Clinical factors influencing the outcomes of inpatient rehabilitation in patients with complex regional pain syndrome

학위논문(석사) -- 서울대학교대학원 : 의과대학 의학과, 2022.2. 임재영.Introduction: Patients with complex regional pain syndrome (CRPS) suffer from chronic refractory pain and a reduced quality of life. Providing timely and proper rehabilitation treatments can alleviate the pain, improve the quality of life, and reduce the burden of medical expenses. This study investigated factors influencing the effectiveness of inpatient rehabilitation in CRPS patients and identifies indications for such treatment. Methods: We retrospectively reviewed medical records from January 2017 to June 2020. Patients over 18 years of age who were diagnosed with CRPS according to the Budapest criteria and received inpatient rehabilitation during that period were included. The rehabilitation program included medication, interventions, and physiotherapy. The primary outcome of the present study was the pain intensity at discharge minus the pain intensity at admission according to a numeric rating scale (NRS). To analyze the effect of inpatient rehabilitation on pain improvement, the following factors were analyzed: demographic factors, duration of disease, using an intravenous opioid as a rescue medicine, having a spinal cord stimulator, receiving scrambler treatment, CRPS severity score, CRPS type, region affected by CRPS, three-phase bone scan (TPBS) result, electromyography result, thermography result, and NRS score at admission. The Mann–Whitney test, simple linear regression test, and multiple regression analysis were performed to identify variables associated with pain improvement. Results: A total of 51 patients (19 male and 32 female) were included. Patients without abnormalities in their TPBS had better pain relief than those with abnormalities (mean difference = 0.82, P = 0.041). However, patients without abnormalities in the thermography test had worse outcomes than those with abnormalities (mean difference = 1.89, P = 0.032). Patients who had pain intensity ≥ 5 at initial admission had better results from inpatient rehabilitation than those who had pain intensity < 5 (mean difference = 1.49, P = 0.001). A simple linear regression test also revealed that the initial pain intensity significantly influences the effect of inpatient rehabilitation therapy, with the effect increasing with the initial pain intensity (R2 = 0.263, β = −0.486, P < 0.001). In the multiple regression analysis, only the initial pain intensity showed statistically significant results (adjusted R2 = 0.256, β = −0.584, P = 0.002). Conclusions: Our results suggest that some clinical factors can affect the pain relief effect of inpatient rehabilitation. Severe initial pain intensity, abnormalities in a thermography test, and a lack of abnormalities in a TPBS gave better outcomes from inpatient rehabilitation. We suggest that these are indicators for inpatient rehabilitation therapy for patients with CRPS.복합부위통증증후군(CRPS)환자는 만성 통증과 삶의 질 저하로 고통 받는다. 이 환자들에게 시기 적절하고 적합한 재활 치료를 제공하면 통증을 완화하고 삶의 질을 향상시키며 의료비 부담을 줄일 수 있다. 이 연구는 CRPS 환자에서 입원환자 재활의 효과에 영향을 미치는 요인을 조사하고 입원환자 재활의 적응증을 확인하는 것을 목적으로 한다. 환자의 의무기록을 2017년 1월부터 2020년 6월까지 후향적으로 분석하였다. 부다페스트 기준에 따라 CRPS로 진단되어 해당 기간 동안 입원 재활치료를 받은 18세 이상의 환자를 본 연구의 대상으로 하였다. 입원재활치료로는 약물 치료, 통증에 대한 중재 시술 및 물리 치료가 포함되었다. 주요 결과는 숫자 등급 척도(NRS)로 표기된 통증 점수의 입원시점과 비교하여 퇴원 시점에서의 호전 정도이다. 퇴원 시 통증 강도 값에서 입원 시 통증 강도 값을 뺀 값이다. 입원재활이 통증 개선에 미치는 영향을 분석하기 위해 인구통계학적 요인, 유병 기간, 정맥 아편계 약물 사용 여부, 척수 자극기 보유 여부, 스크램블러 치료를 받았는지 여부, CRPS 중증도 점수, CRPS 유형, CRPS 이환 부위, 3상 골스캔 검사 결과, 근전도 결과, 열화상 검사 결과 및 입원 시점에서의 NRS 점수를 요인으로 분석하였다. 통계방법으로는 Mann-Whitney 테스트와 단순 선형 회귀 분석 및 다중 회귀 분석을 하였다. 총 51명(남 19/여 32)의 환자가 포함되었다. 3상 골스캔 검사 검사에서 이상이 없는 환자는 검사에서 이상이 있는 환자보다 통증 완화 정도가 더 좋았다. (평균 차이: 0.82; P=0.041) 그러나 열화상 검사에서 이상이 없는 환자는 검사에서 이상이 있는 환자보다 치료에 대한 반응이 더 안 좋았다. (평균차: 1.89; P=0.032) 초기 입원 시 통증 강도가 5점 이상이었던 환자는 입원 당시 통증 강도가 5 미만이었던 환자보다 입원 재활의 결과가 더 좋았다. (평균 차이: 1.49; P=0.001) 단순선형회귀검사에서도 초기 통증 강도가 입원환자 재활치료의 효과에 유의한 영향을 미치는 것으로 나타났으며, 초기 통증 강도가 높을수록 입원환자 재활치료의 효과가 높은 것으로 나타났다. (R2=0.263, β= -0.486; P<0.001) 다중회귀분석에서는 초기 통증 강도만 통계적으로 유의한 결과를 보였다. (adjusted R2=0.256, β= -0.584, P=0.002) 이번 연구 결과는 일부 임상 요인이 입원 환자 재활의 통증 완화 효과에 영향을 미칠 수 있음을 시사한다. 심한 초기 통증 강도, 열화상 검사에서 이상이 있는 경우, 3상 골스캔 검사에서 이상이 없는 경우 입원 재활에서 더 나은 결과를 보였다. 이러한 결과로부터 CRPS 환자의 입원환자 재활치료 적응증을 제시할 수 있을 것이다.제 1 장 Introduction 1 제 2 장 Materials and Methods 3 제 1 절 Study design and participants 3 제 2 절 Assessment and evaluation 3 제 3 절 Inpatient management program for CRPS 4 제 4 절 Outcome measures 6 제 5 절 Statistical analysis 7 제 3 장 Results 9 제 1 절 Participant’s demographics and clinical variables 9 제 2 절 Primary outcome 10 제 3 절 Secondary outcome 10 제 4 장 Discussion 12 Reference 16 국문 초록 20 표 목차 [표 1] 22 [표 2] 25 [표 3] 27 그림 목차 [그림 1] 28 [그림 2] 29 [그림 3] 30 [그림 4] 32석

