Sleep architecture variation: a mediator of metabolic disturbance in individuals with major depressive disorder

Remarkable proportions of individuals diagnosed with major depressive disorder (MDD) have comorbid metabolic disturbances (i.e., obesity, type 2 diabetes mellitus (T2DM), hypertension, dyslipidemia), and vice versa. Accumulating evidence suggests that common pathophysiologic pathways such as a chronic, low-grade, proinflammatory state mediate this frequent co-occurrence. However, it remains unclear what traits precede the onset and increase the risk for these pathologic states. The aim of our review was to evaluate the evidentiary base supporting the hypothesis that the increased hazard for metabolic disturbance in MDD subpopulations (and vice versa) is mediated in part by endophenotypic variations in sleep architecture.     

Urban legends series: Sjögren’s syndrome

Oral Diseases (2012) 19 , 46–58 Sjögren’s syndrome (SjS) is one of the most common autoimmune rheumatic diseases, clinically characterized by xerostomia and keratoconjunctivitis sicca. We investigated the following controversial topics: (i) Do we have reliable ways of assessing saliva production? (ii) How important are the quantity and quality of saliva? (iii) Are only anti‐SSA/Ro and anti‐SSB/La relevant for the diagnosis of SjS? (iv) Are the American‐European Consensus criteria (AECC) the best way to diagnose SjS? Results from literature searches suggested the following: (i) Despite the fact that numerous tests are available to assess salivation rates, direct comparisons among them are scarce with little evidence to suggest one best test. (ii) Recent developments highlight the importance of investigating the composition of saliva. However, more research is needed to standardize the methods of analysis and collection and refine the quality of the accumulating data. (iii) In addition to anti‐Ro/La autoantibodies, anti α‐fodrin IgA and anti‐MR3 autoantibodies seem to be promising diagnostic markers of SjS, but more studies are warranted to test their sensitivity and specificity. (iv) AECC are classification, not diagnostic criteria. Moreover, recent innovations have not been incorporated into these criteria. Consequently, treatment directed to patients diagnosed using the AECC might exclude a significant proportion of patients with SjS.     

Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages

Introduction

The high mortality and morbidity associated with resection for oesophagogastric malignancy has resulted in a conservative approach to the postoperative management of this patient group. In August 2009 we introduced an enhanced recovery after surgery (ERAS) pathway tailored to patients undergoing resection for oesophagogastric malignancy. We aimed to assess the impact of this change in practice on standard clinical outcomes.

Methods

Two cohorts were studied of patients undergoing resection for oesophagogastric malignancy before (August 2008 – July 2009) and after (August 2009 – July 2010) the implementation of the ERAS pathway. Data were collected on demographics, interventions, length of stay, morbidity and in-hospital mortality.

Results

There were 53 and 55 oesophagogastric resections undertaken respectively for malignant disease in each of the study periods. The median length of stay for both gastric and oesophageal resection decreased from 15 to 11 days (Mann– Whitney U, p<0.001) following implementation of the ERAS pathway. There was no significant increase in morbidity (gastric resection 23.1% vs 5.3% and oesophageal resection 25.9% vs 16.7%) or mortality (gastric resection no deaths and oesophageal resection 1.8% vs 3.6%) associated with the changes. There was a significant decrease in the number of oral contrast studies used following oesophageal resection, with a reduction from 21 (77.8%) in 2008–2009 to 6 (16.7%) in 2009–2010 (chi-squared test, p<0.0001).

Conclusions

The introduction of an enhanced recovery programme following oesophagogastric surgery resulted in a significant decrease in length of median patient stay in hospital without a significant increase in associated morbidity and mortality.     

Neuropathic Pain Post Spinal Cord Injury Part 2: Systematic Review of Dorsal Root Entry Zone Procedure

Background:

Pharmacotherapy may not sufficiently reduce neuropathic pain in many individuals post spinal cord injury (SCI). The use of alternative therapies such as surgery may be effective in reducing neuropathic pain in these individuals. However, because of the invasive nature of surgery, it is important to examine the evidence for use of this treatment.

