The nexus of immigration regulation and health governance: a scoping review of the extent to which right to access healthcare by migrants, refugees and asylum seekers was upheld in the United Kingdom during COVID-19

OBJECTIVES

Complementing the well-established evidence base on health inequalities experienced by migrants, refugees and asylum seekers in the UK; we examined the extent to which their right to equal non-discriminatory access to health services (promotive, preventive, curative) was upheld during the COVID-19 pandemic.

STUDY DESIGN

Arksey and O'Malley's scoping review framework.

METHODS

A comprehensive search was conducted on Medline, PubMed, and CINAHL using detailed MESH terms, for literature published between 01 January 2020 and 01 January 2024. The process was supported by a ten-page Google search and hand searching of reference lists. 42 records meeting the inclusion criteria were charted, coded inductively and analysed thematically in an integrated team-based approach.

RESULTS

Dissonance between immigration regulation and health governance is illustrated in four themes: Health systems leveraged to (re)enforce the hostile environment; Dissonance between health rights on paper and in practice; Structural failures to overcome communication and digital exclusion; and COVID-19 vaccine (in)equity exacerbated fear, mistrust and exclusion. Migrants, refugees and asylum seekers encountered substantial individual, structural and policy-level barriers to accessing healthcare in the UK during COVID-19. Insecure immigration status, institutional mistrust, data-sharing and charging fears, communication challenges and digital exclusion impacted heavily on their ability to access healthcare in an equitable non-discriminatory manner.

CONCLUSIONS

An inclusive and innovative health equity and rights-based responses reaching all migrants, refugees and asylum seekers are warranted if the National Health Service is to live up to its promise of 'leaving no one behind' in post-pandemic and future responses.

The relationship between parental adverse childhood experiences and the health, well-being and development outcomes of their children: a systematic review

OBJECTIVES

A growing body of research is emerging regarding the relationship between parental adverse childhood experiences (ACEs) and negative health, well-being and developmental outcomes in their children. This systematic review seeks to understand the relationship between parental ACEs and the health, well-being and developmental outcomes of their children and whether the relationships differ according to the number and type of parental ACEs.

STUDY DESIGN

Systematic review.

METHOD

The review includes articles published between 2000 and 2021 from studies using quantitative longitudinal methods and multivariate analysis to investigate the relationship between parental ACEs and their offspring's outcomes. Relevant studies were identified through a systematic search of five databases and findings synthesised using a narrative synthesis. This review was registered on PROSPERO (CRD42021274068).

RESULTS

Nineteen studies met the inclusion criteria and were included in the review. This resulted in a combined population sample of 124,043 parents and 128,400 children. Diversity in measurement of parental ACE exposure and in the type of ACEs measured within the studies precluded a meta-analysis. Offspring of parents exposed to ACEs had a higher risk of a range of negative health, well-being and developmental outcomes. This relationship differs according to the number and type of parental ACEs, with a positive relationship observed between the number of parental ACEs and the risk of negative health, well-being and development outcomes in their children.

CONCLUSIONS

These findings indicate that screening for parental ACEs by health visitors, midwives and other health or social care staff may identify an at-risk population of infants, children and adolescents and improve child outcomes.

Cardiovascular structure and function assessed by MRI in healthy South Asians compared to White Europeans: a UK Biobank study

Background

There is limited data on ethnic specific comparisons for measures of cardiovascular structure and function in healthy cohorts. Echocardiographic data indicate South Asian's (SAs) have smaller mass and evidence of more concentric remodelling compared to White Europeans (WEs). Furthermore, there is no data published for strain or strain rates.

Purpose

To compare Cardiac Magnetic Resonance (CMR) derived measures of structure and function between age and sex matched healthy SAs and WEs from the UK biobank cohort.

Methods

South Asian and WE participants from the UK Biobank who underwent CMR imaging were included. Individuals with a history of cardiovascular disease, hypertension, obesity (BMI ≥30 kg/m2 in WEs and ≥27 kg/m2 in SAs) and diabetes were excluded. Ethnic groups were matched according to age and sex at recruitment. Cine images (bSSFP) were analysed blinded to participant details using commercially available software. Left ventricular (LV) mass, LV volumes, global longitudinal and circumferential systolic strain (GLS and GCS), together with peak early diastolic strain rates (PEDSR), were obtained. Data distributions were assessed and T-Test or Man Whitney U conducted as appropriate.