Comparision of Effectiveness between the ThinPrep® and the Cytospin Preparations of the Repeated Urine Cytology

Once diagnosed as "cell paucity"or "atypia" by the cytospin (CS) preparation, this CS preparation does not secure a precise diagnosis by repeated testing alone. Although the ThinPrep (TP) preparation is acknowledged to show increased cellularity, performing the screening tests for the cases that have enough cellularity, according to CS, raises issues for the cost-effectiveness. To obtain a more precise diagnosis through increasing the cellularity by performing TP, we selected the cases that were diagnosed as "cell paucity" or "atypia" by CS, but they required a more precise diagnosis, and the samples were processed via both CS and TP to compare the results. 11 patients diagnosed as "cell paucity" and 22 patients diagnosed as "atypia" by CS participated in this study. When the detection rate of atypical cells in both preparations with repeated urine cytology was compared, the overall detection rate of TP (16cases, 48.5%) was superior than that of CS (11cases, 33.3%), with statistical significance. The cellularity of both preparations was compared on repeated urine cytology; the general cellularity of TP (29cases, 87.9%) was higher than that of CS (20cases, 60.6%), but there was no statistical significance. Particularly, we repeated the TP for the 1 case that was diagnosed as "atypia" and we performed polyoma virus immunohistochemical staining, which confirmed polyoma virus. In conclusion, we can avoid obtaining negative diagnosis from cases with uncertain "atypia" or "cell paucity" by performing repeated TP testing.ope

항 Signal Recognition Particle (신호인식입자) 항체와 연관된 근병증

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Liquid-Based Cytology of the Cerebrospinal Fluid in a Case of Cryptococcal Meningitis

Cryptococcus neoformans is the most common microorganism found in cerebrospinal fluid (CSF) cytology and causes life-threatening infections in immunocompromised hosts. Although its cytomorphologic features in conventional smear cytology have been well described, those in liquid-based cytology have rarely been. A 73-year-old woman with diffuse large B-cell lymphoma presented with mental confusion and a spiking fever. To rule out infectious conditions, CSF examination was performed. A cytology slide that was prepared using the ThinPrep method showed numerous spherical yeast-form organisms with diameters of 4-11 mum and thick capsules. Occasional asymmetrical, narrow-based budding but no true hyphae or pseudohyphae were observed. Gomori methenamine silver staining was positive. Cryptococcosis was confirmed in blood and CSF through the cryptococcal antigen test and culture. Liquid-based cytology allows for a clean background and additional slides for ancillary testing, facilitating the detection of microorganisms in CSF specimens, particularly when the number of organisms is small.ope

