Complex Regional Pain Syndrome: An inflammatory disease

The pathophysiology of Complex Regional Pain Syndrome (CRPS) is complex and still not completely understood. In addition to a convincing role of inflammation, there are a number of arguments why an involvement of the immune system has been suggested in the pathophysiology of CRPS. Therefore, some immunological aspects were further explored with the aim to achieve more insight in both the pathophysiology and possible treatment options in CRPS. The main results: 1. In contrast to what is generally assumed, inflammation may be involved in patients with cold CRPS. 2. The prevalence of antinuclear antibodies (ANA) is significantly higher in CRPS patients than in the healthy population. The prevalence of anti-neuronal antibodies however does not deviate from that in the healthy population. Striking is the fact that the prevalence of ANA was more similar to that observed in patients with an autoimmune disease such as rheumatoid arthritis than that in patients with a classic autoimmune disease. This is a relevant finding because it may affect the choice of treatment. 3. The current empirical evidence for the efficacy of administering the most commonly used immunomodulating medication (i.e. glucocorticoids, TNF-α antagonists, thalidomide, bisphosphonates, and immunoglubulins) is scarce. 4. To test the assumption that TNF-α antagonists can reduce the manifestation of inflammation in CRPS, a double-blind randomized placebo-controlled trial was conducted. Unfortunately, this study was terminated before the required number of patients for sufficient statistical power had been reached. Nevertheless, the limited data showed a trend towards a greater reduction of TNF-α in the intervention group compared with the placebo group. 5. Mast cells are known to be involved in the inflammatory process of CRPS and also play a role in the process of central sensitization. In the development of a more mechanism-based treatment of CRPS, influencing the activity of mast cells might be important

Anaesthetic management of two patients with pompe disease for caesarean section

The introduction of enzyme replacement therapy and the resultant stabilisation or improvement in mobility and respiratory muscle function afforded to patients with late-onset Pompe may lead to an increased number of Pompe patients prepared to accept the challenges of parenthood. In this case report, we describe our anaesthetic management of two patients with Pompe disease for a caesarean section

Sotorasib Interaction with Oxycodone: A Case Report

Lung cancer is the leading cause of cancer-related death and the second most common malignancy in the world. NonSmall Cell Lung Cancer (NSCLC) accounts for approximately 85 percent of newly diagnosed lung cancer cases. The discovery of particular driver mutations and the development of targeted therapy are major breakthroughs in the treatment of advanced NSCLC. Cancer-related pain is a common and devastating symptom, and it is important to achieve adequate analgesia in all cancer patients. As new cancer treatments are being developed, clinicians must be aware of unknown and potentially disastrous drug-drug interactions when choosing an analgesic treatment. Here, we introduce a case of a 62-year-old female patient with advanced NSCLC who had a slow progression of the disease on previous anticancer therapy. The tumor had a Kirsten Rat Sarcoma Virus (KRAS) G12C mutation and the patient was therefore able to start sotorasib. The patient complained of left hip pain, which increased markedly after starting sotorasib. She required increased doses of oxycodone and received radiation therapy. Suspecting a radiation flare, the patient was hospitalized with unbearable pain. An opioid rotation to fentanyl had no effect on the pain. With suspected interaction between sotorasib and fentanyl, an opioid rotation to morphine was performed, after which the patient received almost immediate pain relief. Strong opioids, including oxycodone, are the cornerstone of pharmacological treatment of cancer-related pain. This case highlights the need for ongoing education about potential interactions between the cancer treatment and the analgesic treatment

Different Types of Pain in Complex Regional Pain Syndrome Require a Personalized Treatment Strategy

Complex regional pain syndrome (CRPS) is a debilitating painful state of an extremity that can develop after trauma. CRPS is diagnosed by the new International Association for the Study of Pain (IASP) diagnostic criteria for CRPS. The syndrome is characterized by continuing regional pain with abnormal sensory, motor, sudomotor, vasomotor, edema, and/or trophic signs. The clinical presentation of CRPS can be very heterogeneous because CRPS is a multi-mechanism syndrome. Therefore, mechanism-based subgroups have been suggested to personalize treatment for CRPS. Additionally, the presentation of symptom pain may also be able to identify different subgroups of CRPS. In this review, the types of pain recognized by the IASP―nociceptive, neuropathic, and nociplastic pain―will be discussed as possible subgroups for CRPS. Each pain type should be identified in CRPS patients, with a thorough history taking, physical examination, and diagnostic tests or (novel) biomarkers to optimize treatment effectiveness. Over the course of the syndrome, patients with CRPS probably experience more than one distinct pain type. Therefore, pain specialists should be alert to not only adjust their treatment if underlying pathophysiologic mechanisms tend to change but also to personalize the treatment of the associated type of pain in the CRPS patient.</p

Is there an association between serum soluble interleukin-2 receptor levels and syndrome severity in persistent Complex Regional Pain Syndrome?