Results

Datasets from the UK biobank were screened (n=45000). After applying exclusion criteria, 111 pairs of matched SAs and WEs were available for analysis (n=69 male and n=42 female matched pairs). Mean age of the entire cohort was 58±8 years. Data has been corrected according to body surface area (BSA),(males: WE 2.0±0.1 vs SA 1.8±0.1 m2, p≤0.001; females: WE 1.7±0.2 vs SA 1.6±0.1 m2, p≤0.001). There was no difference in heart rate (males: WE 64.5±9.3 vs SA 65.8±9.6 bpm, p=0.113; females: WE 66.2±7.8 vs SA 69.5±10.3 bpm, p=0.125). Results by sex and ethnicity are displayed in table 1. In males there was no difference in ejection fraction (EF) or indexed LV end diastolic volume (LVEDV). However indexed mass and mass/volume ratio were significantly lower in SAs, and GLS but not GCS was significantly higher than in SAs. Longitudinal PEDSR were significantly higher in SAs than in WE. By contrast, SA females had significantly lower EF with no difference in indexed LVEDV compared to WE females. However, as seen with the males SA females had significantly lower indexed LV mass and mass/volume ratio compared to WE females. Finally, both GLS and GCS were significantly higher in SAs compared to WE females, whereas there was no difference in longitudinal PEDSR.

Conclusion

Substantial differences in cardiovascular structure and function exist between SA and WE ethnic groups, in both men and women. Contrary to previous echocardiographic studies, LV volumes were similar between ethnicities and SA have less, not increased, concentric remodelling than WE. These findings highlight the need for ethnicity and sex-specific healthy reference ranges derived from CMR.

Funding Acknowledgement

Type of funding sources: None.

Peripheral Neuropathy Phenotyping in Rat Models of Type 2 Diabetes Mellitus: Evaluating Uptake of the Neurodiab Guidelines and Identifying Future Directions

Diabetic peripheral neuropathy (DPN) affects over half of type 2 diabetes mellitus (T2DM) patients, with an urgent need for effective pharmacotherapies. While many rat and mouse models of T2DM exist, the phenotyping of DPN has been challenging with inconsistencies across laboratories. To better characterize DPN in rodents, a consensus guideline was published in 2014 to accelerate the translation of preclinical findings. Here we review DPN phenotyping in rat models of T2DM against the 'Neurodiab' criteria to identify uptake of the guidelines and discuss how DPN phenotypes differ between models and according to diabetes duration and sex. A search of PubMed, Scopus and Web of Science databases identified 125 studies, categorised as either diet and/or chemically induced models or transgenic/spontaneous models of T2DM. The use of diet and chemically induced T2DM models has exceeded that of transgenic models in recent years, and the introduction of the Neurodiab guidelines has not appreciably increased the number of studies assessing all key DPN endpoints. Combined high-fat diet and low dose streptozotocin rat models are the most frequently used and well characterised. Overall, we recommend adherence to Neurodiab guidelines for creating better animal models of DPN to accelerate translation and drug development.

Peripheral nerve morphology and intraneural blood flow in chronic kidney disease with and without diabetes

Introduction/Aims

Sonographic alterations of peripheral nerves in pre‐dialytic kidney disease are yet to be determined. We aimed to assess peripheral nerve cross‐sectional area (CSA) and intraneural blood flow in patients with pre‐dialytic chronic kidney disease (CKD) and diabetic kidney disease (DKD).

Methods

Subjects with CKD (n = 20) or DKD (n = 20) underwent ultrasound to assess CSA of the median and tibial nerves as well as intraneural blood flow of the median nerve. Blood flow was quantified using maximum perfusion intensity. Neuropathy was assessed using the Total Neuropathy Score. A 6‐m timed walk test was also performed. Healthy controls (n = 28) were recruited for comparison.

Results

The DKD group had more severe neuropathy (p = .024), larger tibial nerve CSA (p = .002) and greater median nerve blood flow than the CKD group (p = .023). Blood flow correlated with serum potassium in disease groups (r = 0.652, p = .022). Disease groups had larger tibial nerve CSA than controls (p < .05). No blood flow was detected in controls. Tibial nerve enlargement was associated with slower maximal walking speeds in disease groups (r = −0.389, p = .021).

Discussion

Subjects with DKD demonstrated enlarged tibial nerve CSA and increased median nerve blood flow compared to those with CKD. Elevations in serum potassium were associated with increased blood flow. Sonographic alterations were detectable in pre‐dialytic kidney disease compared to controls, highlighting the utility of ultrasound in the assessment of nerve pathology in these patient groups.

Effect of Hemodiafiltration on the Progression of Neuropathy with Kidney Failure: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Neuropathy is a common complication of kidney disease that lacks proven disease-modifying treatments. Hemodiafiltration improves clearance of uremic toxins and is associated with better nerve function than hemodialysis. We aimed to determine whether hemodiafiltration reduces the progression of neuropathy in people receiving hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Filtration in the Neuropathy of End-Stage Kidney Disease Symptom Evolution (FINESSE) study was an open-label, blinded end point assessment, controlled trial that randomized maintenance hemodialysis recipients to hemodiafiltration or high-flux hemodialysis for 48 months or until death or cessation of dialysis at four study centers. The primary outcome was the mean change in the yearly modified total neuropathy score from baseline, with time points weighted equally.