Objective:

The purpose of this study was to conduct a systematic review of published literature on the surgical treatment of neuropathic pain after SCI.

Methods:

MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for articles in which surgical treatment of pain after SCI was examined. Articles were restricted to the English language. Article selection was conducted by 2 independent reviewers with the following inclusion criteria: the subjects participated in a surgical intervention for neuropathic pain; at least 50% of the subjects had an SCI; at least 3 subjects had an SCI; and a definable intervention involving the dorsal root entry zone (DREZ) procedure was used to reduce pain. Data extracted included study design, study type, subject demographics, inclusion and exclusion criteria, sample size, outcome measures, and study results. Randomized controlled trials (RCTs) were assessed for quality using the Physiotherapy Evidence Database (PEDro) assessment scale. Levels of evidence were assigned to each intervention using a modified Sackett scale.

Results:

Eleven studies met the inclusion criteria. One study provided level 2 evidence, and the rest provided level 4 evidence. The DREZ procedure was shown to be more effective for segmental pain than for diffuse pain after SCI. Further, individuals with conus medullaris level injury were found to have a higher level of neuropathic pain relief than those with cervical, thoracic, or cauda equina injury.

Conclusions:

The studies demonstrated that the DREZ procedure may be effective in reducing segmental pain. Hence, DREZ may be important in treatment of neuropathic pain in individuals resistant to less invasive treatments. Because the studies lacked control conditions and examination of long-term effects, there is a need for larger trials with more stringent conditions.Key words: pain, spinal cord injury, surgical treatmentPain is a major cause of distress and disability in persons with spinal cord injury (SCI). It has been shown to lead to social isolation, unemployment, decreased function, decreased quality of life, depression, and even suicide.^1,2 More than 77% of individuals with an SCI indicated that pain interfered with one or more of their daily activities including sleep (40%), exercise (34.9%), and work (33.6%).² The International Association for the Study of Pain (IASP) defines neuropathic pain as “pain caused by a lesion or disease of the somatosensory nervous system.”³ After an SCI, individuals often report the onset of chronic neuropathic pain caudal to the level of the lesion or at the same level within the associated spinal cord segment.⁴ Dijkers et al⁵ reported no difference in the prevalence of pain based on level or completeness.The reported incidence of neuropathic pain after SCI varies greatly among studies, but between 10% and 30% of patients with SCI experience pain severe enough to interfere with their activities of daily living^6,7 and may require surgical intervention to relieve persistent and refractory pain.^4,8 Unmanageable neuropathic pain occurs more often in individuals with conus medullaris and cauda equina lesions where damage also involves the peripheral nerve roots.⁸When pharmacological and other noninvasive treatments fail to reduce pain, surgical spinal cord stimulation and dorsal root entry zone (DREZ) ablation treatments, such as DREZ lesioning and microsurgical DREZotomy (MDT), can be considered as options for the management of refractory pain.⁹ Neurosurgical procedures to reduce neuropathic pain should be reserved for cases in which medical therapies have failed to sufficiently reduce pain.⁴ The risks associated with ablative surgeries can be significant for individuals with incomplete neurological deficits; therefore, DREZ ablation is generally only considered a treatment option when neuropathic pain is present after a complete SCI.⁸ The MDT procedure targets for ablation the nociceptive fibers in the lateral bundle of the dorsal rootlet, the deafferented neurons of the dorsal horn, and the medial portion of the Lissauer tract.^4,6 This systematic review was conducted to assess the effectiveness of DREZ ablation therapies in reducing neuropathic pain in individuals following SCI.     