Perivascular Epithelioid Cell Tumor Arising in the Sacrum: A Case Report

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Angioleiomyoma in the Orbital Apex: A Case Report

A 56-year woman presented eyeball pain and blurred vision. MRI revealed a small well-delineated solid tumor in the apex of right orbit with optic nerve compression. Intraoperatively, the tumor was found very fibrous, hypervascular and adhesive to surrounding structures. The tumor was completely removed with the combination of endoscopic and microscopic technique. Patient experienced transient oculomotor nerve palsy, which completely recovered 3 months after surgery. Herein we report a rare case of angioleiomyoma in the orbital apex.ope

Surgical Management and Long-Term Outcome of Bronchial Carcinoids

Background: Bronchial carcinoids account for approximately 2% of all pulmonary tumor and consist of typical carcinoids and atypical carcinoids. An atypical carcinoid is considered to be an intermediate form of tumor between a low-grade malignant typical carcinoid and a high-grade malignant small cell lung carcinoma. There is still controversy with regard to the extent of resection and the value of systemic adjuvant therapy in atypical carcinoids. We performed a retrospective review of our experiences at Severance Hospital. Material and Method: Between 1990 and 2000, 15 patients with bronchial carcinoids were operated, and 5 of these had atypical carcinoids. Histologic diagnosis was established on the criteria of WHO/IASLC(1999). Result: There were 3 pneumonectomies, 11 lobectomies, and 1 segmentectomy. In typical carcinoids, one patient had regional lymph node metastasis, and 3 patients in atypical carcinoids had mediastinal lymph node metastases. Distant metastases developed in one patient of typical carcinoid, but developed in 4 patients of atypical carcinoids(p=0.0017). The 5-year survival rate in patients with atypical carcinoids was 20%, versus the 100% 5-year survival rate observed in patients with typical carcinoids(p=0.0039). Conclusion: In atypical carcinoids, because of many lymph node metastases on diagnosis and a low long-term survival rate, lobectomy constitutes a mininal procedure. Adjuvant systemic therapy is recommended for patients with lymph node and distant metastasis.ope

Prognostic impact of high p16/cyclin D1 index in breast cancer

Proteins p16 and cyclin D1 (CCND1) are known to tightly regulate the G1/S transition during the cell cycle, but their role in breast cancer development and progression is not clear. We investigated 224 cases of breast cancer from the Kangbuk Samsung Medical Center between 2000-2005. Expression levels of p16 and CCND1 were assessed by tissue microarray-based immunohistochemistry. A p16/CCND1 index was divided into low- and high-expression groups using receiver operating characteristic curves. The p16/CCND1 index was significantly different across molecular subtypes and a high p16/CCND1 index was statistically correlated with survival rates. This p16/CCND1 index may be an indicator of poor patient outcome and thus, represents a potential therapeutic target.ope

The Effects of Anti-inflammatory Drugs on Histologic Findings of the Experimental Prolotherapy Model

Objective: To investigate the effects of nonsteroidal anti- inflammatory drugs (NSAIDs) and acetaminophen on histologic changes of the Achilles tendon in an experimental prolotherapy model. Method: The right Achilles tendon of 60 rats was injected with 20% dextrose on experimental day 1, 7, and day 14, whereas the left was not injected and used as control. Rats were divided into 3 subgroups: NSAIDs medication group (10 mg/kg/day), acetaminophen medication group (100 mg/ kg/day) and no medication group. Medications were given for 3 consecutive days after each injection. Rats were sacrificed at 3 and 6 weeks after first injection. The transverse diameter of gross specimen, the number of fibroblasts on light microscope, and the distribution of collagen fibril on electron microscope were assessed. Results: The transverse diameter and the count of fibroblasts of all groups increased significantly in the injected tendon compared to the non-injected tendon. However, there were no differences among all groups significantly (p＜0.05). On electron micrograph, fibril diameters of injected tendon consisted of mainly smaller sizes with the intermediate sizes. Conclusion: Prolotherapy enhances fibroblastic stimulation and elaboration of extracellular matrix. Short term use of NSAIDs may not have any adverse effects on tissue proliferation after prolotherapy.ope

Pathological Classification of Focal Cortical Dysplasia (FCD) : Personal Comments for Well Understanding FCD Classification

In 2011, the International League against Epilepsy (ILAE) proposed a first international consensus of the classification of focal cortical dysplasia (FCD). This FCD classification had been widely used in worldwide. In this review paper, the authors would like to give helpful comments for better understanding of the current FCD classification. Especially, the basic concepts of FCD type I, such as "radial", "tangential" and "microcolumn" will be discussed with figures. In addition, the limitations, genetic progress and prospect of FCD will be suggested.ope