RESULTS

A total of 124 participants were randomized and followed for a mean of 41 months. At baseline, neuropathy was present in 91 (73%) participants (modified total neuropathy score greater than or equal to two), and 38 (31%) had moderate to severe neuropathy (modified total neuropathy score 9-28). Convection volume in the hemodiafiltration arm was a median of 24.7 (interquartile range, 22.4-26.5) L. The mean modified total neuropathy score (SEM) worsened by 1.7 (0.4)/28 and 1.2 (0.4)/28 in the hemodiafiltration and hemodialysis groups, respectively, with a mean difference of 0.5 (95% confidence interval, -0.7 to 1.7; P=0.37). There was no difference in survival (hazard ratio, 1.24; 95% confidence interval, 0.61 to 2.51; log rank P=0.55) or any of the prespecified adverse events. There was no difference between groups in the number of participants who suffered an adverse event adjusted by follow-up time (relative risk, 1.05; 95% confidence interval, 0.83 to 1.32; P=0.68).

CONCLUSIONS

Neuropathy is still a common complication of kidney disease without disease-altering therapy. Hemodiafiltration did not affect neuropathy progression compared with hemodialysis.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Filtration in the Neuropathy of End-Stage Kidney Disease Symptom Evolution (FINESSE), ACTRN12609000615280.

Impact of the metabolic syndrome on peripheral nerve structure and function in type 2 diabetes

BACKGROUND AND PURPOSE

There is a strong association between the metabolic syndrome in diabetes and the development of peripheral neuropathy; however, the pathophysiological mechanisms remain unknown.

METHODS

Participants with type 2 diabetes and metabolic syndrome (T2DM/MetS, n = 89) and type 2 diabetes alone (T2DM; n = 59) underwent median nerve ultrasound and excitability studies to assess peripheral nerve structure and function. A subset of T2DM/MetS (n = 24) and T2DM (n = 22) participants underwent confocal microscopy to assess central and inferior whorl corneal nerve structure. Neuropathy severity was assessed using the modified Toronto Clinical Neuropathy Score (mTCNS). Diabetes groups were similar for age, sex distribution, diabetes duration, hemoglobin A_1c , insulin treatment, and renal function. Sixty healthy controls similar for age and sex distribution were recruited for comparison.

RESULTS

Participants with T2DM/MetS manifested with a greater mTCNS compared to T2DM (p < 0.05). Median nerve cross-sectional area was larger in the T2DM/MetS group compared to the T2DM cohort (p < 0.05). Participants with T2DM/MetS had reductions in central (all p < 0.01) and inferior whorl (all p < 0.05) nerve measures. Compared to T2DM, the T2DM/MetS group demonstrated more severe changes in nerve excitability measures, which was due to reduced sodium channel permeability and sodium-potassium pump function. In comparison, only sodium channel permeability was reduced in the T2DM group.

CONCLUSIONS

Compared to participants with type 2 diabetes alone, those with diabetes and metabolic syndrome manifested greater alterations in peripheral nerve structure and function, which may be due to reduced function of the sodium-potassium pump.

Peripheral Neuropathy: An Important Contributor To Physical Limitation And Morbidity In Stage 3-4 Chronic Kidney Disease

BACKGROUND

Impaired physical function drives adverse outcomes in chronic kidney disease (CKD). Peripheral neuropathy is highly prevalent in CKD, though its contribution to physical function in CKD patients is unknown. This study examined the relationships between neuropathy, walking speed and quality of life (QoL) in CKD.

METHODS

This was a prospective observational study investigating neuropathy in CKD patients with an eGFR 15-60ml/kg/min-1. A total of 109 patients were consecutively recruited. The presence and severity of neuropathy was determined using the Total Neuropathy Score (TNS). Walking speed was assessed at both usual and maximal speed, and QoL was assessed using the SF-36 questionnaire.

RESULTS

Peripheral neuropathy was highly prevalent: 40% demonstrated mild neuropathy and 37% had moderate-severe neuropathy. Increasing neuropathy severity was the primary predictor of reduced walking speed (R2=-0.41, p<0.001) and remained so after multivariable analysis adjustment for diabetes. This association was evident for both usual and maximal walking speeds. Neuropathy correlated significantly with low scores on multiple domains of SF-36 including physical function (r=-0.570, p<0.001). Subanalysis according diabetic status revealed a high prevalence of neuropathy both with-and-without diabetes; relationships to walking speed remained evident in subgroup analysis. However, those with diabetes demonstrated greater severity of neuropathy, slower walking speed and lower scores in QoL.

CONCLUSIONS

Moderate to severe peripheral neuropathy was common in stage 3-4 CKD, associated with reduced walking speed independent of diabetes status and was correlated with patient reported QoL. This suggests that neuropathy is an important contributor to declining physical function in CKD irrespective of diabetes status. Targeted diagnosis and management of peripheral neuropathy during CKD progression may improve functional outcomes and QoL.