OBJECTIVE: A potentially useful biomarker for Complex Regional Pain Syndrome (CRPS) is the serum soluble interleukin-2 receptor (sIL-2R) level, which is a marker for T-cell activation. Elevated serum sIL-2R levels have been described in CRPS patients compared to healthy controls. In T-cell mediated inflammatory diseases such as sarcoidosis and rheumatoid arthritis, the serum sIL-2R levels correlate with disease severity. In this study, we investigate whether an association exists between serum sIL-2R levels in CRPS patients and CRPS severity. METHODS: A cross-sectional cohort study was conducted in a tertiary pain referral center in the Netherlands. Adult CRPS patients diagnosed by the IASP criteria were included between October 2018 until October 2022. The main study parameters were serum sIL-2R levels and the CRPS severity score. RESULTS: Fifty-three CRPS patients were included with a mean syndrome duration of 84 months (Q3 - Q1:180 - 48). The majority had persistent CRPS with a syndrome duration &gt;1 year (n = 52, 98%). The median pain Numerical Rating Score (NRS) was 7 (Q3 - Q1: 8 - 5) and the mean CRPS severity score was 11 (SD ± 2.3). The median serum sIL-2R level was 330 U/mL (Q3 - Q1:451 - 256). No statistically significant correlation was observed between serum sIL-2R levels and the CRPS severity score (rs = 0.15, P = .28). CONCLUSIONS: Our findings suggest that serum sIL-2R levels cannot be used as a biomarker for syndrome severity in persistent CRPS (syndrome duration &gt;1 year). Serial measurements of serum sIL-2R from early CRPS to persistent CRPS are needed to investigate whether serum sIL-2R levels can be used to monitor T-cell mediated inflammatory syndrome activity.</p

How Do We Treat Children with Anterior Cutaneous Nerve Entrapment Syndrome and Is the Biopsychosocial Model Also Being Applied? A Scoping Review

Background: Evidence-based guidelines for managing anterior cutaneous nerve entrapment syndrome (ACNES) in children are absent. The primary aim of this review was to scrutinize the evidence supporting currently used treatment interventions. In accordance with the World Health Organization (WHO) guidelines for managing chronic pain in children, these patients and their families and caregivers should be treated within the context of the biopsychosocial model; pain should not be treated purely as a biomedical problem. Therefore, our second aim was to evaluate whether these interventions are applied within the context of the biopsychosocial model, utilizing an inter- or multidisciplinary approach. Materials and Methods: A scoping review of the literature was conducted to explore treatment strategies for ACNES in children. To ensure a comprehensive overview of published literature on this topic, the search was not restricted based on study type. Two reviewers independently assessed titles and abstracts. After excluding records unrelated to children, full texts were screened for inclusion. Any discrepancies in judgement were resolved through discussion with a third reviewer. Results: Out of 35 relevant titles, 22 were included in this review. Only 4 articles provided information on long-term outcomes. The overall quality of the review was deemed low. The majority of reports did not address treatment or education within the psychological and social domains. A structural qualitative analysis was not feasible due to the substantial heterogeneity of the data. Conclusion: The evidence supporting current treatment strategies in children with ACNES is of low quality. More research is needed to establish an evidence-based treatment algorithm for patients with this challenging pain problem. In line with the WHO recommendation, greater emphasis should be placed on a biopsychosocial approach. The ultimate goal should be the development of a generic treatment algorithm outlining an approach to ACNES applicable to all professionals involved.</p

The prevalence of autoantibodies in complex regional pain syndrome type i

Autoimmunity has been suggested as one of the pathophysiologic mechanisms that may underlie complex regional pain syndrome (CRPS). Screening for antinuclear antibodies (ANA) is one of the diagnostic tests, which is usually performed if a person is suspected to have a systemic autoimmune disease. Antineuronal antibodies are autoantibodies directed against antigens in the central and/or peripheral nervous system. The aim of this study was to compare the prevalence of these antibodies in CRPS patients with the normal values of those antibodies in the healthy population. Twenty seven (33%) of the 82 CRPS patients of whom serum was available showed a positive ANA test. This prevalence is significantly higher than in the general population. Six patients (7.3%) showed a positive result for typical antineuronal antibodies. This proportion, however, does not deviate from th