Clinical evaluation of diamine silver fluoride/potassium iodide as a dentine desensitizing agent. A pilot study

Background: The aim of the present study was to compare the efficacy of an experimental diamine silver fluoride/potassium iodide product with an oxalic acid‐based preparation in reducing dentine hypersensitivity. Methods: The study was conducted as a double‐blind, randomized clinical trial. A total of 19 subjects with dentine hypersensitivity on both sides of their upper arch were selected. The most sensitive tooth in each quadrant was identified and received a cold stimulus. The response was recorded on a visual analogue scale (VAS). The tooth thus selected was treated with one of the treatment agents. One week later the level of dentine sensitivity was assessed. Participants were also asked for their subjective assessment of treatment effects. Results: The mean difference between VAS at baseline and seven days for teeth treated with diamine silver fluoride/potassium iodide was greater than that for teeth treated with the oxalic acid‐based preparation (p = 0.0134). The subjects’ subjective assessment of changes in dentine hypersensitivity indicated that more obtained relief with the diamine silver fluoride/potassium iodide treatment (p = 0.0129). Conclusions: It was concluded that an experimental diamine silver fluoride/potassium iodide product has potential as a treatment for dentine hypersensitivity.     

Subthalamic deep brain stimulation affects heading perception in Parkinson’s disease

Journal of Neurology - Parkinson’s disease (PD) presents with visuospatial impairment and falls. It is critical to understand how subthalamic deep brain stimulation (STN DBS) modulates...     

An Update on Intradialytic Cardiac Dysfunction

Cardiac dysfunction is a key factor in the high morbidity and mortality rates seen in hemodialysis (HD) patients. Much of the dysfunction is manifest as adverse changes in cardiac and vascular structure prior to commencing dialysis. This adverse vascular remodeling arises as a dysregulation between pro‐ and antiproliferative signaling pathways in response to hemodynamic and nonhemodynamic factors. The HD procedure itself further promotes cardiomyopathy by inducing hypotension and episodic regional cardiac ischemia that precedes global dysfunction, fibrosis, worsening symptoms, and increased mortality. Drug‐based therapies have been largely ineffective in reversing HD‐associated cardiomyopathy, in part due to targeting single pathways of low yield. Few studies have sought to establish natural history and there is no framework of priorities for future clinical trials. Targeting intradialytic cardiac dysfunction by altering dialysate temperature, composition, or ultrafiltration rate might prevent the development of global cardiomyopathy, heart failure, and mortality through multiple pathways. Novel imaging techniques show promise in characterizing the physiological response to HD that is a unique model of repetitive ischemia‐reperfusion injury. Reducing HD‐associated cardiomyopathy may need a paradigm shift from empirical delivery of solute clearance to a personalized therapy balancing solute and fluid removal with microvascular protection. This review describes the evidence for intradialytic cardiac dysfunction outlining cardioprotective strategies that extend to multiple organs with potential impacts on exercise tolerance, sleep, cognitive function, and quality of life.     

Effect of birth weight on adulthood renal function: A bias‐adjusted meta‐analytic approach

While the association between low birth weight (LBW; <2500 g) and development of adult chronic renal disease (CKD) is inconsistently reported, less information is available regarding association of high birth weight (HBW; ≥4000 g) with CKD. We undertook a systematic review and meta‐analysis on studies published before 30 September 2015 and report associations between birth weight and renal function. Blood (glomerular filtration rate (GFR)) and urine (microalbuminuria/albumin excreation rate (AER)/urinary albumin creatinine ratio (ACR)) parameters were used to define CKD. Three different effect size estimates were used (odds ratio, regression coefficient and mean difference). The odds of developing CKD in the life course among those born LBW was 1.77 (95% CI: 1.42, 2.20) times and 1.68 (1.27, 2.33) times, assessed by blood and urine parameters respectively. Higher risk was also observed among Asian and Australian populations (blood: OR 2.68; urine: OR 2.28), individuals aged ≤30 years (blood: OR 2.30; urine: OR 1.26), and ≥50 years (blood: OR 3.66; urine: OR 3.10), people with diabetes (blood: OR 2.51), and aborigines (urine: OR 2.32). There was no significant association between HBW and CKD. For every 1 kg increase in BW, the estimated GFR increased by 2.09 mL/min per 1.73 m² (1.33–2.85), and it was negatively associated with LogACR (ß ?0.07, 95% CI: ?0.14, 0.00). LBW inborn had lower mean GFR ?4.62 (?7.10, ?2.14) compared with normal BW. Findings of this study suggest that LBW increased the risk of developing CKD, and HBW did not show any significant impact.