Associations between acute glucose control and peripheral nerve structure and function in type 1 diabetes

AIM

To examine the associations between continuous overlapping net glycaemic action (CONGA), percentage time in hyperglycaemia (%HG) or normoglycaemia (%NG) and peripheral nerve structure and function in type 1 diabetes.

METHODS

Twenty-seven participants with type 1 diabetes underwent continuous glucose monitoring followed by corneal confocal microscopy and nerve excitability assessments. CONGA, %HG (> 10.0 mmol/l) and %NG (3.9-10.0 mmol/l) were correlated against corneal nerve fibre length and density in the central cornea and inferior whorl region, corneal microneuromas, and a nerve excitability score while controlling for age, sex, diabetes duration and HbA_1c .

RESULTS

An increase in CONGA [median 2.5 (2.0-3.1) mmol/l] or %HG (mean 46 ± 18%) was associated with a worse nerve excitability score (r = -0.433, P = 0.036 and r = -0.670, P = 0.0012, respectively). By contrast, greater %NG (51 ± 17%) correlated with better nerve excitability scores (r = 0.672, P = 0.0011). Logistic regression revealed that increasing %HG increased the likelihood of abnormal nerve function [odds ratio (OR) 1.11, 95% confidence interval (CI) 1.01-1.23; P = 0.037). An increase in CONGA and %HG were associated with worsening nerve conduction measures, whereas longer %NG correlated with improved nerve conduction variables. CONGA and %HG were associated with inferior whorl corneal nerve fibre length (r = 0.483, P = 0.034 and r = 0.591, P = 0.021, respectively) and number of microneuromas (r = 0.433, P = 0.047 and r = 0.516, P = 0.020, respectively).

CONCLUSIONS

Short-term measures of glucose control are associated with impaired nerve function and alterations in corneal nerve morphology.

Evidence of Altered Peripheral Nerve Function in a Rodent Model of Diet-Induced Prediabetes

Peripheral neuropathy (PN) is a debilitating complication of diabetes that affects >50% of patients. Recent evidence suggests that obesity and metabolic disease, which often precede diabetes diagnosis, may influence PN onset and severity. We examined this in a translationally relevant model of prediabetes induced by a cafeteria (CAF) diet in Sprague–Dawley rats (n = 15 CAF versus n = 15 control). Neuropathy phenotyping included nerve conduction, tactile sensitivity, intraepidermal nerve fiber density (IENFD) and nerve excitability testing, an in vivo measure of ion channel function and membrane potential. Metabolic phenotyping included body composition, blood glucose and lipids, plasma hormones and inflammatory cytokines. After 13 weeks diet, CAF-fed rats demonstrated prediabetes with significantly elevated fasting blood glucose, insulin and impaired glucose tolerance as well as obesity and dyslipidemia. Nerve conduction, tactile sensitivity and IENFD did not differ; however, superexcitability was significantly increased in CAF-fed rats. Mathematical modeling demonstrated this was consistent with a reduction in sodium–potassium pump current. Moreover, superexcitability correlated positively with insulin resistance and adiposity, and negatively with fasting high-density lipoprotein cholesterol. In conclusion, prediabetic rats over-consuming processed, palatable foods demonstrated altered nerve function that preceded overt PN. This work provides a relevant model for pathophysiological investigation of diabetic complications.

Altered peripheral nerve structure and function in latent autoimmune diabetes in adults

AIM

The present study was undertaken to investigate mechanisms of peripheral nerve dysfunction in latent autoimmune diabetes in adults (LADA).

MATERIALS AND METHODS

Participants with LADA (n = 15) underwent median nerve ultrasonography and nerve excitability to examine axonal structure and function, in comparison to cohorts of type 1 diabetes (n = 15), type 2 diabetes (n = 23) and healthy controls (n = 26). The LADA group was matched for diabetes duration, glycaemic control, and neuropathy severity with the type 1 and type 2 diabetes groups. A validated mathematical model of the human axon was utilized to investigate the pathophysiological basis of nerve dysfunction.

RESULTS

The most severe changes in nerve structure and function were noted in the LADA group. The LADA cohort demonstrated a significant increase in nerve cross-sectional area compared to type 1 participants and controls. Compared to type 1 and 2 diabetes, measures of threshold electrotonus, which assesses nodal and internodal conductances, were significantly worse in LADA in response to both depolarising currents and hyperpolarising currents. In the recovery cycle, participants with LADA had a significant increase in the relative refractory period. Mathematical modelling of excitability recordings indicated the basis of nerve dysfunction in LADA was different to type 1 and 2 diabetes.

CONCLUSIONS

Participants with LADA exhibited more severe changes in nerve function and different underlying pathophysiological mechanisms compared to participants with type 1 or 2 diabetes. Intensive management of risk factors to delay the progression of neuropathy in LADA may be required.

