peripheral neuropathy (PN). The present study categorized subjects with symptoms suggestive of CTS into four groups by standardized electrodiagnostic criteria: (1) CTS, (2) PN, (3) CTS and PN, (4) normal. At least seven subjects were in each group. Erythrocyte glutamine oxaloacetic acid transaminase (EGOT) activity with and without in vitro enhancement with pyridoxal phosphate was used as a means of identifying subjects with and without pyridoxine metabolic abnormalities. A significant difference in pyridoxine metabolic activity (PMA) was found between groups by both chi square (p less than 0.05) and analysis of variance (p less than 0.05). Further evaluation showed that this difference was associated with the presence or absence of PN (p less than 0.05). There was no difference in PMA when groups were separated on the basis of CTS. Results showed that a PMA abnormality was a factor highly correlated with the presence of PN but not CTS. This finding suggested that the positive response reported previously in subjects with CTS taking supplemental pyridoxine may actually be related to an unrecognized PN, which was compounding the symptomatology.

Biochemical studies of pyridoxal and pyridoxal phosphate status and therapeutic trial of pyridoxine in patients with carpal tunnel syndrome

A number of recent studies report response of patients with carpal tunnel syndrome to pyridoxine treatment. Neurological and biochemical studies were therefore performed on six patients both before and after treatment with pyridoxine for at least 9 weeks. Free pyridoxal, pyridoxal phosphate, and total pyridoxal were assayed in plasma and neutrophils. The pyridoxal status was also estimated by assaying red cell aspartate aminotransferase. No evidence was obtained to suggest that these patients were deficient in either pyridoxal or pyridoxal phosphate. Although four of the patients claimed some partial symptomatic relief, there was no consistent improvement in clinical findings or neurophysiological measurements following pyridoxine treatment.

Carpal tunnel syndrome, diabetes and pyridoxal

Serum pyridoxal concentrations were estimated in 13 patients who had both diabetes and carpal tunnel syndrome. The clinical features and response to treatment in these patients did not differ from that seen in non-diabetic patients with this syndrome. No significant difference in mean serum pyridoxal concentrations was noted between diabetics with carpal tunnel syndrome, diabetics without neuropathy, and normal subjects. These results indicate that carpal tunnel syndrome in diabetics is distinct from polyneuropathy in that it is not associated with a reduction in serum pyridoxal levels which is a feature of diabetic polyneuropathy.

Biochemical evidence for a deficiency of vitamin B6 in the carpal tunnel syndrome based on a crossover clinical study

In a patient with severe carpal tunnel syndrome and a significant deficiency of vitamin B(6), the evidence for the deficiency was an extraordinarily low basal specific activity of the glutamic-oxaloacetic transminase of the erythrocytes (EGOT). This enzyme was also deficient in pyridoxal phosphate. The patient was treated with the recommended dietary allowance of pyridoxine, 2 mg/day, for 11 weeks, then 100 mg/day for 12 weeks, a placebo for 9 weeks, and again pyridoxine at 100 mg/day for 11 weeks. Sixty-one monitorial assays of EGOT over 48 weeks supported the following interpretations. (i) His diet permitted the development of a debilitating carpal tunnel syndrome. (ii) Treatment with pyridoxine at 2 mg/day reduced the deficiency of EGOT activity from about 70% to 50%, maintained a deficiency of pyridoxal phosphate, and relieved but allowed a marginal syndrome. (iii) Treatment at 100 mg/day for 12 weeks nearly achieved a "ceiling" level of EGOT and eliminated the deficiency of pyridoxal phosphate. (iv) After placebo for 7 weeks, the deficiencies of EGOT activity and pyridoxal phosphate reappeared, and clinical symptoms become worse. (v) Retreatment at 100 mg/day reestablished a "ceiling" EGOT, with no deficiency of pyridoxal phosphate, and the patient was asymptomatic. These data also support the concept that a deficiency of vitamin B(6) is significant in the etiology of the carpal tunnel syndrome. Mechanistically, a state of deficiency of the coenzyme seems to lower the level of the apoenzyme; a state of no deficiency of the coenzyme regulates a ceiling level of the transaminase. The latter state is presumably desired for health.