Potassium control in chronic kidney disease: implications for neuromuscular function

In Australia, approximately 1.7 million adults have evidence of chronic kidney disease (CKD). This complex disease can result in a multitude of complications, including hyperkalaemia, which is common and well recognised. The advent of new therapeutics aimed at lowering serum potassium has raised the possibility of optimising potassium control to enable greater use of renin-angiotensin-aldosterone system inhibitors in the management of CKD. Recent studies suggest that hyperkalaemia also has implications for peripheral neuropathy in CKD, a complication that substantially contributes to patient morbidity. This review examines evidence of the relationship between potassium and peripheral neuropathy, with a discussion of clinical implications. We searched PubMed for original and review articles using pre-specified key words, clinical guidelines and population data. The major findings were that contemporary CKD cohorts demonstrate a high prevalence of peripheral neuropathy, even in stage 3-4 CKD, including those without diabetes. The severity of the problem has been emphasised by an ominous rise in foot complications and amputation rates in dialysis patients, highlighting the need for increased awareness of the condition in earlier stages of CKD and targeted treatment strategies. It is likely that the pathophysiology of peripheral neuropathy in CKD is multifaceted, with potential influences from potassium, vascular abnormalities, diabetes, inflammation and unknown middle molecules. Despite these complexities, the relationship between potassium and nerve function in dialysis has been well established, and recent research in stage 3-4 CKD suggests that assertive potassium control may improve neuromuscular outcomes in CKD. These small studies should be confirmed in large, multicentre settings.

Neuroinflammation and Functional Connectivity in Alzheimer's Disease: Interactive Influences on Cognitive Performance

Neuroinflammation is a key part of the etio-pathogenesis of Alzheimer's disease (AD). We tested the relationship between neuroinflammation and the disruption of functional connectivity in large-scale networks, and their joint influence on cognitive impairment. We combined [11C]PK11195 positron emission tomography (PET) and resting-state functional magnetic resonance imaging (rs-fMRI) in 28 patients (12 females/16 males) with clinical diagnosis of probable AD or mild cognitive impairment with positive PET biomarker for amyloid, and 14 age-, sex-, and education-matched healthy controls (8 females/6 males). Source-based "inflammetry" was used to extract principal components of [11C]PK11195 PET signal variance across all participants. rs-fMRI data were preprocessed via independent component analyses to classify neuronal and non-neuronal signals. Multiple linear regression models identified sources of signal covariance between neuroinflammation and brain connectivity profiles, in relation to the diagnostic group (patients, controls) and cognitive status.Patients showed significantly higher [11C]PK11195 binding relative to controls, in a distributed spatial pattern including the hippocampus, frontal, and inferior temporal cortex. Patients with enhanced loading on this [11C]PK11195 binding distribution displayed diffuse abnormal functional connectivity. The expression of a stronger association between such abnormal connectivity and higher levels of neuroinflammation correlated with worse cognitive deficits.Our study suggests that neuroinflammation relates to the pathophysiological changes in network function that underlie cognitive deficits in Alzheimer's disease. Neuroinflammation, and its association with functionally-relevant reorganization of brain networks, is proposed as a target for emerging immunotherapeutic strategies aimed at preventing or slowing the emergence of dementia.SIGNIFICANCE STATEMENT Neuroinflammation is an important aspect of Alzheimer's disease (AD), but it was not known whether the influence of neuroinflammation on brain network function in humans was important for cognitive deficit. Our study provides clear evidence that in vivo neuroinflammation in AD impairs large-scale network connectivity; and that the link between neuro inflammation and functional network connectivity is relevant to cognitive impairment. We suggest that future studies should address how neuroinflammation relates to network function as AD progresses, and whether the neuroinflammation in AD is reversible, as the basis of immunotherapeutic strategies to slow the progression of AD.

Relative contributions of diabetes and chronic kidney disease to neuropathy development in diabetic nephropathy patients

OBJECTIVE

Chronic kidney disease (CKD) caused by diabetes is known as diabetic kidney disease (DKD). The present study aimed to examine the underlying mechanisms of axonal dysfunction and features of neuropathy in DKD compared to CKD and type 2 diabetes (T2DM) alone.

METHODS

Patients with DKD (n = 30), CKD (n = 28) or T2DM (n = 40) and healthy controls (n = 41) underwent nerve excitability assessments to examine axonal function. Neuropathy was assessed using the Total Neuropathy Score. A validated mathematical model of human axons was utilised to provide an indication of the underlying causes of nerve pathophysiology.

RESULTS

Total neuropathy score was significantly higher in patients with DKD compared to those with either CKD or T2DM (p < 0.05). In DKD, nerve excitability measures (S2 accommodation and superexcitability, p < 0.05) were more severely affected compared to both CKD and T2DM and worsened with increasing serum K⁺ (p < 0.01). Mathematical modelling indicated the basis for nerve dysfunction in DKD was an elevation of extracellular K⁺ and reductions in Na⁺ permeability and the hyperpolarisation-activated cation current, which was similar to CKD.

CONCLUSIONS

Patients with DKD manifested a more severe neuropathy phenotype and shared features of nerve dysfunction to that of CKD.

SIGNIFICANCE

The CKD, and not diabetes component, appears to underlie axonal pathophysiology in DKD.

Polymer brush based fluorescent immunosensor for direct monitoring of interleukin-1β in rat blood

A sandwich immunosensor was successfully developed for monitoring of interleukin-1β (IL-1β) in rat whole blood. The substrate stainless steel (SS) was first coated with a polydopamine layer and subsequently grafted with poly(ethylene glycol) methacrylate brushes, onto which a sandwich immunosensor was modified for detection of IL-1β. The device has been successfully applied for monitoring of IL-1β with a limit of detection of 4.7 pg mL^-1, and a linear detection range of 12.5-200 pg mL^-1. Good specificity and selectivity for monitoring of IL-1β in rat macrophage secretion were achieved. Furthermore, this device was validated by detection of IL-1β in rat whole blood samples with greater concentrations observed in obese rats compared to control, and strong positive correlation between concentrations of IL-1β and blood glucose. These results suggest this device is feasible for direct detection of target analytes in biological samples.

Infantile hypertrophic pyloric stenosis: profile, management and outcome of patients admitted to a tertiary hospital in Bloemfontein, South Africa

BACKGROUND

Infantile hypertrophic pyloric stenosis (IHPS) is the thickening of both muscle layers of the pylorus and is most commonly found in first-born males. It usually presents with projectile, non-bilious vomiting. Late presentation leads to severe dehydration and malnutrition with deranged serum-electrolytes and acid-base imbalance delaying treatment and prolonging hospital stay. This study aims to evaluate the profile, management and outcome of IHPS at a tertiary hospital in Bloemfontein, South Africa.

METHOD

The study was a retrospective, descriptive record review including all patients with IHPS admitted to Universitas Hospital from January 2008 to February 2016. Of the 22 patients admitted, files for 19 patients were available for inclusion.

RESULTS

Sixteen (84.2%) of the 19 patients were male. Of the 11 patients with available birth order, two were first-, two second-, six third- and one fourth-born. The patients' ages ranged from 27 to 194 days (median 51 days). The most common symptoms were projectile vomiting (78.9%) and poor weight gain (68.4%). Six patients had no ultrasound done, and 17 patients underwent a Ramstedt-pyloromyotomy. Eight patients received atropine as part of their initial management. The duration of symptoms ranged from 1 to 58 days (median 14 days). There was no reported mortality. The length of stay ranged from 2 to 60 days (median 7 days).

CONCLUSION

The gender distribution and age at presentation were in keeping with the literature but not the birth order. The delay before surgery emphasises the poor general health and deranged biochemical state the patients present at the hospital.

Trends in patient outcome over the past two decades following allogeneic stem cell transplantation for acute myeloid leukaemia: an ALWP/EBMT analysis

BACKGROUND

Outcomes for patients with acute myeloid leukaemia (AML) undergoing allogeneic stem cell transplantation (allo-SCT) have significantly improved in recent years.

OBJECTIVES

To assess the incremental improvement of transplanted AML patients in the last two decades.

METHODS

Patients included in this analysis were adult AML patients who underwent allo-SCT from an HLA-matched sibling donor (MSD) or HLA-matched unrelated donor (MUD) in first remission. Patient outcomes were assessed between three cohorts according to the year of transplant (1993-2002, 2003-2007 and 2008-2012).

RESULTS

The analysis comprised a total of 20 187 patients of whom 4763 were transplanted between 1993 and 2002, 5835 in 2003 and 2007, and 9589 in 2008 and 2012. In multivariate analysis, leukaemia-free survival (LFS) rates were significantly improved in more recently transplanted patients compared to patients transplanted in 1993-2002 [Hazard ratio (HR) = 0.84, confidence interval (CI) 95%, 0.77-0.92; P = 0.003], a benefit which also extended to improved overall survival (OS; HR = 0.8, CI 95%, 0.73-0.89; P < 0.0001), and decreased nonrelapse mortality (NRM) rates (HR = 0.65, CI 95%, 0.56-0.75; P < 0.0001). Subset analysis revealed that in MSD, the rates of LFS, NRM and OS significantly improved in patients in the more recent cohort with similar results also seen in MUD. Finally, the incidence of acute graft-versus-host disease (GVHD) was significantly reduced leading to improved GVHD-free/relapse-free survival (GRFS) rates in more recently transplanted patients.

CONCLUSION

Outcome of allo-SCT for AML patients has markedly improved in the last two decades owing to decreased nonrelapse mortality and improved rates of leukaemia-free survival resulting in significantly longer survival.

Models to predict positive and negative effects of cochlear implantation on tinnitus

Objectives

The effect of cochlear implantation on tinnitus is heterogeneous: implantation does not always reduce tinnitus and may even worsen tinnitus. Therefore, it is important to know which factors influence the consequences of cochlear implantation for tinnitus. To date, no consensus has been reached regarding the factors that influence tinnitus. This study aimed to create prognostic models, using binary logistic regression analyses to predict positive or negative changes in tinnitus after cochlear implantation.

Methods

For this study we retrospectively sent two questionnaire packages to 117 cochlear implant patients.

Results

In the binary logistic regression analyses of the responses to the questionnaires, it was not possible to create a significant model to predict a positive effect of cochlear implantation on tinnitus. However, a negative effect of cochlear implantation on tinnitus was predictable, using a backward stepwise selection method in a model including the Abbreviated Profile of Hearing Aid Benefit (APHAB) and Tinnitus Handicap Questionnaire (THQ) (P < .001, Nagelkerke R² = 0.529).

Conclusions

Our results suggest that the lower the preoperative tinnitus handicap and the preoperative hearing handicap, the higher the chance that cochlear implantation will worsen tinnitus. More research needs to be done, preferable in a big prospective study, to make this model instrumental for clinical decision making and preoperative patient counselling. However, our results might suggest that preoperative THQ and APHAB screening could be meaningful. Especially in patients who are afraid to develop tinnitus or tinnitus worsening as complication of cochlear implantation.

Level of Evidence

4

In Vivo Electrophysiological Measurement of the Rat Ulnar Nerve with Axonal Excitability Testing

Electrophysiology enables the objective assessment of peripheral nerve function in vivo. Traditional nerve conduction measures such as amplitude and latency detect chronic axon loss and demyelination, respectively. Axonal excitability techniques "by threshold tracking" expand upon these measures by providing information regarding the activity of ion channels, pumps and exchangers that relate to acute function and may precede degenerative events. As such, the use of axonal excitability in animal models of neurological disorders may provide a useful in vivo measure to assess novel therapeutic interventions. Here we describe an experimental setup for multiple measures of motor axonal excitability techniques in the rat ulnar nerve. The animals are anesthetized with isoflurane and carefully monitored to ensure constant and adequate depth of anesthesia. Body temperature, respiration rate, heart rate and saturation of oxygen in the blood are continuously monitored. Axonal excitability studies are performed using percutaneous stimulation of the ulnar nerve and recording from the hypothenar muscles of the forelimb paw. With correct electrode placement, a clear compound muscle action potential that increases in amplitude with increasing stimulus intensity is recorded. An automated program is then utilized to deliver a series of electrical pulses which generate 5 specific excitability measures in the following sequence: stimulus response behavior, strength duration time constant, threshold electrotonus, current-threshold relationship and the recovery cycle. Data presented here indicate that these measures are repeatable and show similarity between left and right ulnar nerves when assessed on the same day. A limitation of these techniques in this setting is the effect of dose and time under anesthesia. Careful monitoring and recording of these variables should be undertaken for consideration at the time of analysis.

Rezeptorszintigraphie mit 111In-Pentetreotid beiendokrinen gastroenteropankreatischenTumoren

Die Rezeptorszintigraphie mit 111In-Pentetreotid ist ein komplementäres bildgebendesVerfahren mit einer Sensitivität von 88%, um bei Patienten mitklinischen und biochemischen Symptomen eines endokrinen Tumors desGastrointestinaltraktes oder des Pankreas den Primärtumor und dessen Metastasen zu lokalisieren. Als Ganzkörperszintigraphie erfaßt sie jede Körperregionund stellt auch kleine Tumoren dar, die mit den übrigen bildgebendenVerfahren nicht oder nur schwer zu entdecken sind. Bei 104 Patienten mit GEP-Tumoren oder nach operativer Entfernung eines solchen Tumors erwiessich die Rezeptorszintigraphie als dem Ultraschall und der Computertomographie bei 34% in der Aussagekraftüberlegen, bei 52% als gleich und bei 14%als unterlegen.

Randomized, Controlled Trial of the Effect of Dietary Potassium Restriction on Nerve Function in CKD

BACKGROUND AND OBJECTIVES

Neuromuscular complications are almost universal in CKD by the time that a patient commences dialysis. Recent studies have indicated that chronic hyperkalemia may contribute to the development of neuropathy in CKD. This study was undertaken to determine whether dietary restriction of potassium intake may be a neuroprotective factor in CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A 24-month prospective, single-blind, randomized, controlled trial was undertaken in 47 consecutively recruited patients with stages 3 and 4 CKD. The intervention arm (n=23) was prescribed a diet focusing on potassium restriction to meet a monthly serum potassium level of ≤4.5 mEq/L, with oral sodium polystyrene sulfonate provided if dietary advice failed to achieve the target. The control arm (n=24) received dietary advice regarding general nutrition. The primary outcome was the change in the total neuropathy score evaluated by a blinded observer. Secondary outcomes included electrolyte levels, gait speed, neurophysiologic parameters, and health-related quality of life scores. Five patients withdrew before initiation of treatment, and final analysis consisted of n=21 in each group.

RESULTS

There was a greater increase in total neuropathy score from baseline to final assessment in the control arm compared with the intervention arm (6.1±6.2-8.6±7.9 controls; 7.8±7.4-8.2±7.5 intervention; change 2.8±3.3-0.4±2.2, respectively; P<0.01). The intervention significantly reduced mean serum potassium compared with controls (4.6±0.1-4.8±0.1 mEq/L mean recorded every 6 months over the trial duration; P=0.03). There were no adverse changes in other nutritional parameters. Improved gait speed was also noted in the intervention arm compared with the control arm, with a mean increase of 0.15±0.17 m/s in the intervention group versus 0.02±0.16 m/s in the control group (P=0.01).

CONCLUSIONS

Our results provide important preliminary evidence that dietary potassium restriction confers neuroprotection in CKD and should be confirmed in a larger multicenter trial.

Search for Neutrinoless Quadruple-β Decay of ^{150}Nd with the NEMO-3 Detector

We report the results of a first experimental search for lepton number violation by four units in the neutrinoless quadruple-β decay of ^{150}Nd using a total exposure of 0.19 kg yr recorded with the NEMO-3 detector at the Modane Underground Laboratory. We find no evidence of this decay and set lower limits on the half-life in the range T_{1/2}>(1.1-3.2)×10^{21}  yr at the 90% C.L., depending on the model used for the kinematic distributions of the emitted electrons.

Effects of hemodialysis on intraneural blood flow in end-stage kidney disease

INTRODUCTION

We quantified intraneural blood flow (INBF) in 18 patients with end-stage kidney disease (ESKD) and examined its relationship with nerve size, neuropathy severity, and nerve excitability parameters.

METHODS

Sonographic measurements of the median nerve were performed at the same site before and after hemodialysis. INBF was quantified by analyzing power Doppler sonograms to obtain the vessel score (VSc) and maximum perfusion intensity (MPI). Corresponding median motor nerve excitability studies were performed. Neuropathy severity was assessed using Total Neuropathy Score.

RESULTS

A total of 39% of ESKD patients had detectable INBF compared with none in the control group (P < 0.0001). Patients with detectable INBF had larger nerves and more severe neuropathy (P < 0.01). INBF parameters were significantly reduced after a session of dialysis (VSc: P < 0.01; MPI: P < 0.01). A significant relationship was found between interdialytic change in INBF and changes in nerve excitability.

CONCLUSIONS

Increased INBF is a potential marker for neuropathy severity in ESKD patients. Muscle Nerve 57: 287-293, 2018.

The Effect of Diabetes on Cortical Function in Stroke: Implications for Poststroke Plasticity

Diabetes may impair the capacity for neuroplasticity such that patients experience a slower and poorer recovery after stroke. The current study investigated changes in cortical function in stroke patients with diabetes to determine how this comorbidity may affect poststroke cortical plasticity and thereby functional recovery. From a cohort of 57 participants, threshold-tracking transcranial magnetic stimulation was used to assess cortical function over the ipsilateral and contralesional hemispheres in 7 patients with diabetes after an acute stroke compared with 12 stroke patients without diabetes. Cortical function was also assessed in 8 patients with diabetes without stroke and 30 normal control subjects. After acute stroke, short-interval intracortical inhibition (SICI) was reduced over both motor cortices in stroke patients without diabetes compared with normal control patients, while in stroke patients with diabetes, SICI was only reduced over the contralesional but not the ipsilesional cortex compared with control patients with diabetes. In addition, SICI was significantly reduced in the control patients with diabetes compared with normal control patients. These results have demonstrated the absence of ipsilesional cortical excitability change after diabetic strokes, suggesting impaired capacity for neuroplasticity over this hemisphere as a consequence of a "double-hit" phenomenon because of preexisting alterations in cortical function in nonstroke patients with diabetes. The reliance on reorganization over the contralesional cortex after stroke will likely exert influence on poststroke recovery in patients with diabetes.

Neuroinflammatory and morphological changes in late-life depression: the NIMROD study

We studied neuroinflammation in individuals with late-life depression, as a risk factor for dementia, using [¹¹C]PK11195 positron emission tomography (PET). Five older participants with major depression and 13 controls underwent PET and multimodal 3T magnetic resonance imaging (MRI), with blood taken to measure C-reactive protein (CRP). We found significantly higher CRP levels in those with late-life depression and raised [¹¹C]PK11195 binding compared with controls in brain regions associated with depression, including subgenual anterior cingulate cortex, and significant hippocampal subfield atrophy in cornu ammonis 1 and subiculum. Our findings suggest neuroinflammation requires further investigation in late-life depression, both as a possible aetiological factor and a potential therapeutic target.